Dialysis: Destination or Journey

The continued poor survival and diminished quality of life for patients treated with dialysis, particularly elderly individuals, is an important health care issue. In this issue of JASN, Vandecasteele and Kurella Tamura propose a change from a process-driven approach to dialysis care to one that incorporates a realistic assessment, in collaboration with the patient, of the relationship between the treatment goals and future outcomes.¹ They argue against the current culture of applying clinical practice guidelines to all patients and challenge the benefits of using biochemical surrogate outcomes. Akin to the revolutionary changes in recent guidelines on cholesterol² and hypertension³ management, they propose that the renal community should change the focus from directives given to physicians to decision-making that incorporates individual patient preferences. For patients with CKD who might require dialysis, the invasive and lifestyle-changing effect of the therapy makes this drive toward improved shared decision-making imperative.

The authors propose that health care providers responsible for the care of these patients should operationalize the proposed new model of care using three patient-centric paradigms.

The first and most familiar of these paradigms is labeled “dialysis as a bridge to transplantation or long-term maintenance.” Patients considered to have a good prognosis and whose goal is transplantation or long-term maintenance dialysis, preferably self-care, would be included in this group. Treatment-specific goals include adherence to stringent treatment targets, similar to those currently used, with the anticipation that this will lead to better long-term health and a sustained ability to engage in professional and private life functioning.

A second identifiable group of patients includes those with a low probability of recovering independent social functioning and those at high risk of imminent death or recurrent hospitalizations. They recommend that these individuals and their families be provided with unbiased information that would allow an informed choice between dialysis therapy and a strategy labeled “active medical management without dialysis.” In practice, this strategy is most applicable to patients with severe dementia and those with poor functional status and high comorbidity. Functional status is an important marker of poor outcomes. Fewer than one third of patients undergoing dialysis and admitted to long-term hospital care ever return home.⁴ Among 3702 nursing home residents in the United States, all of whom had high baseline dependency levels, dialysis initiation was associated with further significant functional decline and a 1-year mortality rate of 58%.⁵ Had these elderly individuals been offered a fully informed option for maximal conservative therapy, would their outcomes have differed? The data are limited to several single-center observational studies, each with unique flaws. The largest of these, from the United Kingdom,⁶ compared the survival of 29 patients (median age, 81.6 years) who chose maximal conservative therapy with that seen in 173 patients (median age, 76.4 years) starting RRT. Although the median unadjusted survival duration was only 13.9 months for the maximal conservative therapy group compared with 41.9 months for the RRT group, the former required fewer days, per patient-year survived, in the hospital (16 days compared with 25) and were four times more likely to die at home or in a hospice compared with those starting RRT.

Despite these data, it remains unclear what is “best.”⁷ The cultural shift within medicine toward patient-centered care⁸ leaves many questions unanswered. We know little of the patients’ experiences, their satisfaction with their lives, or the socioeconomic costs of nondialysis care. Some answers may be provided by an ongoing prospective observational study of dialysis and predialysis patients aged 65 years or older.⁹ This study will address not only survival but also health-related quality of life, economic burden, and comorbidity.

The circumstances under which the elderly initiate long-term dialysis must also be considered. Among 416,657 Medicare beneficiaries age 67 years or older, long-term dialysis was initiated in an inpatient setting in 64.5%; most patients (96.2%) survived to discharge. The patients were divided into five groups, one with outpatient initiation and four defined according to increasing intensity of inpatient care. The median duration of survival of those initiating dialysis as an outpatient was 2.1 years compared with 0.7 years in the group with the most intensive inpatient care.¹⁰ For many of these patients, the discussion that incorporates their preferences will occur after dialysis has been initiated in the setting of AKI.

A third paradigm proposed is “dialysis as a final destination.” Although it is the most likely to be controversial, it is consistent with patient-centered care and personalized medicine. It is also widely applicable to the most vulnerable of our dialysis patients. The authors’ recommendation is that patients who have high levels of comorbidity or unclear prognosis be managed with the understanding that they are undergoing palliative dialysis. These are patients in whom the effects of the disease and the treatments preclude them from integrating back into their social and/or professional environments and who are not eligible for a curative strategy, such as transplantation. “Dialysis as a final destination” would likely be most applicable to a heterogeneous group of individuals, including older patients with poor prognosis who have chosen a trial of dialysis and younger patients with multiple comorbid conditions. It would also include patients previously managed with “dialysis as a bridge to transplantation or long-term maintenance,” who have progressive disease limiting their chances of transplantation and who are unable to resume their previous level of social functioning.

Will this allow us to change our thinking? As we have “improved care standards,” have we merely been slowly substituting a treatment for a disease? In the same way patients with diabetes are rarely renamed as “insulin patients” when they initiate life-long, life-sustaining insulin therapy, perhaps we need to alter how we practice so patients initiating dialysis no longer become “dialysis patients.” Can we prevent the substitution of the treatment for the disease through modifications of our targets and goals of care? The suggestions for “dialysis as a final destination” made in the authors’ Table 2 are modest and argue against using interventions for which there is little supporting evidence or planned clinical trials. They propose reduced attention to protocols used to manage dysphosphatemia, glycemia control, and vascular access. Instead, they advocate the use of protocols that increase psychological support, home care support, and physical rehabilitation. Whether this would improve quality of life by avoidance of treatment-related complications or lead to worse quality of life associated with a reactive rather than a proactive but conservative strategy is unknown.

An editorial in JAMA¹¹ addresses the potential effect of the new guidelines for management of cholesterol and hypertension with the focus on personalized medicine. Three recommendations in that editorial can equally be applied to the management of CKD and dialysis through uptake of these paradigms. The next steps are less clear. As a community we need to determine whether we believe in personalized medicine and, if so, start to evolve in a new direction.

The first recommendation is that informed choice requires strong evidence that can be personalized for patients needing to make a decision. The prospective observational study proposed by Walker and colleagues⁹ should provide much-needed data, particularly for those who might consider “active medical management without dialysis.” Many of the clinical trials that apply to the patients in the “dialysis as a final destination” group have involved single interventions that have failed to affect survival or composite cardiovascular outcomes. This group should be the subject of additional well designed and executed trials, which would include multiple interventions.

The second recommendation is to further evolve tools to help individualize care for patients while simultaneously avoiding inferior medical care. Current tools for shared decision making are being used in other areas of medicine and have been adapted for use in the renal population.^12,13

But the third and perhaps most important recommendation is that we strengthen the patient’s voice. The James Lind Alliance¹⁴ in the United Kingdom is foremost in leading patient-centric research initiatives. They facilitate partnerships across multiple health areas, particularly between patient and clinician, and help prioritize future research directions. In Canada, priority-setting work has started within the renal research community.¹⁵ The top priorities include improving communication between health care providers and the patient and how different modalities of dialysis affect the quality of life of patients and caregivers. However, it remains the ongoing responsibility of health care providers to proactively engage their patients in discussions that encourage and respect the individual patient’s preferences in decisions regarding their health care.

A quotation often attributed to Ralph Waldo Emerson—“Life is a journey, not a destination”—could be applied to dialysis as it is a journey and requires constant re-evaluation over time as circumstances change.

Vandecasteele and Kurella Tamura¹ are to be commended in presenting their thoughts on this subject and for framing it as a proposal that invites thoughtful discussion.

Disclosures

D.N.C. has a consultancy agreement with Amgen Canada Inc. S.V.J. has been a speaker for Amgen Canada Inc. and has received funding from Johnson & Johnson to support a fellowship in Geriatric Nephrology.