Study: More Liberal Use of Renal Replacement Therapy in US Compared with Other Developed Nations

In most developed countries, receipt of renal replacement therapy (RRT) is highly age-dependent and is the exception rather than the rule, but a new study indicates that most US patients with advanced chronic kidney disease (CKD)—even the oldest patients with the highest burden of comorbidity—have likely already received or are preparing to receive RRT. The study, which assessed a national cohort of patients within the Department of Veterans Affairs (VA), is published in the Clinical Journal of the American Society of Nephrology.

The US Medicare Program spends more than $30 billion annually to provide maintenance dialysis and kidney transplantation to more than 400,000 Americans with advanced chronic kidney disease, and the annual incidence of such RRT in the US is severalfold higher than in many European nations. Investigators have wondered whether this higher incidence reflects a greater burden of kidney disease or differences in treatment practices.

To look into the issue, Susan Wong, MD, of the University of Washington and her colleagues conducted a retrospective study that included 28,568 patients with very advanced CKD who were receiving care within the VA between 2000 and 2009. Using a combination of linked administrative data from the VA, Medicare, and the United States Renal Data System, the researchers identified patients who received RRT through October 1, 2010. For a 25% sample of the remaining patients, the researchers performed an in-depth review of VA-wide electronic medical records to understand the clinical course and treatment status of patients’ CKD.

Administrative data revealed that 67.1% of cohort members received RRT. Based on the results of chart review, the team estimates that an additional 7.5% of cohort members had in fact received at least one dialysis treatment not captured in administrative data, 10.9% were discussing and/or preparing for dialysis but had not yet started dialysis at the end of follow-up, and a decision had been made not to pursue dialysis in 14.5% of patients.

The results indicate that at most recent follow-up, the overwhelming majority (85.5%) of patients had either received, or were preparing to receive, RRT. Even among those aged ≥85 years with the highest burden of comorbidity, most received or were preparing to receive RRT at the last follow-up point; 41.1% of these patients were actually treated with RRT.

“Our findings signal more liberal use of dialysis in our study cohort as compared with other developed countries, with differences being especially striking for older age groups,” said Dr. Wong. In Canada, investigators estimated that 51.4% of patients with kidney failure, and only 6.8% of those ≥85 years, are treated with RRT. In New Zealand and Australia, an estimated 51.2% of patients, and <5.0% of elderly patients, are treated with RRT.

“Life expectancy after initiation of maintenance dialysis in very old patients is severely limited, and older patients experience high rates of hospitalization and transition to assisted nursing facilities after initiation of treatment,” Dr. Wong explained. Recent observational studies conducted in European countries have also raised concerns that dialysis may not meaningfully lengthen survival and is associated with poorer quality-of-life compared with more palliative approaches, such as hospice, for older patients with significant comorbidity. “Our findings underscore the importance of shared decision-making for dialysis to ensure that treatment decisions uphold the priorities and preferences of individual patients and are grounded in realistic expectations about prognosis and the expected benefits and harms of this treatment,” said Dr. Wong.

Jennifer Scherer, MD, of NYU School of Medicine, and Alvin Moss, MD, of West Virginia University, noted in an accompanying editorial that the study issues a call to action to the nephrology community, stressing that changes are needed concerning dialysis decision-making with older patients who have advanced CKD.

“Despite the integration of palliative care into the care of patients with cancer and other chronic diseases, a national policy shift towards patient-centered care, and recognition by nephrology fellows over a decade ago that more palliative care education is needed in their training, Wong et al. have shown that nephrology practice in the United States has not kept pace,” Drs. Scherer and Moss wrote. “The leaders in the nephrology interdisciplinary community including nephrologists, nurses, social workers, dietitians, and technicians, in collaboration with palliative care clinicians, need to make the implementation of a comprehensive model of renal supportive care delivery a priority for the growing population of older patients with advanced CKD.”

October/November 2016  (Vol 8, Issue 10/11)