Dialysis for everyone? Maurizio Gallieni

Transcription

1 Dialysis for everyone? Maurizio Gallieni Nephrology and Dialysis Unit Ospedale S. Carlo Borromeo, ASST Santi Paolo e Carlo, University of Milano, Milano, Italy

2 Introduction NDT 2004; 19:

3 www. Kidneyresearchuk.org

4 Timing of Dialysis Initiation

5 IDEAL Study: Early vs. Late Start of Dialysis Between 2000 and 2008 Australia / New Zealand 828 adults Early start: egfr cc/min Late start: egfr 5-7 cc/min Mean age 60.4 years Median follow-up 3.6 years Death Most patients (76%) in the late-start group started dialysis when egfr was > 7 ml/min, because of symptoms Cooper BA et al. N Engl J Med 2010;363:

6 IDEAL Study: Early vs. Late Start of Dialysis In this study, planned early initiation of dialysis in patients with stage V CKD was not associated with an improvement in survival or clinical outcomes (QOL) è OK to delay initiation of dialysis (egfr < 7-10 ml/min) è Dialysis initiation should be based upon clinical grounds (symptoms) rather than egfr alone Cooper BA et al. N Engl J Med 2010;363:

7 Conservative care A treatment plan that treats the symptoms of established kidney disease, using medications, lifestyle changes, psychological, social and family support. Conservative care does not replace the work of kidneys. People who decide to have conservative care instead of a kidney replacement therapy often have other medical conditions or are very frail. They often feel that the day-to-day effort of having dialysis does not outweigh its benefits of managing the disease. Some people who choose conservative care will die of another illness before their kidney failure leads to death. For others, the kidney failure will mean people die sooner as a result of their kidney disease.

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9 Dialysis vs. conservative treatment (not a RCT!): Overall survival P < Murtagh et al. NDT 2007; 22:

10 Dialysis vs. conservative treatment: survival in patients with high comorbidities P = n.s. Murtagh et al. NDT 2007; 22:

11 Dialysis vs. conservative treatment: survival in patients with (A) and without (B) ischemic heart disease P = n.s. P < Murtagh et al. NDT 2007; 22:

12 2010; 340: c112 Objective: To synthesise the views of patients and carers in decision making regarding treatment for CKD, and to determine which factors influence those decisions. 18 studies reporting the experiences of 375 patients and 87 carers were included. 14 studies focused on preferences for dialysis modality

13 Components of each theme identified as influencing end stage kidney disease treatment decisions Morton BMJ 2010; 340: c112

14 Views of patients and carers in treatment decision making for CKD There are several potential consequences of having a fistula created before a full discussion of treatment options. 1. Patients risk having surgery for a treatment they do not wish to pursue. 2. The creation of vascular access may mean that a patient believes a treatment choice has already been made for them. 3. Once vascular access is created, patients are especially reluctant to consider other treatments, even to accept a kidney transplant. 4. Although creation of vascular access may be considered a good back-up regardless of treatment preference, to a patient it can be perceived that a treatment choice has been made thereby limiting their consideration and choice of peritoneal dialysis, pre-emptive transplant, or palliative care Morton BMJ 2010; 340: c112

15 Views of patients and carers in treatment decision making for CKD One third of patients with chronic kidney disease receive information about treatment options after starting dialysis, contrary to current clinical guidelines For patients, lifestyle considerations rank higher than medical consequences of specific treatments in their decision making The problematic timing of information about treatment options and synchronous creation of vascular access may predetermine the use of hemodialysis and limit choice of other treatments, including palliative care Patients have a strong preference for the status quo and are reluctant to change treatments, which may help explain why patients often continue with their initial therapy Morton BMJ 2010; 340: c112

16 2012; 184(5): E277 E283 Sydney School of Public Health (Morton, Webster, Howard), the University of Sydney, Australia Patients approaching end-stage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis.

17 Treatment preferences (dialysis v. conservative care) in end-stage CKD Morton et al. CMAJ. 2012; 184(5): E277 E283.

18 Kidney Int. 2015; 88(3):

19 Conceptual framework for supportive care in CKD Davison KDIGO. Kidney Int. 2015; 88(3):

20 Conclusions Patients with advanced CKD have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. We should focus on improving the outcomes of people living with advanced CKD, including those on dialysis This does not imply that dialysis is always the best choice, even if it improves survival. The quality of prognostic tools in CKD should be assessed from the patients perspective, extending beyond survival to include outcomes that matter most to patients and families, such as HRQL

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