What is the life expectancy of End-Stage Renal Disease (ESRD) patients without dialysis?

Life Expectancy of ESRD Patients Without Dialysis

Without dialysis, patients with end-stage renal disease (ESRD) typically survive between 6 to 23 months, with survival significantly influenced by comorbidities, especially ischemic heart disease. 1

Factors Affecting Survival in ESRD Without Dialysis

Baseline Survival Expectations

• Median overall survival (life expectancy) for ESRD patients choosing not to undergo dialysis is approximately 1.95 years 2
• One-year overall survival rate is about 65% for patients managed conservatively without dialysis 2
• Survival ranges from 6.3 to 23.4 months in various studies of conservative management 1

Comorbidity Impact

• The Stoke comorbidity grade (SCG) is an independent prognostic factor in predicting survival in non-dialytic treatment patients 2
• One-year survival rates by comorbidity grade:
  • Grade 0 (minimal comorbidities): 83%
  • Grade 1 (moderate comorbidities): 70%
  • Grade 2 (severe comorbidities): 56% 2
• The survival benefit of dialysis decreases significantly with increasing comorbidities, particularly ischemic heart disease 1

Age Considerations

• Evidence is mixed regarding whether dialysis prolongs survival in elderly patients compared to conservative management 1
• Elderly patients with multiple comorbidities may experience similar survival with conservative management as with dialysis 1

Conservative Management Approach

Palliative Care Integration

• Conservative management is a reasonable alternative to dialysis, particularly for individuals with:
  • Limited life expectancy
  • Severe comorbid conditions
  • Preference to avoid medical interventions 3
• All patients who choose not to undergo dialysis should receive integrated palliative care 4
• Focus should be on reducing symptom burden and suffering while improving quality of life and well-being 4

Symptom Management

• Patients managed conservatively report a high symptom burden, underscoring the need for concurrent palliative care 1
• Common symptoms requiring management include:
  • Fatigue
  • Sleep disturbances
  • Dyspnea
  • Anxiety
  • Pruritus
  • Xerostomia (dry mouth) 4

Quality of Life Considerations

• Preliminary studies suggest that quality of life may be similar between patients choosing conservative management and those on dialysis 1
• Patients approaching ESRD are often willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis 5
• Patients may forgo up to 7 months of life expectancy to reduce required hospital visits and up to 15 months to increase their ability to travel 5

Decision-Making Process

Shared Decision-Making

• Decisions about dialysis initiation should be made through shared decision-making 3
• Discussions should take place in an open and empathetic manner 4
• Patients should be informed about expected prognosis based on their comorbidity profile 2

Multidisciplinary Approach

• A multidisciplinary team approach is recommended to assist ESRD patients in choosing their modality of treatment 2
• Integration with primary care, community nurses, and palliative care teams enables most treatment to be carried out at home 2
• This approach can allow for a dignified death, with studies showing that 71% of conservatively managed patients who died did so at home 2

Clinical Implications and Recommendations

When to Consider Conservative Management

• Conservative management should be discussed for patients who have:
  • Severely limited life expectancy
  • Low quality of life
  • Refractory pain
  • Progressive deterioration due to an untreatable disease 4

Nutritional and Medical Management

• Patients should be monitored for signs of protein-energy wasting and malnutrition 3
• Blood pressure control and volume management remain important even without dialysis 3
• Vaccination against seasonal influenza, tetanus, hepatitis B, and Streptococcus pneumoniae is advised 3

Unlike withdrawal of dialysis where imminent death is expected, patients who decline dialysis initiation can live for months to years with appropriate supportive care 1. The conservative management approach should focus on maximizing quality of life while managing symptoms effectively.