Let’s start with a case study.
This elderly male, is hospitalized with fever, cough
productive of purulent sputum, pain right lower chest on
coughing and deep inspiration. Evaluation suggested right
lower lobe consolidation with pleural involvement, possibly a
community acquired lobar pneumonia.
His hemogram showed a Hb of 10.2, TLC 14,500 with 90%
neutrophils, RBS was 260mg/dl, serum creat 6.8 mg%, Na 133
mEq/l, K 5.5 mEq/l, S. Alb 3.8 gm/l. Urinalysis showed 2+
protein and bland sediment. Xray chest PA: Right lower lobe
consolidation with obliterated CP angle
He is a diabetic for the last 25 years, hypertensive for 20
years, had cataract extraction both eyes 15 yrs ago when he
was told that he also had NPDR in both eyes. 10 yrs ago
was evaluated for coronary artery disease, had CABG for 3VD.
Preoperative evaluation at that time showed 2+ proteinuria and
a serum creat of 1.8mg/dl. He was under the regular follow up
of the cardiologist but never checked his urine or serum
creat.
He was generally well till the recent episode of fever, used
to go for his regular morning walk, is rather strict with his
diet and medications. Checks his FBS once a week, which was
around 110mg/dl, and sees his cardiologist once in 6 months.
He was on glimepiride 2 mg, Sitagliptin 100 mgm with metformin
1000 mg, and Injection Glargine 14 units at 10 pm. He is on
Metoprolol 50 mg, Aspirin and clopidogrel 75mg each,
Rozuvostatin 20mg and Telmisartan 40mg.
Was managed with Pip/Taz 2.5gm bd and supportives. The OHAs
were stopped and basal bolus analogues were used. He improved
and was discharged on the 7
th day on glargine and
Linagliptin. The pneumonia had cleared, but serum creatinine
was still 5.9 mg/dl with an eGFR of 8.9ml/min/1.73m
2.
This story is very familiar. Longstanding diabetes is
associated with macro and microvascular complications here he
had retinopathy, nephropathy and also CAD which is the major
macrovascular complication. Ideally one has to seek for these
complications and institute corrective measures early in the
course of the disease. The nephropathy was quite evident 10
yrs ago with macroproteinuria, hypertension and elevated
creatinine at the time of his cardiac intervention. We could
have done better, by intervening earlier and modifying the
natural history of the disease.
But now with an eGFR of 8.9ml/mt, and significant
co-morbidities, what should be our advice regarding RRT for
this 70 yr old. An ESRD patient has only 2 options. Dialysis
or a renal transplant.
The basic reason we put our patients on dialytic support is to
improve their quality of life. Following the dictum “not
to add years to life but to add life to years”. And of course,
sticking to the punch theme “Primum non nocere”, but most
often the reverse happens.
Are there any other viable options?
Let us consider “
Conservative care of end-stage renal
disease”. This concept is getting slow acceptance even
in the developed world with the main consideration being
the increasing age of the patient and the presence of
comorbidities. Financial constraints also may be another
reason, especially in our country.
Kidney Disease: Improving Global Outcomes (KDIGO) defines
comprehensive conservative care as planned, holistic,
patient-centered care for patients with stage 5 chronic kidney
disease. Conservative ESRD care is appropriate for patients
who choose not to initiate dialysis or undergo kidney
transplantation. Such patients generally include those with
coexisting, advanced comorbidities who may not gain meaningful
benefit from renal replacement therapy or whose care
preferences are to avoid intensive medical therapies and
receive care that focuses on quality of life. The goals of
conservative care are to optimize quality of life, advance
care planning, treat the symptoms of ESRD without dialysis or
transplant, and, when appropriate, preserve residual renal
function. Conservative care is best delivered through a
collaborative, interdisciplinary team consisting of a
nephrologist, primary care clinician, nurse, dietician, social
worker, and, when appropriate, palliative care team.
We can offer conservative care to all patients who may not
meaningfully benefit from dialysis or whose goals focus on
quality over quantity of life. Conservative care is a
reasonable treatment option alongside renal replacement
options for those who are less likely to benefit from dialysis.
