Recent findings indicate that, when compared to other developed countries, the United States has many more patients with advanced chronic kidney disease who received, or were preparing to receive, renal replacement therapy (RRT). This finding was true even among the oldest patients with the highest burden of comorbidity, which suggests that decisions about RRT in the U.S. reflect clinical practices favoring interventions to extend patients’ lives.
The study, “Decisions about Renal Replacement Therapy in Patients with Advanced Kidney Disease in the US Department of Veterans Affairs, 2000–2011” was published in the Clinical Journal of the American Society of Nephrology.
RRT includes dialysis (hemodialysis or peritoneal dialysis), hemofiltration, and hemodiafiltration, which are various ways to filter blood with or without a machine. Renal replacement therapy also includes the ultimate form of RRT, kidney transplantation.
The U.S. Medicare program spends more than $30 billion annually to give RRT to advanced CKD patients of any age. However, it is not known what proportion of U.S. patients do not go on to receive RRT. In other developed countries, receiving RRT is highly dependent on a patient’s age; for older patients, RRT is the exception rather than the rule.
In the new study, Susan Wong, MD, University of Washington and colleagues used a U.S. cohort of 28,568 adults who were receiving care within the U.S. Department of Veteran Affairs and had sustained renal disease from 2000 to 2009. The goal was to understand how often patients with advanced CKD do not receive RRT, as well as these patients’ characteristics and how clinical RRT decisions are made.
The researchers linked data from the U.S. Renal Data System, the U.S. Department of Veteran Affairs, and Medicare to identify members who received RRT during follow-up through 2011 (19,165 patients). For the remaining patients, researchers conducted an comprehensive analysis of the medical record for a random 25% sample, with the goal of understanding the course and treatment status of patients’ disease.
The results revealed that about two-thirds (67.1%) of these patients were treated with RRT on the basis of administrative data. When reviewing charts, the researchers estimated that at most recent follow-up, an additional 7.5% of cohort members had received dialysis, that 10.9% were preparing to receive dialysis, and that 14.5% had made a decision not to pursue dialysis.
At most recent follow-up, researchers found, 85.5% of patients were treated or were preparing for RRT treatment. Also, results showed that even among members older than 85 years with the highest burden of comorbidity, the majority (51.2%) were treated or were preparing for RRT.
“Our findings signal more liberal use of dialysis in our study cohort, as compared with other developed countries, with differences being especially striking for older age groups,” Wong said in a news release.
In Canada, researchers estimated that 51.4% of patients with kidney failure, and only 6.8% of those older than 85 years, receive RRT. In New Zealand and Australia, research estimated that 51.2% of patients, and less than 5% of elderly patients, receive RRT.
Recent observational studies conducted in European countries also have raised concerns that dialysis may not meaningfully lengthen survival and is associated with poorer quality-of-life when compared with more palliative approaches, such as hospice, for older patients with significant comorbidity.
“Despite the integration of palliative care into the care of patients with cancer and other chronic diseases, a national policy shift toward patient-centered care, and recognition by nephrology fellows over a decade ago that more palliative care education is needed in their training, Wong, et al. have shown that nephrology practice in the United States has not kept pace,” Jennifer Scherer, MD, from the New York University School of Medicine, and Alvin Moss, MD, from West Virginia University wrote In an accompanying editorial.
“The leaders in the nephrology interdisciplinary community including nephrologists, nurses, social workers, dietitians, and technicians, in collaboration with palliative care clinicians, need to make the implementation of a comprehensive model of renal supportive care delivery a priority for the growing population of older patients with advanced CKD,” they said.