Dialysis was first introduced in the UK in 1956.1 Since then dialysis has become more accessible for patients to be treated who may previously have been declined. The prevalence of advanced kidney disease increases with age. Chronic kidney disease (CKD) is classified into five stages using a modified version of the system which originated in the USA.2 Patients with advanced kidney disease refer to those with late stage 4 and stage 5 CKD.3

The median age of those who commence dialysis in the UK is 65 years.4 More than half of these patients have one or more comorbidities.5 Elderly patients on dialysis have a higher risk of mortality compared to some cancers particularly if they are aged more than 80 years old.6 The expected remaining life years of a patient on dialysis aged 65–69 years is 3.9 years compared  to 17.2 years for an aged matched individual in the general population.7

Deciding not to have dialysis
Patients start being considered for dialysis when their estimated glomerular filtration rate (eGFR) is between 15–20 and decisions are made on which dialysis modality is appropriate for them. The European Best Practice Guidelines recommend that renal replacement therapy should commence when a patient with an eGFR<15ml/min/1.73m2 has symptoms or signs of uraemia, fluid overload or malnutrition in spite of medical therapy or before their eGFR has fallen below 6ml/min/1.73m2 in an asymptomatic patient.8 However for some patients dialysis is not the preferred option.

The 2004 National Service Framework part 1 emphasised the importance of patient choice and the need for education in the phase leading up to potential renal replacement therapy.9 The UK Renal Association outlines the use of predialysis education programmes so that patients can receive adequate information about different treatment modalities including the benefits and burdens of renal replacement therapy and the option of not pursuing dialysis: conservative kidney management.10
What is conservative kidney management? Conservative kidney management is defined as full supportive care for those with advanced kidney disease who have decided with their carers and the clinical team to not commence dialysis.3

The conservative kidney population
Conservative kidney patients tend to be older, have comorbidities and are more likely to have a poor functional status.11 The prevalence of cognitive impairment also increases with advancing renal failure, independent of age and other confounding factors.12 There is increasing awareness however that if patients are conservatively managed it does not mean imminent death13 but a period of stability can be maintained and is often preferred instead of a life being led by regular visits to hospital for dialysis. However conservative care patients do still have significant symptom control needs. Common symptoms experienced include fatigue; itch and drowsiness14 and are comparable to patients with advanced cancer.15

Prognosis
For patients already established on dialysis who are withdrawing from renal replacement treatment, the survival tends to be on average 8–10 days.16 However this is not the same for conservatively managed patients. The prognosis of these patients is variable. The median survival in patients opting for conservative care can vary from six months11 to nearly two years.17 There is increasing evidence that for patients who are over 75 with poor performance status or high comorbidity scores, renal replacement therapy may not have a survival benefit compared to conservative management.18 This is particularly if patients have ischaemic heart disease.19

What does conservative care consist of?
Conservative care management includes continuing to monitor fluid balance, treatment of anaemia, and calcium/phosphorus in a similar way to patients on dialysis to help maintain symptom control and a good quality of life. The framework for implementation highlights the importance of integration with primary care and specialist palliative care and reinforces the importance of multidisciplinary team working with each patient having a key worker ensuring co-ordination of care.3

Anaemia management
Patients with chronic kidney disease are often anaemic due to a deficiency of erythropoietin a protein naturally secreted by the kidneys, which helps to make red blood cells. When other causes of anaemia are excluded erythropoiesis stimulating agents that are similar to erythropoietin may be given as a subcutaneous injection usually monthly or fortnightly by community nurses with the aim of keeping haemoglobin levels between 10 and 12g/dl for adults.20 To maintain iron stores ferritin levels are monitored and intravenous iron may be recommended.

Bone metabolism
The kidney has an integral role with the liver in maintaining the balance of calcium and phosphate by converting vitamin D to the biologically active 1,25-dihydroxycholecalciferol.21 In advanced kidney disease this production declines causing less calcium to be absorbed, which results in the development of high phosphate and low calcium levels that causes parathyroid hormone (PTH) to be released. This hormone draws calcium and phosphate from the bones to try and raise blood calcium levels. Patients are treated with dietary phosphate restriction, phosphate-binding tablets and vitamin D supplementation if necessary. A renal dietician can help develop a dietary plan to control phosphate levels in the blood. 

