Original Investigation
Dialysis
Patients Who Plan for Conservative Care Rather Than Dialysis: A National Observational Study in Australia

https://doi.org/10.1053/j.ajkd.2011.08.024Get rights and content

Background

It is unclear how many incident patients with stage 5 chronic kidney disease (CKD) referred to nephrologists are presented with information about conservative care as a treatment option and how many plan not to dialyze.

Study Design

National observational survey study with random-effects logistic regression.

Setting & Participants

Incident adult and pediatric pre-emptive transplant, dialysis, and conservative-care patients from public and private renal units in Australia, July to September 2009.

Predictors

Age, sex, health insurance status, language, time known to nephrologist, timing of information, presence of caregiver, unit conservative care pathway, and size of unit.

Outcomes & Measurements

The 2 main outcome measures were information provision to incident patients about conservative care and initial treatment regardless of planned conservative care.

Results

66 of 73 renal units (90%) participated. 10 (15%) had a formal conservative-care pathway. Of 721 incident patients with stage 5 CKD, 470 (65%) were presented with conservative care as a treatment option and 102 (14%) planned not to dialyze; median age was 80 years. Multivariate analysis for information provision showed that patients older than 65 years (OR, 3.40; 95% CI, 1.97-5.87) and those known to a nephrologist for more than 3 months (OR, 6.50; 95% CI, 3.18-13.30) were more likely to receive information about conservative care. Patients with conservative care as planned initial treatment were more likely to be older than 65 years (OR, 4.71; 95% CI, 1.77-12.49) and women (OR, 2.23; 95% CI, 1.23-4.02) than those who started dialysis therapy. Those with private health insurance were less likely to forgo dialysis therapy (OR, 0.40; 95% CI, 0.17-0.98).

Limitations

Cross-sectional design prohibited longer term outcome measurement. Excluded patients with stage 5 CKD managed in the community.

Conclusions

1 in 7 patients with stage 5 CKD referred to nephrologists plans not to dialyze. Comprehensive service provision with integrated palliative care needs to be improved to meet the demands of the aging population.

Section snippets

Study Design and Participants

We conducted a prospective national survey study of all incident patients with stage 5 CKD (including pre-emptive transplant, dialysis, and conservative-care patients) who were identified during a 3-month period in Australian renal units, the Patient Information about Options for Treatment (PINOT) Study. All adult and pediatric centers and private nephrology practices that contribute to the Australia and New Zealand Dialysis and Transplant Association registry (ANZDATA, www.anzdata.org.au) were

Study Participants

Sixty-six of 73 (90%) Australian renal units participated (Table 1). Ten of 66 (15%) had a formal (written and documented) conservative-care pathway for patients with CKD, and several others were in the process of developing one. Nonparticipating centers included 2 pediatric renal units and 5 small private nephrology practices that managed 30-70 privately insured prevalent hemodialysis patients each. Incident patients from these units would not be expected to differ from those included in the

Discussion

Our study showed that despite only 15% of renal units having a formal conservative-care pathway, two-thirds of patients approaching end-stage kidney disease were presented with information about conservative care as a treatment option. These patients were more likely to be older, have a caregiver, and be well known to their nephrologist compared with patients not presented with this option. One in 7 (14%) of all incident patients with stage 5 CKD planned for conservative care and were more

Acknowledgements

The authors thank the nephrologists and CKD coordinators from Australian renal units who participated in this study.

Support: Ms Morton is supported by National Health and Medical Research Council (NHMRC) grants #457281 and #571372. Dr Turner is supported by NHMRC program grants #402764 and #633003.

Financial Disclosure: The authors declare that they have no other relevant financial interests.

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    Originally published online October 21, 2011.

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