MO473: Conservative Management in Hospitalized Patients With Advanced Chronic Kidney Disease—A Single Centre 4-Years’ Experience
Authors: Silva Rita , Figueiredo Carolina , Romãozinho Catarina , Sa Helena , Alves Rui 
Published: May 2022

Abstract

BACKGROUND AND AIMS
There is an increasing number of patients with advanced chronic kidney disease (CKD) who are older, frail, with multi-morbidity, and with poor functional status. Renal palliative medicine or kidney supportive care is an evolving branch of nephrology. In medicine, strict respect for the patient's wishes related to their health is essential, but the medical decision to suspend or not initiate treatments considered inappropriate or futile is also crucial, whenever the limits of diagnostic and/or therapeutic intervention dictated by the current state of knowledge are exceeded. There is a need for better evidence about medical management versus dialysis at different ages, to better support our patients in all stages of their renal disease.
The aim of this study was to analyze the applicability and outcomes of a conservative management of advanced CKD in patients admitted to a nephrology ward between January 2018 and December 2021.

METHOD
Retrospective observational study was carried out through the analysis of digital data of all patients admitted to a nephrology ward between January 2018 and December 2021. All the patients included in this study had a decision of therapeutic limitation signed. This was applicable in situations of advanced illness and at the end stage of life, in which the use of extraordinary means for sustaining life may be considered inappropriate, or even a cause of damage. Therapeutic limitation parameters include the artificial route for nutrition, parenteral nutrition, use of vasoactive drugs, transfusions, invasive mechanical ventilation, defibrillators, cardiopulmonary resuscitation and renal function replacement techniques.
Data regarding patients’ baseline characteristics, the Katz Index of independence in activities of daily living, comorbidities, symptoms, laboratory findings, length of hospital stay, treatment regimens and clinical outcomes were collected by consulting electronic medical records.
Statistical analyses were performed using SPSS statistics version 23.0.

RESULTS
A total of 102 patients (female 55.9%) with a mean age of 86 ± 9 (range 55–99) years were selected. Prior to hospitalization, patients were mostly residing in nursing homes (n = 41, 40.2%), followed by their private residences (n = 40, 39.2%) and then continuous care units (n = 16, 15.7%). Diseases of the respiratory tract were the most common causes of hospitalization (n = 21, 20.7%), followed by acute kidney injury/worsening of CKD (n = 20, 19.6%) and heart failure (n = 15, 14.8%).
We defined two groups: patients who died (group 1) and patients who were discharged (group 2). G1 (n = 88; 86.3%) and G2 (n = 14; 13.7%) had similar distributions of gender (female: 50.7% versus 54.9%, P = .081) opposite to age (82.9 ± 9 versus 73.8 ± 10 years, P = .016).
At admission, groups were compared for dementia (62.1% versus 47.4%, P &lt; .001), arterial hypertension (48.3% versus 37.9%, P = .061), diabetes (52.2% versus 37.8%, P &lt; .001), oncologic disease (50.4% versus 26.6%, P &lt; 0.001), hypoalbuminaemia (serum albumin &lt;3.0 g/dL) (57.7% versus 59.9%, P = .056) and Katz Index of independence in activities of daily living &lt;3 points (66.9% versus 62.3%, P = .081).
Dialysis was suspended (n = 89; 87%) or not started (n = 13; 13%) in the number total of patients. A total of 86.3% of patients died (n = 88). The average number of days between the decision to limit therapy and death was 7 days (ranging from 1 to 23 days). The rest of the patients were discharged from the hospital, maintaining the conservative strategy.

CONCLUSION
Currently, we have a group of patients with CKD who are older and have more comorbidities. As demonstrated in our study, conservative management or the suspension of supportive treatment is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life. In fact, it is possible to medically ∼10%–15% of patients with advanced CKD and refer them to a renal palliative care consultation.