P120
MORTALITY OF PATIENTS WITH STAGE 4 AND 5 CHRONIC KIDNEY DISEASE
IN EDINBURGH
Duthie, F, MacKenzie, J, Metcalfe, W
Royal Infirmary of Edinburgh
INTRODUCTION: Renal Association guidance states that for patients with chronic kidney disease (CKD) 4 and 5, consideration should be given to renal replacement therapy (RRT).
However, there are patients for whom RRT does not prolong life, nor improve quality of life, and there is increasing recognition of the need for conservative care specialists. The incidence of patients starting RRT in Scotland has not increased over the past 10 years and the median age of such patients has fallen, it is as yet unclear if this is due to increased use of conservative care patient pathways.
We examined the deaths over an 18 month period of patients with CKD 4 or 5 who had been seen at least once in the outpatient clinic, and died without RRT. We aimed to determine the management of advanced CKD and including the role of the conservative care programme.
METHODS: The details of all patients who died between 1/1/2008 and 30/6/2009 were retrieved from the renal electronic patient record. Patients who had stage 4 or 5 CKD at their last outpatient clinic visit prior to death were identified, those on RRT were excluded.
Demographics, cause and location of death, cause and degree of kidney disease and planned management of CKD were analysed for each patient. Further data regarding cause and place of death were obtained from the NHS Central Register.
RESULTS: 122 patients with CKD 4 (88 patients, 72%) and CKD 5 (34 patients) were indentified. 68 (56%) were male. Median age at death was 78 years (range 22 – 93; IQR 71-85).
The cause of CKD was unknown (EDTA code 00) for 53 patients (43%), atherosclerotic renal artery disease for 21 (17%), diabetes for 19 (16%) and acquired obstructive uropathy for 5 (4%).
Conservative care had been identified as the treatment of choice for 39 (32%) patients. Of those
24 (62%) had CKD4. 22(18%) patients had a positive plan for HD but of those 6(27%) had palliative approach adopted during their terminal illness. 7(6%) had planned for peritoneal dialysis. Of the 22 who planned for haemodialysis, 13(59%) had an arteriovenous fistula (AVF) at time of death, and a further 7(32%) had been referred for AVF formation. 6(46%) of those patients with AVF went on to be treated palliatively. For 45(37%) patients there had been no documented discussion of RRT or conservative care, only 3 of these patients had CKD stage 5.
Cause of death was obtained for 119(98%) patients. Ischaemic heart disease was the most common cause 45 patients (38%). Infection caused death in 22(18%), end stage renal failure in
16(13%), and 15(12%) died of malignancy.
Patients who died in the planned conservative care group were older, with median age of 83
(IQR 77-87), compared to 72.5 (IQR 61-80.25) for those who planned haemodialysis.
31% of planned conservative care patients died at home or in a hospice, compared to 22% of patients who had planned for RRT.
CONCLUSION: 56% of patients who died with known CKD 4 or 5 in the outpatient setting had a documented plan for management of their CKD. Only 3(9%) patients with CKD 5 did not.
This could be improved upon, but may reflect that consideration of RRT is complex. 32% of patients had a plan for conservative care.
Striving to meet a target of 65% of patients using an AVF for their first haemodialysis requires investment in vascular access procedures for patients who ultimately do not go on to receive haemodialysis. Cardiovascular disease (38%) was the most common cause of death, and few
(13%) died of end stage renal disease. This may be a contributing factor to the finding that only
31% of conservative care patients died at home or in a hospice.