Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Brown 2015

Type of study:

Prospective cohort study.

Setting:

Single-centre

Country:

Australia

Source of funding:

Supported by a grant from Amgen Australia

Inclusion criteria:

- patients referred to a predialysis  clinic;

Exclusion criteria:

-

N total at baseline:

Intervention: 273

Control:122

Important prognostic factors²:

age ± SD:

I: 67 ± 14

C: 82 ± 9

Describe intervention:

The predialysis clinic is an education clinic where patients learn about ESRD and the process of dialysis, and is staffed by a senior nephrology nurse.

Describe  control:

The RSC clinic is staffed by a palliative care specialist and a senior renal/ palliative care nurse.

Length of follow-up:

Intervention: median 16 months

Control: 10 months

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I:> Hemoglobine (p=0,04), > smoking (P=0,03)

C: > age (p<0,001), < weight (p<0,001), < height (P<0,001), > comorbidities (P<0,001), > non-caucasian (P=0,01)

Not correlated:

eGFR, BMI, Creatinine, albumin, corrected CA, PO4, PTH, Gender

Shum 2014

Type of study:

Retrospective cohort

Setting:

Single-centre

Country:

Hong Kong, China

Source of funding:

Not mentioned

Inclusion criteria:

- Chinese older adults (≥65 years)

- stage 5 CKD (defined as estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73 m2 using the Modification of Diet in Renal Disease equation)

- received “dialysis assessment”

- identified over a 7-year period (from July 1, 2003 to June 30, 2010).

Exclusion criteria:

N total at baseline:

Intervention: 157

Control: 42

Important prognostic factors²:

age ± SD:

I: 73,4± 5,3

C: 75,3 ± 5,7

Describe intervention:

PD group (defined as those who received PD as the first modality of longterm RRT or had made a decision to commence on PD and had begun preparation for the temporary dialysis, PD catheter insertion but had died before dialysis initiation).

Describe  control:

Conservative group (defined as those who received no dialysis or conservative management after “dialysis assessment”

Participants in the conservative group would receive the same level of medical care as those in the PD group except no PD

Length of follow-up:

Median follow-up (interquartile range): 1,96 years (0,90-3,62)

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Mentioned that in general all variables had less than 5% missing data.

Outcome measures and effect size:

Factors significant correlated

I:

C: >age, (p0,04)> stroke (P=0,03), > receiving comphrehensive social security (p=0,01), > no helper for PD (p<0,001).

Not correlated:

Gender, Etiology of disease (diabetic nephropathy, hypertensive nephroscleroris, glomerulonephritis, polycystic kidney, obstructive uropathy), Charlson Comorbidity index, cancer, dementia, liver disease, chronic pulmonary disease, vascular disease, congestive heart failure, coronary artery disease, diabetes mellitus, late referral, mobility, functional aspects, marital status, illiteracy, living status (home, nursing home), eGFR, Sodium, Potassium, Calcium, Phosphate, Bicarbonate, Albumin, Hemoglobin.

Seow 2013

Type of study:

Prospective cohort

Setting:

Multi-clinic.

Country:

Singapore

Source of funding:

This  study  was  supported  by  a  Singhealth  Research  grant. Y.B.C. was supported by the Singapore Ministry of Health Nation-al Medical Research Council.

Inclusion criteria:

- ≥ aged 75 or had an CCM index H;

- eGFR 8-12ml

Exclusion criteria:

- already on RRT;

N total at baseline:

Intervention: 38

Control:63

Important prognostic factors²:

Median age:

I: 60 yr

C: 60 yr

Describe intervention:

Conservative management, no further description

Describe  control:

RRT, no further description.

Length of follow-up:

24 months

Loss-to-follow-up:

8/101 (8%),  not further specified

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > comorbidity (p=0.007), > diabetes mellitus,

C: > age (P<0,001), >Hypertension/Renal artery stenois (P=0,046)

Not correlated:

Gender, Etnicity, Marital status, primary carer, education, Karnofsky performance score, eGFR,

Hussain 2013

Type of study:

Retrospective cohort

Setting:

Single-center

Country:

UK

Source of funding: Research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Inclusion criteria:

- Patients aged over 70 years with a gradual decline in renal function.

-eGFR< 20ml

Exclusion criteria:

- Patients who presented with

CKD stage 5 or had a rapid decline in renal function were

excluded from the analysis.

N total at baseline:

Intervention: 269

Control: 172

Describe intervention:

The decision-making process includes in-depth discussion with physicians as well as specialist nurses who visit the patient’s home environment and provide relevant information regarding the practicalities, risks and benefits of RRT as well as CM. The patients are provided with written information, and if they require, they can further discuss with members of the MDT until a decision is reached. A description of the service has been published elsewhere

The RRT group receives dialysis.

Describe  control:

The decision-making process includes in-depth discussion with physicians as well as specialist nurses who visit the patient’s home environment and provide relevant information regarding the practicalities, risks and benefits of RRT as well as CM. The patients are provided with written information, and if they require, they can further discuss with members of the MDT until a decision is reached. A description of the service has been published elsewhere

CM group continues with best supportive care under the care of a palliative medicine consultant.

