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Original ArticlesDialysis
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Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Rachel C. Carson, Maciej Juszczak, Andrew Davenport and Aine Burns
CJASN October 2009, 4 (10) 1611-1619; DOI: https://doi.org/10.2215/CJN.00510109
Rachel C. Carson
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Maciej Juszczak
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Andrew Davenport
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Aine Burns
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  • Figure 1.
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    Figure 1.

    Flowsheet of all incident dialysis patients who were aged ≥70 yr and patients who opted for MCM, showing outcomes, exclusions and patients who were lost to follow-up.

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    Figure 2.

    Kaplan-Meier survival curves. (A) MCM versus all RRT (from day 0). (B) MCM versus all RRT (from day 90). (C) MCM versus RRT emergency referral subgroup versus RRT nonemergency referral subgroup (from day 0).

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    Figure 3.

    Median survival for MCM cohort and the hemodialysis-only subgroup in the RRT cohort. Data shown are how many days were spent hospital-free, compared with in-patient stays in hospital and outpatient hospital attendances for dialysis.

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    Figure 4.

    Literature survey: Summary graph of survival of elderly patients with ESRD in previous studies.

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    Table 1.

    Baseline characteristics and ESRD management

    CharacteristicRRT(n = 173)MCM(n = 29)P
    Age (yr)0.000001
        mean76.481.6
        median75.083.0
    Female (n [%])54 (31.2)12 (41.4)NS
    Diabetes (n [%])51 (29.5)4 (13.8)NS
    Hemoglobin (g/L; mean ± SD)108 ± 15109 ± 13NS
    Albumin (g/L; mean ± SD)34.4 ± 737.4 ± 15.9NS
    Total cholesterol (mmol/L; mean ± SD)4.5 ± 1.34.5 ± 1.0NS
    CCI score (mean ± SD)4.0 ± 1.63.7 ± 1.8NS
    Age-adjusted CCI score (mean ± SD)7.2 ± 1.67.4 ± 1.9NS
    Ethnicity (n [%])NS
        white133 (76.9)21 (72.4)
        blacka18 (10.4)5 (17.2)
        Asianb15 (8.7)3 (10.3)
        unknown7 (4.0)0 (0.0)
    eGFR at start of dialysis (ml/min per 1.73 m2; median)10.8NA
    Length of follow-up from onset of RRT or PDI (mo; median)26.712.9
    Predialysis care (n [%])
        emergency referral52 (30.1)11 (37.9)NS
        nonemergency referral
            early referral (>120 d)91 (52.6)15 (51.7)NS
            late referral (<120 d)30 (17.3)3 (10.3)
    Dialysis modalities (n [%])
        HD only112 (64.7)NA
        HD then switched to PD6 (3.5)NA
        HD then transplant1 (0.6)NA
        PD only42 (24.3)NA
        PD then switched to HD12 (6.9)NA
    • HD, hemodialysis; PD, peritoneal dialysis.

    • ↵a Includes Caribbean, African, and other.

    • ↵b Includes Indian, Pakistani, Bangladeshi, and Chinese.

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    Table 2.

    Survival, rates of hospitalization, and location of death

    ParameterAll RRTNonemergency Referral RRT Subgroup with ≥14 d of Predialysis Nephrology CareEmergency Referral RRT Subgroup with ≤14 d of Predialysis Nephrology CareHD-Only PatientsMCM
    Value%95% CI or P versus MCMValue%95% CI or P versus RRT Emergency ReferralValue%95% CI or P versus MCMValue%95% CI
    n including first 90 d1731215211229
    n excluding first 90 d1481123626
    Survival, mo
        including first 90 d (median)37.80.00341.5<0.00121.733.9<0.00113.9
        excluding first 90 d (median)41.9<0.00143.00.1725.8––14.8
    Rate of hospitalization (days/pt/yr)
        including first 90 d (mean)256.96.8 to 7.0236.26.0 to 6.3–308.17.9 to 8.3164.34.0 to 4.7
         excluding first 90 d (mean)246.56.4 to 6.6226.05.9 to 6.2–277.47.2 to 7.6154.23.8 to 4.5
    For HD-only and MCM patients
        rate of institutionalization, including first 90 d (mean)–––––––17347.54.7 to 4.8164.34.0 to 4.7
    Location of death, n (%)
        Hospital7070.0<0.054567.2––––936.0
        Home or in Hospice2121.01420.9––––1040.0
        Unknown99.0811.9––––624.0
        Total deaths1006725
        OR of dying in hospital4.151.7 to 10.2––––
        RR for dying in hospital1.941.2 to 3.4––––
    Censored/lost to follow-up (n)116.043.000.0
    • RR, relative risk.

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Clinical Journal of the American Society of Nephrology
Vol. 4, Issue 10
1 Oct 2009
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Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?
Rachel C. Carson, Maciej Juszczak, Andrew Davenport, Aine Burns
CJASN Oct 2009, 4 (10) 1611-1619; DOI: 10.2215/CJN.00510109

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Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?
Rachel C. Carson, Maciej Juszczak, Andrew Davenport, Aine Burns
CJASN Oct 2009, 4 (10) 1611-1619; DOI: 10.2215/CJN.00510109
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  • To dialyse or delay: a qualitative study of older New Zealanders perceptions and experiences of decision-making, with stage 5 chronic kidney disease
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  • Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting
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  • Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD
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  • Patient-Centered Care: An Opportunity to Accomplish the "Three Aims" of the National Quality Strategy in the Medicare ESRD Program
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  • The Ethics of End-of-Life Care for Patients with ESRD
  • Quality of Life and Survival in Patients with Advanced Kidney Failure Managed Conservatively or by Dialysis
  • Critical and Honest Conversations: The Evidence Behind the "Choosing Wisely" Campaign Recommendations by the American Society of Nephrology
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