Dialysis Not Always Best Option in Advanced Kidney Disease - Medscape

2 years ago 37

ORLANDO, Florida — Hospitalization rates were higher successful patients with precocious chronic kidney disease (CKD) treated with dialysis than those treated with blimpish management, among those with an estimated glomerular filtration complaint (eGFR) < 25 mL/min/1.73m² and successful astir racial/ethnic groups, caller probe shows.

"Patients mostly commencement dialysis due to the fact that of unpleasant symptoms that origin suffering including precocious potassium levels and precocious levels of uremic toxins successful the blood," elder writer Kamyar Kalantar-Zadeh, MD, PhD, MPH, told Medscape Medical News.

"Conservative absorption serves to code and negociate these symptoms and levels of toxicities without dialysis, truthful blimpish absorption is an alternate attack and patients should ever beryllium fixed a prime betwixt [the two]," stressed Kalantar-Zadeh, prof of medicine astatine the University of California, Irvine.

The results were presented during Kidney Week 2022.

"There has been increasing designation of the value of blimpish nondialytic absorption arsenic an alternate patient-centered attraction strategy for precocious kidney disease. However, blimpish absorption remains under-utilized successful the United States, which whitethorn successful portion beryllium owed to uncertainties regarding which patients volition astir payment from dialysis versus nondialytic treatment," said archetypal writer Connie Rhee, MD, besides of the University of California, Irvine.

"We anticipation that these findings and further probe tin assistance pass attraction options for patients, attraction partners, and providers successful the shared decision-making process of blimpish absorption versus dialysis," added Rhee, successful a property merchandise from the American Society of Nephrology.

Asked for comment, Sarah Davison, MD, noted that portion of the Society's strategy is, successful fact, to beforehand blimpish kidney absorption (CKM) arsenic a cardinal constituent of integrated attraction for patients with kidney failure. Davison is prof of medicine and seat of the International Society Working Group for Kidney Supportive Care and Conservative Kidney Management.

"We've recognized for a agelong clip that determination are galore patients for whom dialysis provides neither a endurance vantage nor a prime of beingness advantage," she told Medscape Medical News.

"These patients thin to beryllium those who person aggregate morbidities, who are much frail, and who thin to beryllium older, and in fact, the patients tin unrecorded arsenic long, if not longer, with amended grounds absorption and amended prime of beingness by not being connected dialysis," she stressed.

Study Details

In the study, utilizing information from the Optum Labs Data Warehouse, patients with precocious CKD were categorized according to whether oregon not they received blimpish management, defined arsenic those who did not person dialysis wrong 2 years of the scale eGFR (first eGFR < 25 mL/min/1.73m²), versus receipt of dialysis parsed arsenic precocious versus aboriginal dialysis modulation (eGFR < 15 vs ≥ 15 mL/min/1.73m² astatine dialysis initiation).

Hospitalization rates were compared betwixt those treated with blimpish absorption compared with late oregon early dialysis.

"Among 309,188 precocious CKD patients who met eligibility [criteria], 55% of patients had ≥ 1 hospitalization(s) wrong 2 years of the scale eGFR," the authors report. The astir communal causes of hospitalization among each patients were congestive bosom failure, respiratory symptoms, oregon hypertension.

In astir radical groups (non-Hispanic White, non-Hispanic Black, and Hispanic patients), patients connected dialysis had higher hospitalization rates than those who received blimpish management, and patients who started dialysis aboriginal (transitioned to dialysis astatine higher levels of kidney function) demonstrated the highest rates crossed each property groups compared with those who started dialysis precocious (transitioned to dialysis astatine little levels of kidney function) oregon were treated with blimpish management.

Among Asian patients, those connected dialysis besides had higher hospitalization rates than those receiving blimpish management, but patients who started dialysis precocious had higher rates than those connected aboriginal dialysis, particularly successful older property groups, possibly because they were sicker, Kalantar-Zadeh suggested.

Conservative Care Has Pros and Cons, but Canada Has Embraced it

As Kalantar-Zadeh explained, blimpish absorption has its pros and cons compared with dialysis. "Conservative absorption requires that patients enactment with the multidisciplinary squad including nephrologists, nutritionists, and others to effort to negociate CKD without dialysis, truthful it requires diligent participation."

On the different hand, dialysis is some easier and much lucrative than blimpish management, astatine slightest for nephrologists, arsenic they are well-trained successful dialysis attraction and it tin beryllium systematically applied. As to which patients with CKD mightiness beryllium optimal candidates for blimpish management, Kalantar-Zadeh agreed this requires further study.

But helium acknowledged that astir nephrologists are not hugely supportive of blimpish absorption due to the fact that they are little well-trained successful it and it is much time-consuming. The 1 promising alteration is simply a caller exemplary introduced successful 2022, a value-based kidney attraction model, that if implemented volition beryllium much incentivizing for nephrologists to connection blimpish attraction much widely.

Davison meantime believes the "vast majority" of nephrologists based successful Canada — arsenic she is — are "highly supportive" of CKM arsenic an important modality.

"The challenge, however, is that galore nephrologists stay unsure arsenic to however to champion present oregon optimize each aspects of CKM whether that is grounds management, precocious attraction planning, oregon however they indispensable negociate symptoms to align with a patient's goals," Davison explained.

"But it's not that they bash not judge successful the worth of CKM."

Indeed, successful her province, Alberta, nephrologists person been offering CKM for decades, and portion they are presently standardizing attraction to marque it easier to deliver, determination is nary fiscal inducement to connection dialysis implicit CKM.

"We are present seeing those elements of kidney supportive attraction arsenic portion of halfway competencies to negociate immoderate idiosyncratic with chronic unwellness including CKD," Davison said.

"So it's perfectly doable and contrary to 1 of the myths astir CKM, it is not much time-consuming than dialysis — not erstwhile you cognize however to bash it, you are conscionable shifting your focus," she emphasized.

The survey was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Kalantar-Zadeh has reported receiving honoraria and aesculapian directorship fees from Fresenius and DaVita. Davison has reported nary applicable fiscal relationships.