To the Editor,
Patients undergoing kidney replacement therapy (KRT) experience high symptom and treatment burden, especially when approaching end of life [1]. The last phase of life is accompanied by a decline in health-related quality of life (HRQoL) and increased healthcare utilization [2, 3]. Treatment complications, deteriorated health conditions or changing personal preferences may necessitate patients switching between KRT modalities. Due to the profound impact on patients’ lives, such transitions may contribute to a further deterioration of HRQoL [4–6]. Additionally, an increased mortality risk has been observed shortly after switching from peritoneal dialysis (PD) to haemodialysis (HD) and after dialysis initiation [7, 8]. Especially for patients with limited life expectancy, careful consideration of the negative impact of such a transition against potential benefits is of utmost importance. With the increasingly older and multimorbid KRT population, and analogous challenges in healthcare organization, it is important to gain in-depth insight into KRT transitions in the year preceding death.
Little is known about KRT transitions during this critical phase. In this exploratory analysis we aimed to examine the proportion of patients who underwent a treatment transition, defined as initiation of KRT or switch between KRT modalities, during the year preceding death and to describe the characteristics of these groups of patients per KRT trajectory.
We used the nationwide Vektis database containing all health insurance claims in the Netherlands. We extracted data from all individuals aged >65 years and deceased between 1 June 2016 and 31 December 2021, with a health insurance claim for HD, PD or kidney transplantation (KTx) in the year preceding death. To prevent the inclusion of individuals with transient dialysis needs, we excluded individuals with a dialysis duration of <28 days for incident patients (n = 471). For prevalent patients, we excluded individuals who were receiving dialysis at 12 months before death but had <6 months of dialysis during their final year of life (n = 66). This exclusion criterion was applied to account for cases involving transient kidney failure or individuals who moved abroad during their final year of life. We defined a treatment transition as applicable to individuals who initiated or switched KRT modalities and remained on the selected treatment for at least 4 weeks. KRT trajectories with fewer than 10 individuals were aggregated to ensure anonymity. Our cohort does not include information on dialysis withdrawal or conservative care, as this is not captured in the health claims database. Patient and clinical characteristics were gathered including age, sex, KRT modality and KRT vintage. Comorbidities (hypertension, diabetes mellitus, coronary artery disease, cerebrovascular accident/transient ischaemic attack, peripheral artery disease and malignancy) were derived from claims data, as described by van Oosten et al. [9]. Descriptive statistics were used to summarize the KRT trajectories and patient characteristics. Independent samples t-test and chi-square tests were conducted to compare differences between groups.
We identified 7340 decedents who received KRT in the year preceding death. Mean age was 77.6 ± 6.6 years, with 63% being male and a mean time on KRT of 51 ± 32 months. In total, 6212 (84.6%) deceased individuals underwent KRT for >1 year (i.e. prevalent patients), whereas 1128 patients (15.4%) initiated KRT during the year preceding death (i.e. incident patients).
Figure 1 illustrates the KRT trajectories in the year preceding death. The majority, comprising 78.1% of the decedents (n = 5729), were treated with a single KRT modality throughout the entire year. Among prevalent patients, 474 out of 6212 (7.6%) underwent one treatment modality switch. These transitions across KRT modalities were most frequently observed among prevalent PD patients and KTx recipients, with 14.6% (n = 89) of prevalent PD patients switching to HD and 13.7% (n = 257) of KTx recipients switching to HD and 2.8% (n = 52) to PD, whereas 0.8% (n = 29) of prevalent HD patients switched to PD in the final year of life. Only 56 patients (0.8% of the total cohort) received a kidney transplant in their final year of life (either pre-emptive transplantation or following HD or PD; the sample sizes of these categories were too small to report specifically). Thirty-two patients (0.4%) underwent two treatment transitions. All of these patients had initiated KRT during their final year of life: specifically, 15 incident PD patients subsequently switched to HD, and 17 incident HD patients vice versa. Three treatment transitions were observed in fewer than 10 individuals.