Advance care planning
The End of Life Care Strategy highlighted the importance of enabling patients to express preferences regarding end of life care including where their preferred place of death might be.22 Conservatively managed patients are more likely to die at home or in a hospice.23 Advance care planning is the process of discussion between an individual and their healthcare professional about their future care needs and wishes.24

Helping patients with advanced kidney disease establish their priorities for end of life care allows them to maintain control over their future care and prepare for their death.25 Completing an advance care plan can help ensure that a patient’s wishes are respected when they no longer have the capacity to be involved in medical decision making. A randomised controlled trial showed that end of life wishes were more likely to be known and followed in the patients who had undertaken advance care planning (86% versus 30%) for patients who were aged over 80 years.26 The process can also enhance rather lessen hope in patients with advanced kidney disease.27

Palliative care
There is increasing recognition of the need for specialist palliative care involvement for conservative care patients. Part 2 of the National Service Framework (NSF) for renal disease in the UK included a quality requirement for end of life care and recommended that patients with advanced CKD should have a jointly agreed palliative care plan with renal networks establishing links with palliative care services.28 A palliative care approach is important not just at the end of life but can also be beneficial through the whole conservative care patient’s journey for symptom management and advance care planning. The gold standards framework prognostic indicator guide (PIG), which was developed for primary care can be used to help identify patients who may benefit from a palliative care approach and includes specific indicators for advanced renal disease.29

Models of care
Conservative care patients may continue to be seen by the renal team or are discharged back to the care of the primary care team. The framework for end of life care in advanced kidney disease reinforces the importance of co-ordination of service delivery between renal units, palliative care services and primary care.3

A useful model that has been established is the development of joint renal palliative care clinics. Patients are able to choose not to dialyse but continue to be regularly reviewed in the same renal clinic by the multidisciplinary team (MDT). The key is that a palliative medicine consultant reviews the patients with input from the renal consultant if needed. There is increasing recognition of the benefits of collaborative working of palliative care teams with the renal teams and the concept of renal palliative care.30 Patients within this model of care gain greater access to palliative care services and are less likely to be admitted to or die in hospital.18 

Conclusion
There is increasing evidence that deciding not to have dialysis may be an appropriate choice especially for elderly patients with multiple comorbid conditions.31 With the projected increase in the number of older people and the growing incidence of diabetes mellitus there will continue to be patients with advanced kidney disease. Recognising their needs and how to manage them will be an important consideration for all healthcare professionals working with elderly patients. The challenge has been to identify those patients for whom conservative management is the most appropriate. However recent research highlights that for patients over 75 years old the survival advantage that dialysis allows is lost if patients have high comorbidity especially ischaemic heart disease19 This should be taken into consideration when discussing with patients and their relatives their choices prior to initiating renal replacement therapy. The question is not whether to dialyse or not, but who would benefit from conservative management care?


