Letter: Clinicians debate use of medical management without dialysis
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To the edior: After reading your Cover Story on medical management without dialysis in the January 2021 issue, I reviewed two recent articles that point to gaps in knowledge in the kidney community about implementing this modality option.
The first study, by Lunney and colleagues, reviews results from the 2018 Global Kidney Health Atlas (GKHA) survey of conservative kidney management (CKM) and reveals there is still a long way to go to make CKM available in North America and globally. The GKHA surveyed informants from countries around the world as to whether CKM was “generally available” in their country, defined as being available at 50% or more of hospitals and clinics in their country.
On the five elements of CKM measured in the survey, the region including North America and the Caribbean had large deficits on three of the elements, with the biggest gap in provider training.1
This is not surprising given that medical management without dialysis (MMWD) or CKM is not commonly taught in nephrology training programs for physicians, nurses or social workers. The presentation of the GKHA results paint an overly rosy picture, however, even in the highest ranked areas of interdisciplinary team and symptom management. Countries where the component of CKM was “generally available” could represent a bare majority of centers.
To achieve adequate CKM practice in the United States, we need these components consistently available at all care sites for all patients who would benefit from them. The GKHA survey was an important initial step in tracking availability of CKM care and documenting progress in attaining its integration into care for people with kidney failure. Now we need further efforts to map where this care is lacking in the United States and to assess its quality where available.
The second study, by Fu and colleagues, that might bear on MMWD practice is a new meta-analysis of studies comparing impact of dialysis vs. MMWD on mortality. The exciting aspect of the study is the use of a new statistical method to quantify the contribution of unmeasured confounders in observational, non-randomized studies. Using this new technique, the authors confirmed the observed impact of dialysis on mortality for patients from 65 years old to 75 years old is unlikely due to unmeasured differences between patients choosing MMWD vs. dialysis.2
At first read, this seems to be an important contribution to the knowledge base needed to advise patients considering MMWD vs. dialysis, but it disappoints. The results do not apply to patients older than 75 years, which is the subpopulation that earlier work has shown may benefit from MMWD. Further, the results do not address outcomes other than mortality risk. Multiple studies, including the new U.S. Renal Data System special chapter on end-of-life care, show most older adults with kidney failure place comfort and quality of life above length of life in their decision-making.3-5
Together, these two new studies underscore how much more needs to be done to fully implement the ideal of shared decision-making in nephrology. We need further evidence bearing on the question of how treatment options, including MMWD, impact quality of life for the people most likely to benefit from MMWD. Further, providers need education in MMWD – not just in the classroom, but by seeing this modality in action and learning how to provide it themselves – to offer a full spectrum of options that address patients’ range of preferences.
Dale Lupu, MPH, PhD
Research professor, School of Nursing
Professorial lecturer in health policy, School of Public Health
George Washington University
Washington
- References:
- Lunney M, et al. Clin J Am Soc Nephrol. 2020;doi:10.2215/CJN.09070620.
- Fu R, et al. Kidney Med. 2020;doi:10.1016/j.xkme.2020.09.013.
- End Stage Renal Disease: Chapter 12. Patient Experience: End-of-life Care for Patients with ESRD. In: 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases; 2020.
- Saeed F, et al. Clin Nephrol. 2019;doi:10.5414/CN109608.
- Ramer SJ, et al. J Am Soc Nephrol. 2018; doi:10.1681/ASN.2018060657.