People with advanced kidney disease who received conservative management of their condition had fewer hospitalizations than those who received dialysis.
That’s according to a study presented at the American Society of Nephrology Kidney Week 2022 gathering this week.
The findings haven’t been published yet in a peer-reviewed journal.
In the study, researchers compared hospitalization rates among 309,188 people with advanced kidney disease. All were treated with either dialysis or conservative management between 2007 and 2020.
Around 55 percent of all participants were hospitalized at least once during the study period or before end-of-life. The most common reasons for hospitalization were congestive heart failure/fluid overload, respiratory problems, and hypertension.
The researchers reported:
Non-Hispanic white, non-Hispanic Black, and Hispanic patients receiving dialysis had higher hospitalization rates than those who received conservative management.
People who started dialysis early (higher level of kidney function) had the highest hospitalization rates compared to those who started dialysis at lower levels of kidney function and those who received conservative management.
Asian participants on dialysis had higher hospitalization rates than those receiving conservative management, but participants starting late (lower levels of kidney function) had higher rates than those who started early, especially in the older age groups
Deciding whether to do dialysis
The researchers noted that dialysis might not be the right course of treatment for everyone with advanced-stage kidney disease. Some experts prefer conservative management, which focuses on symptom control and quality of life.
“There are some patients where conservative care could be a better option,” Dr. Udayan Bhatt, a nephrologist at The Ohio State University Wexner Medical Center. “The process of dialysis is quite difficult and there are patients with certain health issues, such as advanced liver disease, who may not be able to tolerate the actual dialysis procedure. In addition, those patients with a life expectancy of fewer than 6 months do not experience any survival advantage with dialysis.”
“There is also compelling data that those above 80, those who are totally disabled, those who have limited self-care ability, and those with extensive medical problems experience no survival benefit with dialysis compared to conservative care,” Bhatt added. “I would strongly consider conservative care for those patients.”
What is chronic kidney disease
Around 37 million adults in the United States have chronic kidney disease.
The condition occurs when the kidneys are damaged and cannot filter waste products from the body, according to the National Kidney Foundation.
The deterioration can occur over a long period and many people do not have symptoms until their disease is advanced.
Some people might notice signs, such as:
Muscle cramping, especially at night
Swollen feet and ankles
Puffiness around eyes
Dry, itchy skin
Need to urinate more often
There is no cure for chronic kidney disease, a progressive condition that tends to worsen with time. A person may be able to slow the progression by managing their blood pressure and if they have diabetes, their blood glucose.
If your kidney function continues to decline and reaches less than 15 percent of normal kidney function, you are in kidney failure, according to the National Diabetes and Digestive and Kidney DiseasesTrusted Source.
There are three treatment options for kidney failure:
Peritoneal dialysisTrusted Source
“Most people with advanced kidney disease choose dialysis,” Jennifer Prescott, RN, MSN, owner of Blue Water Homecare in Texas, told Healthline. “Dialysis has many benefits. However, it can be challenging for the person and family. Side effects can include blood clotting issues, skin issues, infection, low blood pressure, muscle cramping, nausea, and nutritional deficiencies.”
What is conservative management
Dialysis or transplant are not the right choices for some people and they might instead choose conservative management, according to UPMC.
“The goal of conservative care includes preserving kidney function as long as possible using medication and diet,” Prescott explained. “Palliative care can be a part of conservative care. During palliative care, we focus on managing symptoms, such as nausea, vomiting, poor appetite, lack of energy, and the psychological impacts of the disease.”
This path focuses on symptom management and quality of life. It might benefit older patients and those who have life-threatening comorbidities, such as cancer. The goal is to prolong life and improve day-to-day life.
“The option for conservative care can occur at any point in a patient’s life. They can make that decision well before dialysis is considered,” Bhatt explained. “Initially, patients who choose conservative care are managed similarly to those who choose dialysis. However, as symptoms worsen, they are managed medically instead of moving to dialysis. Some patients can survive a long time without dialysis. Their survival time is likely affected by underlying health issues.”
A conservative management team typically includes a nephrologist, primary care physician, nurse, dietitian, pharmacist, counselor or social worker, and spiritual advisor, if requested. This type of care directly involves the patient in decisions and advance care planning.
One review of studiesTrusted Source reported that most people utilizing conservative management lived for several years after the decision to forgo dialysis. Their physical, mental, and quality of life improved over time or remained stable until late in their illness.
As with the current study, the review found that those who chose conservative management spent less time in the hospital than those on dialysis.
During conservative management, patients may receive the following:
Medical management of conditions caused by kidney disease, such as anemia
Medical management of conditions that cause kidney diseases, such as high blood pressure and diabetes
Treatment of vitamin deficiencies or build-ups, such as phosphates, iron, calcium, and vitamin D
Psychological and spiritual counseling
Treatment for anxiety
Treatment for nausea, including non-pharmaceutical interventions when possible and pharmaceutical interventions when necessary
Help with advance planning
“The last phase of care for someone with advanced kidney disease is hospice care. During hospice care, there is a shift from cure to caring,” Prescott explained. “Symptom control is the most common focus of hospice care and supporting the person and the family. The most common symptoms include fatigue (due to anemia), breathlessness, pain, and itching. The hospice team consists of a hospice and palliative care physician specializing in care for people at the end of life. This physician understands the complexity of kidney disease and can prescribe medications best suited for someone with this type of disease. The other members include an RN, hospice aide, chaplain, social worker, and volunteer.”
“It is helpful to have ongoing conversations with your nephrologist and care team to determine the best management modality for your situation,” Prescott added. “Many find benefits to a more conservative approach to care focusing on the quality of life vs. quantity of life.”
The status of kidney disease care in the United States
The authors of the study noted that the United States lags behind other countries in offering conservative care to advanced-stage kidney patients.
Bhatt believes one of the reasons is that healthcare resources, such as dialysis, are more available in the United States.
“In countries where healthcare resources are more finite than in the U.S., decisions of care options are made by economics and outside of the doctor-patient environment,” Bhatt explained. “Therefore, dialysis may not even be an option for patients in some countries. But I don’t think that is the entire answer.”
“Patients who regret the decision to pursue dialysis report a number of factors related to family and doctor-patient relationships that impacted their decision to choose dialysis over more conservative care,” he added. “I think that we, as healthcare providers can educate our patients better on the actual process of dialysis.”
“There is a myth, even among healthcare providers, that dialysis is a treatment you get three times per week for a few hours, and the rest of the time, you are back to normal,” he added. “That is far from accurate. Many patients have complications associated with dialysis itself (shortness of breath, nausea, headaches, massive blood pressure fluctuations, etc.) that can make the treatment and the time between treatments very difficult. Educating the patients is something that we can always work on to improve.”