#5794 WHERE DOES THE PATIENT ON CHRONIC RENAL REPLACEMENT TREATMENT DIE?
Authors: Petrosino Anna , Bellardinelli Silvia , Bruno Serena , Porri Maria Grazia , D'alonzo Silvia , Grandaliano Giuseppe , Panocchia Nicola 
Published: June 2023

Abstract

Background and Aims
In the last years, the age of patients on maintenance renal replacement treatment (RRT) became higher and higher. In addition, they have an increasing number of serious comorbidities, such as cardiovascular diseases, diabetes, chronic obstructive pulmonary diseases and peripheric vascular disease. Consequently, there was a rise in hospitalization rate for these patients, nearly achieving 1.48 per person-year, in 2020. One out of 11 hospital discharges among End Stage Renal Disease (ESRD) patients in 2020 was followed by death without re-hospitalization within 30 days. The 5-years survival rate for patients in hemodialysis is 40%, with a median lifespan of 47 months [1]. In the clinical practice, nephrologists use to focus on the complex clinical picture of these patients, but rarely they consider them for palliative care [2]. Nephrology community awareness is growing up concerning palliative care and end-of-life issue, taking into account a simultaneous palliative care, for these patients and their families as well [3].
The aim of the study was to investigate the end-of-life treatment of patients on chronic dialysis.

Method
We analyzed data of patients dead on maintenance renal replacement therapy (RRT) in Policlinico A. Gemelli (Rome), in a five years period from January 2018 to January 2023. We collected relevant data from clinical and administrative records. In particular, we focused on demographic data, comorbidities (Figure 1), causes and places of deaths (home, hospital, hospice). We considered place of death as a surrogate indicator of the use of palliative care.

Results
Ninety four out of 623 patients on maintenance dialysis (15%) died in the 5 years of observation, with a mean age of 73.8 ± 8.9 years (median 76 years) and an average dialytic vintage of 5.9 ± 4.5 years (median 4.4 years). Seventy-three patients died on chronic hemodialysis (68.6%) and 24 patients on peritoneal dialysis (22.6%). None of them died from dialysis withdrawal, and we did not stop RRT close to death in any patient. The main cause of death were cardiovascular diseases (35.6%), followed by sepsis (20.2%) and malignancies (12.5%) (Figure 2). Sudden cardiac death occurred in 7 patients (7.4%), while cachexia in 4 (4.2%). Only 5 patients (4.7%) were considered for palliative care: 4 of them died before the start of palliative treatment and 1 died one month later. Sixty-seven (67.3%) patients died during hospitalization. Only 26 (27.6%) patients died at home and 1% in hospice (n = 1).

Conclusion
The high percentage of in-hospital mortality, the low in-hospice mortality and the absence of mortality due to treatment withdrawal, indicate a lacking of end-of-life recognition in RRT patients. Hence, our experience demonstrates that the use of palliative care in patients on chronic dialysis is still poor and underestimated. Therefore, we need an urgent educational program about end-of-life issue for nephrologists, aiming at an earlier multidisciplinary approach, in order to improve patients’ quality of life and of their end-life.