Patients who plan for conservative care rather than dialysis: a national observational study in Australia

It is unclear how many incident patients with stage 5 chronic kidney disease (CKD) referred to nephrologists are presented with information about conservative care as a treatment option and how many plan not to dialyze.

National observational survey study with random-effects logistic regression.

Incident adult and pediatric pre-emptive transplant, dialysis, and conservative-care patients from public and private renal units in Australia, July to September 2009.

Age, sex, health insurance status, language, time known to nephrologist, timing of information, presence of caregiver, unit conservative care pathway, and size of unit.

The 2 main outcome measures were information provision to incident patients about conservative care and initial treatment regardless of planned conservative care.

66 of 73 renal units (90%) participated. 10 (15%) had a formal conservative-care pathway. Of 721 incident patients with stage 5 CKD, 470 (65%) were presented with conservative care as a treatment option and 102 (14%) planned not to dialyze; median age was 80 years. Multivariate analysis for information provision showed that patients older than 65 years (OR, 3.40; 95% CI, 1.97-5.87) and those known to a nephrologist for more than 3 months (OR, 6.50; 95% CI, 3.18-13.30) were more likely to receive information about conservative care. Patients with conservative care as planned initial treatment were more likely to be older than 65 years (OR, 4.71; 95% CI, 1.77-12.49) and women (OR, 2.23; 95% CI, 1.23-4.02) than those who started dialysis therapy. Those with private health insurance were less likely to forgo dialysis therapy (OR, 0.40; 95% CI, 0.17-0.98).

Cross-sectional design prohibited longer term outcome measurement. Excluded patients with stage 5 CKD managed in the community.

1 in 7 patients with stage 5 CKD referred to nephrologists plans not to dialyze. Comprehensive service provision with integrated palliative care needs to be improved to meet the demands of the aging population.