Does the Evidence Support Conservative Management as an Alternative to Dialysis for Older Patients with Advanced Kidney Disease?

There is ongoing debate whether older adult patients with stage 5 CKD gain survival advantagewhen treated with dialysis comparedwith conservative management. Comprehensive conservative management that is chosen or medically advised (1) focuses on optimizing quality of life and is recommended by international experts in the field to include advance care planning, provision of symptom and painmanagement, coordinated end of life care, timely hospice care, psychologic and bereavement support, and a multidisciplinary approach (2–4). Clinical practice guidelines suggest that dialysis may impose considerable burden (5). Furthermore, dialysis may not offer a survival advantage or an improvement in functional status or quality of life among older patients with stage 5 CKD, especially those living with a high burden of comorbidities, functional impairment, or chronic malnutrition (5). Compared with conservative management, dialysis is associated increased hospitalization and reduced likelihood of dying at home or in a hospice (6). When adult patients nearing stage 5 CKDwere asked about tradeoffs between treatment options, they reported willingness to trade considerable life expectancy to reduce the burdens of dialysis treatment. For instance, patients were willing to forgo 7 months of life expectancy to reduce hospitalization and forgo 15months of life expectancy to increase their ability to travel (7). The issue of whether to support or resist conservative care is particularly pertinent in countries where dialysis is widely available, including the United States, European countries, Canada, and Australia. Patients not treated with dialysis may or may not receive comprehensive conservativemanagement. In theUnitedStates, the number of incident cases of dialysis treatment among patients with stage 5 CKD ages $75 years old seems to be stable over the past decade, despite the increasing incidence 10–20 years ago (8,9). In European countries, approximately 20%–45% of incident patients treatedwith dialysis are people ages$75 years old (10). In Canada, almost 30% of incident patients treatedwith dialysis are patients ages $75 years old, the age group with the highest incidence rate of people treated with dialysis in the country (11). People ages 75–84 years old in Australia have the highest incidence rate of people treated with dialysis (12). However, in both Canada andAustralia, dialysis treatment rates are substantially lower for people ages$85 years old (13,14) (e.g., about 95% of people ages $85 years old with kidney failure in Australia are not treated with dialysis [14]). In this issue of the Clinical Journal of the American Society of Nephrology, Verberne et al. (15) compared survival of older patients with stage 5 CKD treated with dialysis with survival of those on conservative management in a retrospective single–center cohort study from TheNetherlands. Using data that included patients ages $70 years old over the period of a decade (2004–2014), Verberne et al. (15) reported on 204 patients who were treated with dialysis (although four people underwent renal transplantation, three of which had a transplant after dialysis) and 107 patients who were treated with conservative management. Survival analysis was conducted using the Kaplan–Meier method with varying starting points (e.g., from time of treatment decision and different eGFR cutoffs, including ,20, ,15, and ,10 ml/min per 1.73 m2). They found a higher overall median survival for patients treated with dialysis compared with those treated with conservative management, regardless of the starting point (e.g., from time of treatment decision: 3.1 [interquartile range (IQR), 1.5–6.9] years for the dialysis group compared with 1.5 [IQR, 0.7–3.0] years for the conservatively managed group; P,0.001) (15). This survival advantage observed from the dialysis groupwas substantially reduced in patients with cardiovascular comorbidity and those with higher comorbidity in general (Davis comorbidity scores $3).A statistically significant survival advantagewasno longer observed between the treatment groupswhen focusing onpatientswhowere ages$80 years old, regardless of the starting point. For example, among patients ages $80 years old, the median survival from time of treatment decision for the dialysis group was 2.1 (IQR, 1.5–3.4) years comparedwith 1.4 (IQR, 0.7–3.0) years for the conservatively managed group. Verberne et al. (15) also considered rate of decline in eGFR and observed that the dialysis group sustained its survival advantage among patients with rapid or slow eGFR decline. A recent systematic review (16) on survival outcomes of dialysis therapies versus conservative care among older adult populations found no meaningful differences. Foote et al. (16) reported that the annual *Department of Community Health Sciences and Department of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada