Abstract and Introduction
Background: Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice.
Methods: Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions.
Results: A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m2 ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted.
Conclusions: Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.
Dialysis is the most frequently chosen treatment for patients with kidney failure. Current guidelines recommend presenting comprehensive conservative care (CC) as a treatment alternative to vulnerable patients.[1,2] CC captures a range of pharmacological, clinical and lifestyle interventions, except dialysis, to delay the progression of kidney disease, minimize risks and complications and provide active symptom management and psychosocial support. Although CC is generally more focused on maintaining health-related quality of life (HRQoL) than potentially increasing survival, reliable estimation of the survival outcomes of both CC and dialysis might help to inform patients and healthcare professionals in shared decision making.
Previous attempts have been made to systematically compare survival data for kidney failure patients choosing between dialysis and CC.[3–6] Most recent reviews suggest a survival benefit for dialysis over CC but highlight the heterogeneity of included studies.[5,6] Comparability between both groups is hampered due to confounding by indication, which occurs when CC is more often chosen by or offered to patients deemed to have a worse prognosis, e.g. older or more frail patients. Additionally, the start of CC is difficult to define compared with dialysis, potentially resulting in selection bias. Using both the explicit treatment decision and aligning the starting point for survival analysis is therefore critical.
The aim of this systematic review was to compare the survival of patients with kidney failure who made an explicit choice for a dialysis pathway versus CC, e.g. excluding studies where dialysis was withheld on medical grounds, in line with a recently published systematic review on HRQoL. Additionally, we looked at subgroups of patients >80 years of age and those with severe comorbidity and frailty. We aimed at including studies that evaluated outcomes from predefined time points, preferably the moment of treatment decision, as an equivalent time point for treatment start itself is difficult to identify in both treatment pathways.
Nephrol Dial Transplant. 2022;37(8):1529-1544. © 2022 Oxford University Press