In particular, older patients are candidates for conservative
care since they tend to incur more of the burdens of dialysis
rather than intended benefits. Older patients, especially
those with underlying comorbidities, are at risk for loss of
independence, diminished quality of life, and poor health in
general. Dialysis may not improve and may even worsen these
problems. Symptoms of uremia (which are common indications for
dialysis initiation) often overlap with common geriatric
syndromes; Not only will dialysis not improve the underlying
condition, but it may lead to increased hospitalizations and
functional debility. And in our country, the financial
constraints result in inadequate dialysis which may be more
deleterious than not having dialysis.
Conservative care without dialysis can both avoid the
potential setbacks accompanying dialysis and provide
meaningful quality of life for older patients with advanced
comorbidities.
Older patients who choose conservative care are more likely to
spend their remaining survival outside of the hospital, with
greater opportunity for symptom management and end-of-life
care with palliative care and hospice services compared with
those who choose dialysis. In addition, older patients can
survive a significant amount of time without dialysis if there
is a slow rate of renal disease progression and glomerular
filtration rate (GFR) loss.
Hemodialysis may hasten the
loss of residual renal function. The ability to maintain
even small amounts of residual renal function has been shown
to be associated with improved survival and quality of life.
The Renal Physician Association guideline for shared decision
making recommends that conservative care be offered to
patients with advanced chronic kidney disease (CKD) over 75
years of age who have two of the following poor prognostic
factors:
1. Impaired functional status
2. Severe malnutrition (serum albumin <2 g/dL)
3. Multiple comorbidities
4. And a positive response to the surprise question: "No, I
would not be surprised if this patient died within the next
year"
The discussion regarding conservative care should occur at the
time of the first mention of dialysis as an option of his or
her treatment. Ideally, this is when the estimated GFR (eGFR)
is dropping below 30 mL/min/1.73 m
2.
Many a time in India we do not get this chance and the patient
presents generally for an emergency dialysis in severe
azotemia or pulmonary edema where you are forced to do
dialysis to save the patient.
The conversation should involve the patient, caregiver, and
essential members of the renal team, including nephrologist,
nurse, and, when appropriate, social worker and palliative
care expert. The decision to elect conservative care should
incorporate the patient's values and priorities as well as
clinical prognosis and availability of finance to continue the
programme. Patient decision aids (PDAs) are tools to
facilitate decision making and have been developed to address
conservative care decisions. Once conservative care is
elected, this treatment plan should be reassessed regularly,
with increased frequency for patients experiencing clinical or
functional setbacks.
It is helpful for patients who are deciding between dialysis
versus conservative care for the clinician to describe
survival and quality-of-life studies. Many a time even the
western studies favour conservative care.
The decision to opt for conservative care does not mean no
active treatment. We just decide to avoid RRT. That’s
all.
The components of conservative care include the following:
Medical management of kidney disease
Symptom management including quality end-of-life care
Advance care planning (ACP)
Practice guidelines exist for medical management of kidney
disease and symptom control for patients receiving
conservative management. Patients with predictable prognosis
and acceptable quality of life are the most likely to benefit
from both medical management focused on preservation of
residual renal function and symptom management. This treatment
plan may also be reasonable for those patients whose goals are
to live as long as possible with the hope of achieving
acceptable quality of life. By contrast, patients with
predictably poor prognosis and/or poor quality of life
generally do not benefit from treatments to prolong longevity,
and care should focus mainly on symptom management. For
patients with a less predictable prognosis, the treatment plan
may include aspects of both medical management of kidney
disease and symptom management.
A patient's prognosis and quality of life may change over
time, warranting modifications to the treatment plan.
.
Medical management
For healthier patients who have a predictable prognosis and
preserved quality of life, treatments that focus on longevity
such as minimization of renal progression and management of
secondary complications of kidney disease are reasonable.
Hence, medical management in this scenario is often the same
as that of CKD patients who are awaiting the initiation of
renal replacement therapies. This management may also be
reasonable for patients with an unpredictable prognosis.
Minimization of renal progression: Treatments to
minimize renal progression, particularly including
renin-angiotensin system (RAS) inhibitors, should incorporate
overall prognosis and level of renal function. One should not
advocate restricting protein, given potentially adverse effect
on quality of life and dubious short-term benefit.
