Nephrology Care for Patients with Advanced CKD Not Undergoing Dialysis

Boston—There are few available data on how patterns of end-of-life care for patients with advanced chronic kidney disease (CKD) who opt to forgo maintenance dialysis are shaped by prior care from a nephrologist. Susan Wong, MD, MS, and colleagues at the US Veterans Administration (VA) Puget Sound Health Care System, Seattle, Washington, conducted an analysis of data on patients who did not pursue maintenance dialysis prior to death. The researchers reported results of the analysis during a poster session at the NKF Spring Clinical Meetings in a poster titled Nephrology Care in Patients with Advanced Kidney Disease Not Treated with Maintenance Dialysis.

The case series included 812 patients in the VA healthcare system between 2000 and 2011 with advanced CKD who did not pursue maintenance dialysis prior to death. The researchers compared differences in patterns of end-of-life care among patients with advanced CKD (estimated glomerular filtration rate [eGFR], <15 mL/min/1.73 m²) who had no nephrology clinic visits, those who had fewer than four nephrology clinic visits, and those who had four or more nephrology clinic visits during the year prior to cohort entry.

Of the total cohort, 46.8% had no visits to the nephrology clinic, 35.1% had fewer than four visits, and 18.1% had four plus visits. Median time from cohort entry to death for patients who had no nephrology clinic visits was 96 days, compared with 250 days for those who had fewer than four visits and 273 days for those who had four or more visits. Compared with the patients who had no visits to the nephrology clinic, those with four plus visits were more likely to have received a palliative care consultation (66.0% vs 47.1%; odds ratio [OR], 1.76; 95% confidence interval [CI], 1.15-2.7) and be enrolled in hospice care (54.4% vs 31.1%; OR, 2.16; 95% CI, 1.423-3.30) prior to death.

There were no differences in the proportion of patients who were hospitalized or had received an intensive procedure during the final month of  life and had died in a hospital setting. Differences in time for cohort entry to death and rates of hospice enrollment between groups were attenuated in sensitivity analyses and were no longer statistically significant among patients with more rapid decline in eGFR (>1 mL/min/1.73 m²).

In summary, the researchers said, “Receipt of more nephrology care was associated with a longer time between eGFR <15 mL/min/1.73 m² to death and more frequent receipt of supportive care services such as palliative care and hospice, but not in patients with more rapid progression of their CKD. Our findings suggest potential value in initiating advance care planning and active nephrology management upstream in the illness trajectory of patients who are considering not undergoing dialysis.”

Source: Wong S, O’Hare A, Hebert P, Liu C-F. Nephrology care in patients with advanced kidney disease not treated with maintenance dialysis. Abstract of a poster presented at the National Kidney Foundation 2019 Spring Clinical Meetings, May 8-12, 2019, Boston, Massachusetts.