In frail elderly patients with advanced Chronic Kidney Disease (CKD), does dialysis improve survival and quality of life compared to conservative care?

Comprehensive Conservative Care Should Be Offered as a Viable Alternative to Dialysis for Frail Elderly Patients with Advanced CKD

For frail elderly patients over 75 years with advanced chronic kidney disease and multiple comorbidities or poor functional status, the survival advantage of dialysis disappears, making comprehensive conservative care a medically appropriate treatment option that reduces hospitalizations and increases the likelihood of home death. 1

Evidence on Survival Outcomes

The KDIGO Controversies Conference explicitly states that the survival advantage of dialysis disappears in patients over 75 years of age with high levels of comorbidity and/or poor functional status. 1 This represents the highest-quality guideline evidence available and should fundamentally reshape treatment discussions for this population.

Key Survival Data:

• Patients aged ≥80 years with high comorbidity burden or poor functional status show no survival benefit from dialysis compared to conservative management 2, 3
• When stratified by age and comorbidity, renal replacement therapy failed to demonstrate survival advantage over conservative management in patients older than 80 years or with WHO performance score ≥3 3
• Annual mortality for dialysis patients exceeds 20%, with 3-year and 5-year survival of only 55% and 40% respectively 4
• Median survival for conservative management ranges from 6-30 months, while dialysis provides 8-67 months, but this difference vanishes in the frail elderly subgroup 5

Quality of Life Considerations

The high level of disability and symptom burden in patients with advanced CKD is not necessarily improved by dialysis. 1 This is a critical point that challenges the default assumption that dialysis improves quality of life.

Quality of Life Evidence:

• Conservative care yields symptom experiences and quality of life compatible with those of patients on dialysis 6
• Hospitalization rates are reduced for patients receiving comprehensive conservative care 1, 2
• Home death rates are increased with conservative care (76% accessed community palliative care vs 0% on dialysis) 3
• Only 47% of conservative management patients died in hospital compared to 69% undergoing dialysis 3
• The majority of dialysis patients die in acute care facilities receiving high-intensity care that may be unwanted 1

Clinical Decision-Making Algorithm

Step 1: Identify High-Risk Patients

Use the "Surprise Question": Would you be surprised if this patient died within the next year? 2

Explicitly offer comprehensive conservative care if the patient has:

• Age ≥75 years AND
• ≥2 of the following: multiple comorbidities, frailty, functional impairment, cognitive impairment, or "no" response to Surprise Question 2

Step 2: Frame Treatment Options Appropriately

Dialysis should NOT be viewed as the default therapy for frail elderly patients. 1 Instead, present both options as medically appropriate:

1. Comprehensive conservative care (chosen or medically advised)
2. Dialysis therapy (with realistic expectations)
3. Time-limited trial of dialysis (for uncertain prognosis) 2, 4

Step 3: Define Comprehensive Conservative Care Components

The KDIGO guidelines provide a specific definition that must include: 1

• Interventions to delay CKD progression and minimize complications
• Shared decision making
• Active symptom management using validated tools (ESAS-R, iPOS-R) 2, 4
• Detailed communication including advance care planning
• Psychological, social, family, cultural, and spiritual support
• Multiprofessional team delivery (nephrologist, nurse, psychosocial worker, dietician, palliative care specialist) 1, 2

Step 4: Implement Systematic Symptom Management

• Regular symptom screening using validated tools 2, 4
• Dietary management with controlled phosphate intake and appropriate protein 2
• Pharmacological support including loop diuretics and sodium polystyrene sulfonate 2
• Management of fatigue, sleep disturbances, dyspnea, anxiety, pruritus 4

Common Pitfalls to Avoid

Do not apply a one-size-fits-all approach - seriously ill patients constitute 20% of the dialysis population with different prognosis and needs 2

Do not focus solely on laboratory values when determining treatment intensity; consider symptoms, functional status, and quality of life 2

Do not initiate dialysis at higher GFR levels - earlier dialysis initiation does not improve survival and leads to greater resource utilization without clinical benefit 2

Do not assume dialysis improves quality of life - the evidence shows symptom burden may not improve and hospitalization rates increase 1, 6, 3

Nuances in the Evidence

While observational studies show dialysis patients generally survive longer than conservative management cohorts 5, 7, this survival advantage disappears when properly stratified by age, comorbidity, and functional status 3. The ethical challenges of randomizing between dialysis and conservative care mean all evidence is observational with inherent biases 1. However, the consistency across multiple international guidelines and cohort studies strengthens the conclusion that frail elderly patients do not benefit from dialysis.

Advance Care Planning Requirements

Execute advance directives to improve documentation of treatment preferences: 2, 8

• Conduct early and ongoing discussions about life expectancy and quality of life
• Document preferences regarding resuscitation and emergency treatments
• Complete medical orders (DNR, POLST)
• Reassess treatment goals when major complications occur
• Offer bereavement support to families 4

When Conservative Care Is Medically Advised

Comprehensive conservative care should be provided as a viable, quality treatment option for patients who are unlikely to benefit from dialysis. 1 This includes frail elderly patients over 75 with multiple comorbidities, poor functional status (WHO performance score ≥3), or high Charlson Comorbidity Index scores 3. The care should be accessible across settings including home, hospital, hospice, and nursing homes 1.