Temporal Trends in Decisions to Forgo KRT

After decades of rise, dialysis initiation rates are now declining. In parallel, conservative kidney management has emerged as an important therapeutic alternative to dialysis. However, contemporary trends in patients opting to forgo dialysis are poorly understood.

This retrospective cohort study included adults with advanced kidney disease as defined by ≥2 outpatient measures of estimated glomerular filtration rate ≤15 mL/min/1.73m2 for ≥90 days, who were receiving care in a large US health system between 2012-2020. Patients were followed through death or December 31, 2022. Administrative codes were used to identify patients who received KRT during follow-up. For remaining patients, documentation in their clinical progress notes was reviewed to determine the KRT decision made closest to the end of follow-up. Descriptive analyses evaluated trends in the distribution of treatment decisions made in 3-year periods (2012-2014, 2015-2017 and 2018-2020) and stratified by age group (<65, 65-74, 75-85, and ≥85 years).

Among the 12,678 patients in the cohort (age 66±15 years, 49% non-Hispanic White, 52% male), 90% received KRT based on either administrative codes or chart documentation, 4% had been discussing and/or preparing for KRT, and 6% decided against KRT over a median follow-up of 3 (1-5) years. The distribution of KRT decisions did not meaningfully change over time. The proportion of patients in 2012-2014, 2015-2017 and 2018-2020 who went on to be treated with KRT was 90%, 91% and 90%, respectively. Across the same time periods, 7%, 6% and 6% of patients had forgone KRT. The distribution of KRT decisions remained stable for all age groups over time.

Forgoing KRT is uncommon. Over the recent decade, most patients approaching kidney failure receive or are preparing to receive KRT, underscoring its continued use as a default approach to kidney failure care.