From: Treatment decisions for older adults with advanced chronic kidney disease
Clinical Issues | Suggested Trackb | Comments | |
---|---|---|---|
Dialysisc | Conservatived | ||
Renal Function Trajectory (RFD) | RFD defined as rate of decline of a patient’s estimated GFR (eGFR) per yeare | ||
Slow < 3 ml/min/1.73 m2 /yearf | |||
Low Comorbidityg | □h | Patients are unlikely to be faced with a dialysis decision, but if their RFD increases, or they have an AKI episode, they may be good candidates for chronic dialysis. | |
High Comorbidityi | □□□ | These patients are the most likely to remain in a conservative care track due to slow loss of renal function and high probability of death from comorbidity related issues. | |
Medium 3–5 ml/min/1.73 m2 /yearj | |||
Low Comorbidity | ❍❍ | Compared with patients who have a slow RFD, these patients are more likely to require dialysis, especially if starting from an eGFR close to 15 ml/min/1.73 m2 (see Fig. 2). | |
High Comorbidityi | □□ | Due to the relationship between faster RFD and worse survival [23, 36], these patients are likely to die before dialysis is required and therefore remain on a conservative track. | |
Fast >5 ml/min/1.73 m2 /yeark | |||
Low Comorbidity | ❍❍❍ | These patients are the most likely to require dialysis and should be offered all treatment modalities, including renal transplant [2]. | |
High Comorbidity | ⧠⧠ | Likelihood of remaining in conservative track may be low for most patients. Patient and family input with emphasis on a patient’s treatment goals is critical (Fig. 1, Table 2). Short survival on dialysis likely. | |
Acute Kidney Injury (AKI | Defined as patients who have a sudden sustained serum creatinine increase e [3] and most often uses a serum creatinine of ≥ 2x baseline creatinine [51]. Dialysis may in many cases be initiated “early” (eGFR > 10 ml/min/1.73 m2), [50, 52,53,54] and eGFR may overestimate true GFR [7, 52]. | ||
Low Comorbidity | ❍❍ | If patients have renal failure symptoms dialysis may be necessary. Preemptive dialysis, without a conventional dialysis indication, has not been shown to be beneficial [53, 54]. Recovery of renal function should be tracked [81, 82] | |
High Comorbidity | □□ | Non-dialysis management should be considered during joint decision discussions due to a predicted short survival after dialysis initiation. Surrogate decision makers may choose dialysis if patients have not expressed a desire for non-dialysis management [19]. |