Global Variation in Predictors of Uptake of Conservative Kidney Management: A Systematic Review and Meta-Analysis

For older people and those with more comorbidities, kidney replacement therapy may not offer a mortality benefit. Conservative kidney management represents an alternative treatment pathway for kidney failure without dialysis.

To identify the clinical and socioeconomic factors associated with choosing a non-dialysis care pathway and to explore geographical variation.

MEDLINE, Embase and Web of Science databases were searched. Studies, which included patients with kidney failure choosing non-dialysis care and a comparator group of patients preparing for or receiving kidney replacement therapy, were selected. Exposures included clinical and socioeconomic factors. The outcome was a choice to have non-dialysis care. Random-effects meta-analysis was performed; with subgroup analysis by region.

In total 43 studies, including 51,872 participants, were selected. Female sex was associated with choosing non-dialysis care (pooled OR 1.47, 95% CI 1.26-1.71). There was no overall association between non-white ethnicity and treatment choice in Western countries. However, in North America non-White groups had lower odds of receiving non-dialysis care compared to white patients (OR 0.70, 95% CI 0.60-0.81). Socioeconomic deprivation was associated with choosing non-dialysis care in Asia, as was low educational attainment (OR 2.85, 95% CI 1.54-5.26). There was an overall association between living alone and non-dialysis care (pooled OR 1.55, 95% CI 1.24-1.93).

The geographical variation in these results highlights the importance of social and political context in understanding treatment access. We identify living alone and low socioeconomic status as possible predictors of choosing non-dialysis care. This analysis cannot ascertain if these associations arise from appropriate shared decisions, challenges to the decision making process or barriers to accessing kidney replacement therapy. Nevertheless, this review illustrates the interplay of socioeconomic, interpersonal and systemic factors at play and lays the foundation to unravelling these complexities.