Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis

Abstract

Background and objectives: Benefits of dialysis in elderly dependent patients are not clearcut. Some patients forego dialysis, opting for conservative kidney management (CKM). This study prospectively compared quality of life and survival in CKM patients and those opting for dialysis.

Design, setting, participants, & measurements: Quality-of-life assessments (Short-Form 36, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale) were performed every 3 months for up to 3 years in patients with advanced, progressive CKD (late stage 4 and stage 5).

Results: After 3 years, 80 and 44 of 170 patients had started or were planned for hemodialysis (HD) or peritoneal dialysis, respectively; 30 were undergoing CKM; and 16 remained undecided. Mean baseline estimated GFR ± SD was similar (14.0 ± 4.0 ml/min per 1.73 m(2)) in all groups but was slightly higher in undecided patients. CKM patients were older, more dependent, and more highly comorbid; had poorer physical health; and had higher anxiety levels than the dialysis patients. Mental health, depression, and life satisfaction scores were similar. Multilevel growth models demonstrated no serial change in quality-of-life measures except life satisfaction, which decreased significantly after dialysis initiation and remained stable in CKM. In Cox models controlling for comorbidity, Karnofsky performance scale score, age, physical health score, and propensity score, median survival from recruitment was 1317 days in HD patients (mean of 326 dialysis sessions) and 913 days in CKM patients.

Conclusions: Patients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.

Figure 1.

Schematic flow chart depicting study processes. Recruitment took place over 24 months. Quality-of-life (QoL) assessments were continued every 3 months until 12 months after dialysis initiation (dialysis groups) and 3 years or as long as was practical (conservative kidney management [CKM] group) (QoL follow-up period). Patients were followed for an additional period to ensure a minimum of 30 months of follow-up for survival (survival follow-up period). Analysis of QoL and survival data were based on the composition of the modality groups at the end of the QoL follow-up period.

Figure 2.

Adjusted Cox survival functions for patients receiving hemodialysis (HD), peritoneal dialysis (PD), and conservative kidney management (CKM). Adjustments were made for high comorbidity, dependency (Karnofsky performance scale score <70), age older than 75 years, and selection bias. As time progresses, the number of observed events decreases, the modeled events take over, and the curves become more similar.