Renin-angiotensin system inhibitors: The benefit
of starting or continuing RAS inhibitors in patients who elect
conservative care is unclear and depends on the patient's
prognosis, degree of proteinuria, and renal function. The
renoprotective benefits of RAS inhibitors have been
demonstrated in numerous studies. However, the application of
these studies to older patients and those with limited life
expectancy is less clear.
The patients who are most likely to benefit from these agents
are those with milder disease and significant proteinuria
(>500 to 1000 mg/day) Older patients are less likely to
have significant proteinuria, which may limit the
antiproteinuric effects of RAS inhibitors.
For most patients undergoing conservative care who have very
advanced renal disease (ie, estimated glomerular filtration
rate {eGFR} <20 mL/min/m
2) or are experiencing
an accelerated rate of loss, it would be prudent not using RAS
inhibitors to preserve renal function, even in the setting of
significant proteinuria. Such patients are less likely to live
long enough to experience the protective benefits and are more
likely to experience worsening kidney function and
hyperkalemia.
Limitation of dietary protein intake: For most
CKD patients undergoing conservative care, daily protein
intake of approximately 0.8 g/kg, which is the same as for
adults without kidney disease. Elderly do not eat well and
there is no real need of restricting proteins especially
proteins of vegetable origin for our patients
Do not prescribe very low protein diets (ie, 0.3 g/kg of body
weight), particularly among older patients, especially those
with comorbidities. Although such diets may provide some
benefits, the beneficial effects of are tempered by their
potential negative impact on patient quality of life.
Blood pressure management — The goal of management is to avoid
the deleterious effects of excessively high blood pressures,
including stroke and cardiovascular outcomes, and progression
of renal disease. Blood pressure goals are the same for CKD
patients who are awaiting dialysis. However, evidence now
supports more intensive blood pressure control (systolic blood
pressure <120 mmHg versus <140 mmHg) in patients over
the age of 75. Intensive blood pressure control may be harmful
for those with cognitive decline who are vulnerable to the
unwanted side effects of low blood pressure, including falls,
light headedness, and fatigue. For patients who are undergoing
conservative care, blood pressure management should include
close attention to the patient's comorbidities and cognition
when considering initiating or titration of blood pressure
medications. Blood pressure targets should be individualized
for a given patient, taking into account fall risk, symptoms
of lightheadedness and fatigue, and cognitive impairment.
Anemia and iron deficiency — For most conservatively managed
patients, administer erythropoiesis-stimulating agents (ESAs)
and iron administration to treat anemia. ESAs and iron can
improve symptoms of fatigue and weakness. The dose and
frequency of these agents should reflect the hoped-for goals
of the treatment and may not strictly adhere to standard
guidelines. As an example, the Kidney Disease: Improving
Global Outcomes (KDIGO) guidelines suggest that ESAs should
generally not be used to maintain hemoglobin (Hb)
concentrations >11.5 g/dL However, for selected patients, a
target of higher levels may be associated with clinically
significant improvements in symptoms. For patients who are
receiving conservative care, do not target Hb levels >13
g/dL. Hb targets >13 g/dL are associated with adverse
outcomes.
For CKD patients who have active malignancy and whose goals
focus on the quality of life, use ESAs to treat symptoms of
fatigue and weakness related to CKD-associated anemia. The
KDIGO guidelines recommend that ESAs be used with great
caution, if at all, in CKD patients with active malignancy,
especially if cure is anticipated, or with a history of stroke
or a history of malignancy. However, these guidelines do not
address patients with limited life expectancy whose goals are
focused on improving quality of life rather than longevity. An
informed discussion of potential risks and benefits associated
with ESAs should take place with patients and families of
patients who have active malignancy.
Mineral and bone disease — Phosphorous-binding agents and the
use of vitamin D analogs can assist management of symptoms of
pruritus and renal-related bone disease.