Conflicts of interest: none declared
References


1. Brown EA. Epidemiology of Renal Palliative Care. J Palliat Med 2007; 10 (6): 1248–52
2. NICE, Chronic kidney disease. Early identification and management of chronic kidney disease in adults in primary and secondary care. Clinical guideline CG73. 2008; London. http://www.nice.org.uk/guidance/cg73 (accessed 10/12/14)
3. NHS Kidney Care/National End of Life Care Programme. End of life care in advanced kidney disease: a framework for implementation. 2009.
4. Farrington K, Rao R, Gilg J, Ansell D, Feest T. New adult patients starting renal replacement therapy in the UK in 2005 (chapter 3) Nephrol Dial Transplant 2007; 22 (S7): vii11–vii29
5. Tomson C, Udayaraj U, Gilg J, et al. Comorbidities in UK patients at the start of renal replacement therapy (chapter 6). Nephrol Dial Transplant 2007; 22(S7): Suppl 7: vii58–vii68
6. Swidler MA. Geriatric renal palliative care. J Gernontol A Biol Sci Med Sci 2012; 67(12): 1400–1409
7. United States Renal Data Systems Annual Data Report. 2008
8. European Best Practice Guidelines. The initiation of dialysis. Nephrol Dial Transplant 2007; 20 (S9): ix3–ix7
9. Department of Health. The National Service Framework (NSF) for Renal Services Part 1: Dialysis and Transplantation. 2004 https://www.gov.uk/government/publications/national-service-framework-kidney-disease (accessed 10/12/14)
10. Farrington K, Warwick G.Planning,initiating and withdrawal of renal replacement therapy. UK Renal Association 2009; http://www.renal.org/docs/default-source/guidelines-resources/RRT_-_Current_version_-_17_September_2009_FINAL.pdf?sfvrsn=0 (accessed 10/12/14)
11. Smith C, Da Silva-Gane M, Chandna S, et al, Farrington K. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure Nephron Clinc Pract 2003; 95(2) : 40–46
12. Kurella TM, Wadley V, Yaffe K, et al. Kidney function and cognitive impairment in US adults: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Am J Kidney Dis 2008; 52: 227–34
13. Davison SN. integrating palliative care for patients with advanced chronic kidney disease: recent advances, remaining challenges. J Palliat Care 2011; 27(1): 53–61
14. Murtagh FE Addington-Hall JM, Edmonds PE, et al. Symptoms in Advanced Renal Disease: A Cross-sectional survey of symptom prevalence in stage 5 Chronic Kidney Disease Managed without Dialysis J Palliat Med 2007; 10 (6): 1266–76
15. Saini T, Murtagh FE, Dupont PJ, et al. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 2006; 20: 631–36
16. Murtagh F, Cohen LM, Germain MJ. Dialysis discontinuation: quo vadis? Adv Chronic Kidney Dis 2007;14: 379–401
17. Wong CF, McCarthy M, Howse ML, Williams PS.Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 2007; 29: 653–59
18. Hussain JA, Mooney A, Russon L. Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med 2013;. 27(9): 829–39
19. Murtagh FE, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22: 1955–62
20. National Clinical Guideline Centre. Anaemia management in people with chronic kidney disease. London (UK): NICE; 2011 Feb. 38 p. (Clinical guideline; no. 114).
21. Kumar P, Clark M. Clinical Medicine (Eighth ed ): Saunders. Elsevier: 2012
22. Department of Health. End of Life Strategy. 2008. http://www.cpa.org.uk/cpa/End_of_Life_Care_Strategy.pdf (accessed 10/12/14)
23. Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4: 1611–19
24. Royal College of Physicians, National Council for Palliative Care, British Society of Rehabilitation Medicine, British Geriatrics Society, Alzheimer’s Society, Royal College of Nursing, Royal College of Psychiatrists, Help the Aged, Royal College of General Practitioners. Advance care planning. Concise Guidance to Good Practice series No12. 2009; London: RCP
25. Davidson SN, Torgunrud C.The creation of an Advance Care Planning Process for Patients with ESRD. Am J Kidney Dis 2007; 49 (1): 27–36
26. Detering KM, Hancock AD, Reade MC et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340: c1345
27. Davison SN, Simpson C. Hope and advance care planning in patients with end stage renal disease: Qualitative interview study. BMJ 2006; 333 (7574): 886
28. Department of Health. The National Service Framework for Renal Services Part 2: Chronic Kidney disease, acute renal failure and end of life care. 2005
29. Thomas K. The Gold Standards Framework Centre in End of Life Care, 2011; http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/Prognostic%20Indicator%20Guidance%20October%202011.pdf (accessed 10/12/14)
30. Ackroyd R, Russon L. Development of a renal palliative care service. Eur J Pall Care 2010; 17(6): 270–73
31. O’Connor NR. Kumar P. Conservative Management of End-Stage Renal Disease without dialysis: A Systematic review. J Pall Med 2011; 15(2): 228–35