Conservative and Palliative Care in Old Age Individuals with End-Stage Renal Disease

  • Luis Miguel Gutiérrez RobledoEmail author
  • Ricardo Correa-Rotter


In developed countries, trends in adjusted end-stage renal disease incidence rate are displaying a rising trend, particularly in the older age group. These trends pose major challenges to healthcare systems, given the greater healthcare utilization by and more comorbid conditions among elderly adults. Older patients with kidney disease face both a shortened life expectancy and a high symptom burden. They will benefit from early supportive care interventions. The goal of supportive care is to relieve suffering and to support the best possible quality of life for patients and their families, regardless of their stage of disease or the need for other therapies, in accordance with their values and preferences. Developing a patient-centered approach, with a patient-centered care plan, which includes conservative, nondialytic care, is increasingly recognized as an important issue when caring for advanced chronic kidney disease patients, in particular those who are elder and with multiple comorbidities. When treating these patients, unavoidably, ethical issues arise. Current clinical practice guidelines consider some of them, but there is a lack of comprehensive information about the full range of relevant ethical issues in this condition. Palliative care is sometimes referred to as supportive care; its goal is always to achieve the best possible quality of life by controlling symptoms, relieving pain, and restoring functional capacity while respecting the patients personal, cultural, and spiritual beliefs and practices.


Palliative care Conservative and supportive care End-stage renal disease care Advance directives Person-centered care 


  1. 1.
    Zhang Q-L, Rothenbacher D. Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health. 2008;8:117.CrossRefGoogle Scholar
  2. 2.
    Abdulkader RCRM, Burdmann EA, Lebrão ML, Duarte YAO, Zanetta DMT. Aging and decreased glomerular filtration rate: an elderly population-based study. PLoS One. 2017;12(12):e0189935.CrossRefGoogle Scholar
  3. 3.
    2017 USRDS annual data report.Google Scholar
  4. 4.
    Thakar CV, Quate-Operacz M, Leonard AC, Eckman MH. Outcomes of hemodialysis patients in a long-term care hospital setting: a single-center study. Am J Kidney Dis. 2010;55(2):300–6.CrossRefGoogle Scholar
  5. 5.
    Kurella Tamura M, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539–47.CrossRefGoogle Scholar
  6. 6.
    Hsu CY, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008;74:101–7. AKI. [PubMed: 18385668].CrossRefGoogle Scholar
  7. 7.
    Schmitt R, et al. Recovery of kidney function after acute kidney injury in the elderly: a systematic review and meta-analysis. Am J Kidney Dis. 2008;52(2):262–71.CrossRefGoogle Scholar
  8. 8.
    Renal Physicians Association. Shared decision-making in the appropriate initiation of and withdrawal from dialysis. 2nd ed. Rockville: Renal Physicians Association; 2010.Google Scholar
  9. 9.
    Williams AW, Dwyer AC, Eddy AA, Fink JC, Jaber BL, Linas SL, Michael B, O’Hare AM, Schaefer HM, Shaffer RN, Trachtman H, Weiner DE, Falk AR, American Society of Nephrology Quality, Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7:1664–72.CrossRefGoogle Scholar
  10. 10.
    Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transpl. 2011;26:1608–14.CrossRefGoogle Scholar
  11. 11.
    Morton RL, Turner RM, Howard K, Snelling P, Webster AC. Patients who plan for conservative care rather than dialysis: a national observational study in Australia. Am J Kidney Dis. 2012;59:419–27.CrossRefGoogle Scholar
  12. 12.
    Cohen LM, Ruthazer R, Moss AH, Germain MJ. Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol. 2010;5(1):72–9.CrossRefGoogle Scholar
  13. 13.
    Chowdhury R, Peel NM, Krosch M, Hubbard RE. Frailty and chronic kidney disease: a systematic review. Arch Gerontol Geriatr. 2017;68:135–42.CrossRefGoogle Scholar
  14. 14.
    Kurella Tamura M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539–47.CrossRefGoogle Scholar
  15. 15.
    Jassal SV, Chiu E, Hladunewich M. Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med. 2009;361:1612–3.CrossRefGoogle Scholar
  16. 16.
    Gomez AT, Kiberd BA, Royston JP, Alfaadhel T, Soroka SD, Hemmelgarn BR, Tennankore KK. Comorbidity burden at dialysis initiation and mortality: a cohort study. Can J Kidney Health Dis. 2015;2:34. eCollection 2015.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Pugh J, Aggett J, Goodland A, et al. Frailty and comorbidity are independent predictors of outcome in patients referred for pre-dialysis education. Clin Kidney J. 2016;9(2):324–9.CrossRefGoogle Scholar
  18. 18.
    RPA. Shared decision-making in the appropriate initiation of withdrawal from dialysis. Rockville: Renal Physicians Association (RPA); 2010.Google Scholar
  19. 19.
    Warwick G, Mooney A, Russon L, Hardy R. Planning, initiating and withdrawal of renal replacement therapy UK Renal Association 2014.Google Scholar
  20. 20.
    Burns A, Davenport A. Maximum conservative management for patients with chronic kidney disease stage 5. Hemodial Int Int Symp Home Hemodial. 2010;14(Suppl 1):S32–7.CrossRefGoogle Scholar
  21. 21.
    Reindl-Schwaighofer R, Kainz A, Kammer M, Dumfarth A, Oberbauer R. Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5. PLoS One. 2017;12(7):e0181345. Scholar
  22. 22.
    Murtagh FE, Addington-Hall J, Edmonds P, et al. Symptoms in the month before death for stage 5 chronic kidney disease patients managed without dialysis. J Pain Symptom Manag. 2010;40:342–52.CrossRefGoogle Scholar
  23. 23.
    Douglas C, Murtagh FE, Chambers EJ, Howse M, Ellershaw J. Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group. Palliat Med. 2009;23:103–10. Scholar
  24. 24.
    Levin A, Hemmelgarn B, Culleton B, et al. Guidelines for the management of chronic kidney disease. CMAJ. 2008;179:1154–62.CrossRefGoogle Scholar
  25. 25.
    Brown SA, Tyrer FC, Clarke AL, et al. Symptom burden in patients with chronic kidney disease not requiring renal replacement therapy. Clin Kidney J. 2017;10(6):788–96.CrossRefGoogle Scholar
  26. 26.
  27. 27.
    Department of Health, Western Australia. Pathway for renal palliative care services in Western Australia. Perth: Health Networks Branch, Department of Health, Western Australia; 2012.Google Scholar
  28. 28.
    The Lancet Global Health. End-stage kidney disease in LMICs: rising to the challenge. Lancet Glob Health. 2017;5(4):e370.CrossRefGoogle Scholar
  29. 29.
    Bates MJ, Chitani A, Dreyer G. Palliative care needs of patients living with end-stage kidney disease not treated with renal replacement therapy: an exploratory qualitative study from Blantyre, Malawi. Afr J Prim Health Care Fam Med. 2017;9(1):e1–6.CrossRefGoogle Scholar
  30. 30.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Luis Miguel Gutiérrez Robledo
    • 1
    Email author
  • Ricardo Correa-Rotter
    • 2
  1. 1.National Institute of GeriatricsMexico CityMexico
  2. 2.Nephrology DepartmentNational Institute of Medical Sciences “Salvador Zubiran”Mexico CityMexico

Personalised recommendations