Hypovitaminosis D and secondary hyperparathyroidism have been
associated with fracture risk in older patients. For patients
with a favorable prognosis and acceptable quality of life, the
initial approach to the treatment of hyperphosphatemia and
hyperparathyroidism is similar to that for CKD patients who
are awaiting renal replacement therapy. However, it may be
difficult to achieve target serum phosphorus, vitamin D, or
parathyroid hormone (PTH) goals in patients with very advanced
kidney disease. In addition, the pill burden may be burdensome
and not benefit overall quality of life. For such patients who
have difficulty achieving PTH or phosphorus goals or whose
goals are to avoid added pills, higher PTH and phosphorus
concentrations may be permitted
In patients with relatively limited prognosis, do not treat
hyperphosphatemia, or hyperparathyroidism unless very severe.
In most patients, efforts to reduce fracture risk are more
important than are attempts to control hyperphosphatemia.
Acidosis — The approach to metabolic acidosis for patients
undergoing conservative care is generally the same as for CKD
patients awaiting renal replacement therapy. Use oral
bicarbonate as well as base-containing fruits to treat
metabolic acidosis resulting from advanced kidney disease.
Treatment of metabolic acidosis may decrease renal disease
progression and has also been associated with improved
nutritional status.
Hyperkalemia — Patients with advanced kidney disease often
have difficulties with hyperkalemia, which can be life
threatening. The first step to management involves review of
medications that increase potassium through inhibition of the
renin-angiotensin-aldosterone system. These medications should
be discontinued or decreased as the risk of hyperkalemia
outweighs potential benefit of renal protection. If
hyperkalemia persists despite discontinuing the
angiotensin-converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB), can be treated with cation exchange
resins such as SPS or initiation of diuretics, both of which
may lower serum potassium levels.
Symptom management focused on optimizing quality of life —
Symptom management can occur concurrently with medical
management of kidney disease or as the primary treatment plan.
Symptom management alone may be most appropriate for patients
who have a predictable and poor prognosis and for those whose
prognosis is unpredictable, whose goals are for comfort.
Medications that do not address comfort or whose benefits will
not be actualized due to limited survival should be stopped.
Examples include but are not limited to multivitamins,
statins, and aspirin. This medication reconciliation allows
opportunities to initiate medications that treat symptoms.
Importantly, patients facing end of life often experience
increasing and unstable symptoms that require active
medication adjustments.
Symptom evaluation — Attention to symptoms is a critical
component of conservative care. Patients who elect
conservative care experience a similar number and severity of
symptoms as those on dialysis. These symptoms may result from
complications of advanced kidney disease as well as coexisting
conditions such as diabetes, heart failure, and cancer. How
symptoms are evaluated depends on the resources and staffing
of a given renal team. Surveys completed by the patient and,
in some cases, with the help of a caregiver or support staff,
may be used to assess symptoms. Ideally, symptoms are
evaluated at each clinic visit and reviewed by the provider.
Patient-completed symptom assessment tools have been validated
in conservatively managed CKD patients. One can use a
modification of the Patient Outcome Scale – Symptoms Renal
(POS-S Renal). This modified tool (IPOS-Renal) includes 11
common symptoms experienced by renal patients plus additional
items focused on psychological symptoms and caregiver concerns
and is accessible online on the Palliative care outcome scale
on the web site.
Assessment tools to measure psychological symptoms have also
been used and validated in CKD patients. These include the
Patient Health Questionnaire-9 (PHQ-9) and the Beck Depression
Inventory (BDI). The PHQ-9 since it is shorter and does not
require adjustment for somatic symptoms. The PHQ9 is a
nine-item screening tool to assess the presence of depressive
thoughts or feelings over the past two weeks. A score of 10 or
higher indicates a depressive disorder. The PHQ-2 is a
two-question tool comprised of the first two questions from
the PHQ-9 that has demonstrated validity in CKD patients as a
screening tool for depression. The PHQ-2 is intended to be an
initial screen, with those who screen positive undergoing
confirmatory screening with PHQ-9.
The BDI may also be used to screen patients. The BDI is a
21-item screening tool that has also been validated in CKD and
ESRD patients. The cut-off score (≥10) for a depressive
disorder is higher in CKD (≥11) and ESRD (≥14 to 16) patients
to account for a greater somatic symptom burden in these
patients.
Patients who screen positive for depressive symptoms require a
comprehensive assessment to determine whether these symptoms
stem from depression itself or spiritual/existential concerns
that may accompany those living with advanced illness.
Patients benefit from exploration of spiritual/existential
concerns.
Management of symptoms — Conservatively managed patients often
experience fatigue, pain, lack of appetite, pruritus, and
breathlessness and edema. Diuretics can assist symptoms of
edema and breathlessness, even at the risk of accelerating
renal progression.
Medications to manage common secondary complications of kidney
disease such as anemia and hyperphosphatemia can also treat
associated symptoms. The goals of management are focused on
symptom control rather than achieving Hb or serum phosphorus
targets. The benefits of these treatments are limited by
expected prognosis and quality of life. When distressing
symptoms persist despite managing secondary kidney disease
complications, medications should be initiated to treat the
undergoing symptoms.
Fatigue — Fatigue is a common symptom of patients with
advanced kidney disease. The evaluation of fatigue should
include an assessment of anemia. ESAs can assist
anemia-associated fatigue. Target Hb levels may exceed
standard guidelines for CKD; however, avoid targeting levels
above 13 g/dL. If symptoms do not improve with an Hb of 13
g/dL, the fatigue is likely independent of anemia, and the ESA
dose should not be increased. The provider should also
consider psychological symptoms such as depression, anxiety,
and existential suffering.
Anorexia, nausea, vomiting — Symptoms of anorexia, nausea, and
vomiting may signify advancement of kidney disease or overall
decline. Symptoms may be addressed with antiemetics and
management of acidosis. Metoclopramide is a dopamine
antagonist that has both antiemetic and prokinetic properties
and is effective for gastroparesis and uremia. Metoclopramide
should be dosed for renal impairment. Other effective agents
include ondansetron and low-dose haloperidol. Side effects of
these agents include extrapyramidal reactions that should be
monitored closely.
Patients with persistent symptoms benefit from assessment of
end-of-life needs.
Pain — Pain is common, distressing, and warrants a
comprehensive assessment in conservatively managed patients.
Pain may be due to progression of kidney disease, concurrent
comorbidities (diabetic neuropathy, peripheral vascular
disease), or a secondary complication of kidney disease
(calciphylaxis, bone pain from renal osteodystrophy).
Untreated pain can negatively impact health-related quality of
life and contribute to depressive symptoms.
Pruritus — Pruritus is common and can be bothersome. Similar
to the dialysis population, first-line treatment
recommendations include management of PTH, phosphorous, and
calcium and use of topical treatments.
For resistant symptoms, antihistamines, gabapentin and
sertraline effective.
A retrospective cohort study examined the efficacy of
gabapentin for symptoms of pruritus and restless leg syndrome
among 34 patients undergoing conservative care in Australia.
Thirty of 34 patients had uremic pruritus. The median dose
achieved was 100 mg (range 39 to 455 mg). By the fourth visit
(median 12.6 weeks of treatment) and the final visit (median
27 weeks), over 80 percent of patients demonstrated
improvements in pruritus scores.
If gabapentin is used, it should be started at a low dose (100
mg/day). In the study from Australia, compared with dialysis
patients, the conservatively managed patients had more side
effects such as drowsiness, with 17 percent discontinuing the
drug
Psychological symptoms — Kidney disease is a risk factor for
psychological conditions such as depression and anxiety.
Persistent psychological symptoms can worsen physical
symptoms, can negatively impact quality of life, and have been
associated with increased hospitalization. Conservatively
managed patients face limited survival and are at risk for
existential and spiritual concerns that accompany end of life.
Evidence is lacking for pharmacologic management of depression
in patients with kidney disease. Selective serotonin reuptake
inhibitors, however, have a better safety profile for patients
with cardiovascular disease and may be a safe choice in kidney
disease patients. We use sertraline as a first-line agent as
it does not require dose adjustment in renal disease and
assists with anxiety symptoms. Side effects with sertraline
include hyponatremia, bleeding, and gastrointestinal symptoms.
Treatment caveats include consideration of the
pharmacokinetics and dose adjustments for renal dysfunction.
Patients may also benefit from nonpharmacologic treatments
such as exercise, support groups, and therapy. Cognitive
behavioral therapy, a structured form of psychotherapy that
supports logical thinking and reorganizes negative thoughts
and behaviors, has been effective in reducing depressive
symptoms in dialysis patients; however, less is known in ESRD
patients undergoing conservative care. How treatment is
delivered depends on the comfort of the provider and available
resources. Referral to psychiatry for assistance with
diagnosis and management is reasonable.
Advance care planning — ACP is the process by which patients,
family members, and providers reflect upon the patient's goals
and values to help inform current and future medical care
plans . Patients who have engaged in ACP are less likely to
undergo intensive care at end of life and instead receive care
consistent with their wishes. Bereaved families who have been
part of ACP experience better adjustment, with fewer
psychological symptoms.
The ACP conversation begins with the decision to elect
conservative care. Providers must prepare patients for future
setbacks and define how best to care for them as end of life
nears. Many patients may be asymptomatic at the time
conservative care is elected. When symptoms do arise, patients
may respond with fear and reconsider dialysis as a "fix."
Without adequate preparation, patients may view conservative
care as a temporary plan that may change over time, depending
on their current health state and life circumstances.
Therefore, the discussion to elect conservative care is
incomplete without a meaningful discussion addressing the
end-of-life trajectory with conservative care and outlining
the patient's care preferences. This can involve periodic
check-in conversations using open-ended questions such as
"What thoughts do you have about your kidney management?" This
question allows the patient to express potential concerns,
satisfaction, or questions about the current treatment plan.
These conversations are particularly helpful in the setting of
a clinical change, hospitalization, or worsening lab indices.
Patients may also change their mind and request dialysis. This
is not unexpected, as patient preferences are shaped by their
experience, values, and uncertainty of the future. Some of
these requests may reflect emotion such as worries and fears
of end of life.
Palliative care expertise — An interdisciplinary palliative
care team may assist with difficult-to-treat symptoms or
conflicting goals of care. A number of studies have analyzed
different models for providing palliative care for
conservatively managed ESRD patients. Some renal programs
without access to palliative care programs have educated
members within the renal team to provide palliative care
services. More advanced models have incorporated palliative
care clinics within the nephrology clinic. As an example, the
Australian conservative care model at St. George Hospital has
a well-developed renal supportive care clinic staffed by a
palliative care specialist and renal/palliative care nurse,
with additional supports alongside standard pre dialysis
clinic . In a prospective cohort study, patients who received
renal supportive care experienced greater improvements in
symptoms over time compared with patients undergoing standard
pre dialysis care.
End-of-life care — Patients who elect conservative care face
limited prognosis and the expectation that symptom burden will
worsen as end of life approaches. End of life for patients
with ESRD (with or without dialysis) is associated with high
symptom burden. In a prospective cohort study of
conservatively managed patients, the last two months of life
were characterized by an increase in symptoms, especially lack
of energy, pruritus, drowsiness, dyspnea, agitation, and pain.
Additionally, patients and caregivers experienced high levels
of psychological concerns near end of life, including high
anxiety, low mood, family anxiety, and increased information
needs and practical concerns.
End-of-life symptoms — Symptoms that warrant special attention
include dyspnea, pain, myoclonus, and agitation.
Low-dose opioids and benzodiazepines can be useful to address
the symptoms of breathlessness and anxiety that accompany
dyspnea. Morphine should be used with caution, if at all,
since the active metabolites accumulate in renal failure and
contribute to neuro excitability and myoclonus. Safer opioids
include methadone and fentanyl. Active metabolites of
oxycodone and hydromorphone can accumulate in renal failure,
though less so than with morphine.
Myoclonus and agitation can be treated with benzodiazepines
and haloperidol.
Patients on conservative care and their caregivers benefit
from hospice services. Depending on the country, end-of-life
care may be termed palliative care or hospice care, although
the philosophy of care may be the same. Within the United
States, the Hospice Medicare Benefit includes
interdisciplinary services to ensure that the patient's needs
are met, caregivers are supported, and care occurs in the
patient's/caregiver's desired location. Patients who elect
hospice would rather focus on their comfort and typically do
not elect to return to the hospital for acute illnesses or
setbacks. Patients who undergo hospice care are more likely to
experience less symptom burden at end of life and receive care
consistent with their care preferences. Location of death is
more likely not to be in the hospital as well. We in India, do
not have such a hospice care and may have to do with well
supported domiciliary care
Some patients, especially those with predictable and favorable
prognosis, may elect conservative care yet still desire acute
hospitalization for acute illnesses. These patients would be
appropriate for palliative care services for symptom
management and continued discussion about goals of care.
To conclude, the concept of good conservative care without
attempting renal replacement options in a CKD 5 /ESRD appears
a very attractive proposition in India. But with the
increasing diabetes burden,and the aging population, we may
have to deal with a staggering number of ESRD patients in
future, which India can hardly cope with. A
comprehensive preventive strategy will be more appropriate by
early detection and aggressive management of diabetes and
hypertension to prevent or at least slow down the dreaded
complication of chronic kidney disease.
Money invested now in establishing such a preventive program
for CKD in India is certainly going to give results in years
to come and, ultimately, in the long run, will still be cost
effective. But, there should be a sea change in the mind sets
of our health planners and a strong political will to
implement it.
References
1. World Health Organization: Preventing Chronic Disease: A
Vital Investment. Geneva, WHO, 2005.
2. Agarwal SK: Chronic kidney disease and its prevention in
India. Kidney Int 2005;98: S41–S45.
3. Dash SC, Agarwal SK: Incidence of chronic kidney disease in
India. Nephrol Dial Trans- plant 2006;21:232–233.
4. TG Mathews, E Mathews : journal of Biomedical Sciences ISSN
2676-1343 eISSN 2382-5545.
5. Christina Bradshaw, Noble gracious et al : Paying for
Hemodialysis in Kerala, India: A Description of Household
Financial Hardship in the Context of Medical Subsidy. KI
Reports 2019 March, 4(3) 390-398.
6. Murtagh FE, Burns A etal. Supportive care : comprehensive
conservative care in End Stage Kidney Disease. CJASN 2016;
11:1009.
7. Burns A, Carson R. Maximum conservative Management: A
worthwhile treatment for elderly patients with renal failure
who choose not to undergo dialysis. J Palliat Med 2007;
10:1245.
8. Kurella M, Covinsky KE, Collins AJ : Octogenerians and
Nonagenarians starting dialysis in United States. Ann Inern
Med 2007 ; 146: 177.
9. Brown MA, Collett GK, Josland EA, et al. CKD in elderly
patients managed without dialysis : survival,symptoms,and
quality of life CJASN 2015;10:260.
10. O’Connor NR, Kumar P. Conservative management of end stage
renal disease without dialysis : A systematic review. J
Palliat Med. 2012;15:228.
11. Chandna SM,Da Silva- Gane M, Marshall C, et al. Survival
of elderly patients with stage 5 CKD: comparison of
conservative management and renal replacement therapy. Nephrol
Dial Transplant 2011; 26:1608.
12 Couchoud C, Labeeuw M, Moranne O, et al. A clinical score
to predict 6-month prognosis in elderly patients starting
dialysis for ESRD. Nephrol Dial Transplant 2009; 24: 1553.
13. Thamer M, Kauffman JS,Zhang Y, etal. Predicting early
death among elderly dialysis patients Development and
validationof a risk score to assist shared decision making for
dialysis initiation. AJKD 2015; 66:1024.
14. Davison SN. Tupala B. Vasylynuk BA. et al. Recommendations
for the care of patients receiving conservative kidney
management of CKD and symptoms. CJASN 2019; 14:626.
15. Chapter 1 : diagnosis andevaluation of anemia in CKD.
Kidney International Supplement (2011) 2012: 2;288.
16. Murphy EL. Murtagh FE. et al. Understanding symptoms in
patients with advanced CKD managed without dialysis: Use of a
short patient completed assessment tool.Nephron Clin Pract
2009;111:c74.
17. Abdel-kader K, Unruh MLWeisbord SD. Symptoms burden,
depression, and quality of life in ESKD. CJASN 2009:4:1057.
18. Murtagh FE, Addington-Hall J, Edmonds P, et al. Symptoms
in the month before death for Stage V CKD patients managed
without dialysis.J Pain Symptom Manage 2010: 40:342.