Figure 1:
KRT trajectories during the year preceding death. The left half of the figure illustrates individuals without treatment transitions (n = 5729), while the right half illustrates individuals with one treatment transition (n = 1611). The utmost right lines represent two transitions (n = 15 and n = 17).
Table 1 describes the patients’ characteristics according to their KRT trajectory. Incident patients had a lower age at death than prevalent patients, with a mean age of 76.8 ± 6.0 versus 77.7 ± 6.3 years (P < .0001). Both groups had similar comorbidity burden, except for hypertension and coronary artery disease, which were more prevalent in incident patients (96% vs 88%, P < .0001 and 22% vs 19%, P = .0318, respectively). Regardless of KRT modality (HD, PD or KTx) and treatment status (incident or prevalent), individuals who switched treatment modality were younger than their non-switching counterparts (74.2 ± 5.5 years vs 77.8 ± 5.8 years, P < .0001).
Table 1:
Patient characteristics per KRT trajectory.
| Prevalent patients | Incident patients | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| All modalities | HD | PD | KTx | Not specifieda | Alla modalities | HD | PD | |||||||
| Total study population | No switch | Switch to PD | No switch | Switch to HD | No switch | Switch to dialysis | KTx | No switch | Switch to PD | No switch | Switch to HD | |||
| n = 7340 | n = 6212 | n = 3658 | n = 29 | n = 509 | n = 89 | n = 1562 | n = 309 | n = 56 | n = 1128 | n = 937 | n = 17 | n = 159 | n = 15 | |
| Age, years | 77.6 ± 6.6 | 77.7 ± 6.3 | 79.6 ± 6.6 | 74.7 ± 6.9 | 78.3 ± 6.3 | 77.5 ± 6.5 | 74.4 ± 5.3 | 73.6 ± 5.2 | 74.4 ± 5.3 | 76.8 ± 6.0 | 76.9 ± 6.0 | 76.0 ± 6.1 | 76.8 ± 6.1 | 76.2 ± 6.0 |
| Male sex, n (%) | 4653 (63) | 4518 (73) | 2242 (61) | 15 (52) | 340 (67) | 66 (74) | 996 (64) | 196 (63) | 39 (70) | 759 (67) | 624 (67) | 12 (71) | 114 (72) | 9 (60) |
| KRT duration, months | 51 ± 32 | 59 ± 24 | 53 ± 26 | 34 ± 26 | 39 ± 21 | 37 ± 24 | 78 ± 24 | 75 ± 24 | 37 ± 22 | 8 ± 12 | 8 ± 3 | 8 ± 3 | 7 ± 5 | 7 ± 3 |
| Comorbidities, n (%) | ||||||||||||||
| Hypertension | 6519 (89) | 5439 (88) | 3065 (84) | 26 (90) | 476 (94) | 86 (97) | 1452 (93; | ) 280 (91) | 54 (96) | 1080 (96) | 890 (95) | 17 (100) | 158 (99) | 15 (100) |
| Diabetes mellitus | 3574 (49) | 3015 (49) | 1646 (45) | 18 (62) | 245 (48) | 39 (44) | 863 (55) | 169 (55) | 35 (63) | 559 (50) | 469 (50) | <10 | 75 (47) | <10 |
| CAD | 1430 (19) | 1184 (19) | 704(19) | <5 | 116 (23) | 25 (28) | 243 (16) | 77 (25) | 16 (29) | 246 (22) | 199 (21) | <10 | 37 (23) | <10 |
| CVA/TIA | 753 (10) | 632 (10) | 364(10) | <10 | 64(13) | 10 (11) | 149 (10) | 35 (11) | <5 | 123 (11) | 104 (11) | <5 | 14 (9) | <5 |
| PAD | 2094 (29) | 1781 (29) | 1168 (32) | 12 (41) | 150 (29) | 29 (33) | 310 (20) | 98 (32) | 14 (25) | 311 (28) | 263 (28) | 46 (29) | <5 | |
| Malignancy | 2303 (31) | 1972 (32) | 961 (26) | <10 | 122 (24) | 26 (29) | 734 (47) | 109 (35) | 12 (21) | 330 (29) | 276 (29) | <10 | 43 (27) | <10 |
aThirty-seven patients received HD prior to KTx, 10 received PD prior to KTx and <10 underwent a pre-emptive transplantation. We merged these groups to ensure anonymity.
CAD, coronary artery disease; CVA/TIA, = cerebrovascular accident/transient ischaemic attack; PAD, peripheral artery disease.
This population-based cohort study, using data between 2016 and 2021 among decedents receiving KRT, demonstrated that 15.4% initiated KRT and 7.0% switched KRT modalities in the year preceding death. Two or more KRT transitions in the year prior to death occurred infrequently.
Studies specifically addressing end-of-life KRT switches are lacking in the existing literature. KRT trajectories in a typical year have been analysed in the French registry data of 2019. In the subsequent year, 8% of all HD patients switched to PD or home HD, 2% received a KTx and 20% died. Among PD patients, 38% ceased PD in the subsequent year; 13% switched to HD, 9% underwent KTx and 16% died. Among patients with a functioning transplant, 3% switched to dialysis in the subsequent year and an additional 3% deceased [10]. During the year preceding death, we observed a higher proportion of KTx recipients switching to dialysis. The proportion of HD patients switching to PD was lower in our study, and the number of patients transitioning from PD to HD was similar as reported in a typical year.
Our finding that 22% of patients undergo at least one treatment transition (i.e. initiation or switch) in their final year emphasizes the need for ongoing contemplation by healthcare professionals of whether a patient is approaching the end of life and whether a patient is likely to benefit from such a transition. Conservative care is a viable option worth considering [11]. In particular, the transition from KTx to dialysis may prompt healthcare professionals to carefully consider the possibility of a patient approaching end of life. Advance care planning and discussions about expectations and goals in life are crucial to empower patients to make decisions aligning with their preferences and to optimize end-of-life care [12, 13].
The absence of clinical context and cause of death limited us to evaluate the clinical appropriateness of individual treatment transitions. Furthermore, the composition of our cohort, comprising exclusively deceased individuals, precluded the calculation of survival rates. Nonetheless, given the limited existing information in this area, our findings offer new insights into end-of-life KRT trajectories among patients with kidney failure, which may serve as a starting point for additional exploration. This research letter is a call to further investigate end-of-life KRT trajectories, incorporating the clinical context and patient-relevant outcomes of transitions, and to enhance our understanding of end-of-life care in patients with kidney failure. Further understanding in the dynamics of KRT transitions in the final year of life could potentially assist in refining clinical practices.
ACKNOWLEDGEMENTS
We thank Vektis for providing access to the health claims data. We thank Nefrovisie for data handling and facilitating this analysis. The visual representation accompanying this manuscript was produced by M.S. Zuurmond.
Contributor Information
Micha Jongejan, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, The Netherlands.
Martijn J H Leegte, Dutch Renal Registry, Nefrovisie Foundation, Utrecht, The Netherlands.
Alferso C Abrahams, Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands.
Marjolijn van Buren, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Nephrology, Haga Hospital, The Hague, The Netherlands.
Mattijs E Numans, Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, The Netherlands.
Willem Jan W Bos, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.
Carlijn G N Voorend, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
FUNDING
This work was financed by a grant from Boehringer Ingelheim.
AUTHORS’ CONTRIBUTIONS
The conceptualization of this work was primarily undertaken by C.G.N.V. and M.J. Data analysis was performed by M.J.H.L. and M.J. Critical review of the manuscript was done by M.v.B., A.C.A., W.J.W.B., M.E.N., M.J.H.L. and C.G.N.V. All authors read and approved the final manuscript.
