Outcomes of patients in a pre-dialysis clinic and implications for shared decision making

The association of end-stage kidney disease (ESKD) with poor outcomes is well recognized. Education and discussions with patients with advanced chronic kidney disease (CKD) are important to facilitate shared decision making regarding care.

This study reports longitudinal follow-up of all patients who attended the Advanced Kidney Care Service (AKCS) in a tertiary renal centre in the UK. Patients are routinely referred to AKCS once their estimated glomerular filtration rate (eGFR) drops below 20 mL/min/1.73 m². A total of 1957 patients who first attended between September 2011 and September 2018 were included, with a minimum of 5 years follow-up to 30 September 2023.

During follow-up, 55.7% of the cohort commenced renal replacement therapy (RRT), the initial modality was haemodialysis in 57.2%, peritoneal dialysis in 27.3% and a pre-emptive transplant in 15.5%, of which 42.6% were from live donors. Conservative management was chosen by 17.9% of patients. Of those who had opted for RRT, 26.7% died before reaching it. The 5-year survival was 49.6% from first attendance at AKCS. The 5-year survival rates by age group were: <50 years, 84.2%; 50-64 years, 66.1%; 65-79 years, 40.1%; and ≥80 years, 22.3% (P < .001). The 5-year survival on haemodialysis was 49.6%, peritoneal dialysis 54.7% and 92.3% for pre-emptive transplant 92.3%. For those over 80 years of age a modest survival benefit was seen with RRT, with a median survival of 17.4 months from RRT commencement, compared with 11.8 months once the eGFR declined below 10 mL/min/1.73 m² in the conservative group.

This study highlights the high competing mortality in an advanced CKD cohort. The high rates of pre-emptive transplantation and peritoneal dialysis initiation demonstrate the benefits of a structured AKCS strategy. Older patients with ESKD, particularly those aged over 80 years, have poor outcomes, regardless of whether they choose RRT or conservative management.