DATA AVAILABILITY STATEMENT
The data underlying is study cannot be shared publicly because they are the property of Vektis, who have restricted public access on grounds of patient privacy. The data is managed by Vektis and subsets of the database are available for researchers after request and under specific conditions. Data are available from Vektis (info@vektis.nl) for researchers who meet the criteria for access to confidential data. Vektis will consider the possibilities of the research proposal and decide to grant access if the research questions can be answered with use of the Vektis data.
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no relevant financial interests. The results presented in this article have not been published previously in whole or part. A.C.A., W.J.W.B. and M.v.B. are conducting a prospective study to compare outcomes between conservative care and dialysis in older patients.
REFERENCES
- 1. Fletcher BR, Damery S, Aiyegbusi OL et al. Symptom burden and health-related quality of life in chronic kidney disease: a global systematic review and meta-analysis. PLoS Med 2022;19:e1003954. 10.1371/journal.pmed.1003954. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Lopes AA, Bragg-Gresham JL, Satayathum S et al. Health-related quality of life and associated outcomes among hemodialysis patients of different ethnicities in the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2003;41:605–15. 10.1053/ajkd.2003.50122. [DOI] [PubMed] [Google Scholar]
- 3. Chambers S, Healy H, Hoy WE et al. Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5. BMC Palliat Care 2018;17:57. 10.1186/s12904-018-0310-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Griva K, Davenport A, Harrison M et al. The impact of treatment transitions between dialysis and transplantation on illness cognitions and quality of life—a prospective study. Br J Health Psychol 2012;17:812–27. 10.1111/j.2044-8287.2012.02076.x. [DOI] [PubMed] [Google Scholar]
- 5. Holvoet E, Verhaeghe S, Davies S et al. Patients’ experiences of transitioning between different renal replacement therapy modalities: a qualitative study. Perit Dial Int 2020;40:548–55. 10.1177/0896860819896219. [DOI] [PubMed] [Google Scholar]
- 6. Dumaine CS, Fox DE, Ravani P et al. Health related quality of life during dialysis modality transitions: a qualitative study. BMC Nephrol 2023;24:282. 10.1186/s12882-023-03330-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Nadeau-Fredette AC, Sukul N, Lambie M et al. Mortality trends after transfer from peritoneal dialysis to hemodialysis. Kidney Int Rep 2022;7:1062–73. 10.1016/j.ekir.2022.02.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Robinson BM, Zhang J, Morgenstern H et al. Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int 2014;85:158–65. 10.1038/ki.2013.252. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. van Oosten MJM, Logtenberg SJJ, Hemmelder MH et al. Polypharmacy and medication use in patients with chronic kidney disease with and without kidney replacement therapy compared to matched controls. Clin Kidney J 2021;14:2497–523. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Cremades A, Moranne O, Couchoud C. Trajectoires des patients en suppléance. Nephrol Ther 2022;18:18/5S–e21–4. [DOI] [PubMed] [Google Scholar]
- 11. Murakami N, Reich AJ, Pavlakis M et al. Conservative kidney management in kidney transplant populations. Semin Nephrol 2023;43:151401. 10.1016/j.semnephrol.2023.151401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol 2006;1:1023–8. 10.2215/CJN.01050306. [DOI] [PubMed] [Google Scholar]
- 13. Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am 2015;99:391–403. 10.1016/j.mcna.2014.11.010. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data underlying is study cannot be shared publicly because they are the property of Vektis, who have restricted public access on grounds of patient privacy. The data is managed by Vektis and subsets of the database are available for researchers after request and under specific conditions. Data are available from Vektis (info@vektis.nl) for researchers who meet the criteria for access to confidential data. Vektis will consider the possibilities of the research proposal and decide to grant access if the research questions can be answered with use of the Vektis data.