Length of follow-up:

Not mentioned

Loss-to-follow-up:

No  loss-to-follow-up.

Incomplete outcome data:

Reported that there was missing data, not reported how much.

Outcome measures and effect size:

Factors significant correlated

I:

C: > age (P<0,001), < albumin (p=0,01), > diabetes mellitus (p=0,02),  > hypertension (p=0,04) >chronic lung disease (p=0,003), > dementia (p<0,001). > CCI score (p=0,006), < performance status (P< 0,001)

Not correlated:

Gender, ethnicity, cause of renal failure,

ESRD stadium 5 excluded because this group did not have limited time for education.

Moranne 2012

Type of study:

Prospective cohort;

Setting:

Multi-center study.

Country:

France

Source of funding:

This work was supported by company Roche and Shire for employment of clinician research assistant and by a grant of “Agence de la biomede-

cine: Appel d’offres REIN 2010.”

Inclusion criteria:

- patients aged ≥ 75;

- eGRF < 20 ml;

Exclusion criteria:

- acute renal failure;

- late referral;

N total at baseline:

Intervention:  135

Control: 45

Control 2: 48

Important prognostic factors²:

age ± SD:

I: 81 ± 4

C:85 ± 5

C2: 86 ± 5

Describe intervention:

Inclusion  questionnaire  asked  for  demographic  data, clinical condition (primary renal disease, comorbid conditions, and disabilities), mobility (walk without help, need assistance with mobility,  and totally dependent  for  trans-fers), way of living (Home living [alone or with someone] or institutionalized), biological data (blood and urine), treatment (including medication for hypertension and renal protection), type of follow-up physicians (general practitioner, gerontologist, and nephrologist, other), and therapeutic projects about the option for dialysis for each patient. During the follow-up, at each visit will be recorded renal function, clinical condition, way of life, mobility, treatments, therapeutic project options for dialysis, dialysis start, death, and stopping  follow-up  by  nephrologist. Nephrologists  will specify the criterion of dialysis start and the modality of

treatment.

Describe control:

Inclusion  questionnaire  asked  for  demographic  data, clinical condition (primary renal disease, comorbid conditions, and disabilities), mobility (walk without help, need assistance with mobility,  and totally dependent  for  trans-fers), way of living (Home living [alone or with someone] or institutionalized), biological data (blood and urine), treatment (including medication for hypertension and renal protection), type of follow-up physicians (general practitioner, gerontologist, and nephrologist, other), and therapeutic projects about the option for dialysis for each patient. During the follow-up, at each visit will be recorded renal function, clinical condition, way of life, mobility, treatments, therapeutic project options for dialysis, dialysis start, death, and stopping  follow-up  by  nephrologist. Nephrologists  will specify the criterion of dialysis start and the modality of

treatment.

C1: patients preference.

C2: nephrologist’s preference

Length of follow-up:

48 months

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > Men, > unassisted walking, > living at home (P<0,001)

C: > age (p<0,001)

C2: > age (p<0,001), > dementia (P<0,001), > cancer (P=0,002),

Not correlated:

eGFR,

Da Silva-Gane 2012

Type of study:

Prospective cohort

Setting:

Single-centre

Country:

UK

Source of funding:

The authors received a project grant for this work from the British

Renal Society.

Inclusion criteria:

- Patients with progressive CKD;

Exclusion criteria:

- Lacking capacity or with poor understanding of English.

N total at baseline:

Intervention: 124

Control:30

Describe intervention:

After medical evaluation, patients were assessed at home by a senior nurse and renal counselor/social worker. Assessments were considered by the wider multidisciplinary team, and provisional modality options were recommended. These were discussed with patient and family or caregivers during several clinic visits, and an individualized treatment plan was created.

Dialysis was initiated for persistent uremic symptoms,volume overload, hyperkalemia, or acidosis. HD patients received high-flux treatments, including online hemodiafiltration in 40% of patients. Target two-pool equilibrated Kt/V was 1.2 (12). Target weekly total Kt/V for peritoneal dialysis (PD) was 2.0

Describe  control:

After medical evaluation, patients were assessed at home by a senior nurse and renal counselor/social worker. Assessments were considered by the wider multidisciplinary team, and provisional modality options were recommended. These were discussed with patient and family or caregivers during several clinic visits, and an individualized treatment plan was created.

Patients opting for CKM were offered ongoing medical treatment and multidisciplinary support (5) by a team that included nephrologists, specialist nurses, renal counselors, social workers, dietitians, and community and hospice services.

Length of follow-up:

Minimal of 30 months

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > Karnofsky performance score > 70 (P<0,001),> SF-36, < HADS anxiety score (P<0,04),  physical score (p<0,001)

C: > age (P=0,02), high comorbidity (P<0,001),

Not correlated:

Gender, weight, eGFR, SF-36 mental health, HADS depression score, Satisfaction with life score.

Chandna 2011

Type of study:

Retrospective cohort

Setting:

Single-centre

Country:

UK

Source of funding:

Not mentioned

Inclusion criteria:

- Patients with

stage 5 CKD based on eGFR estimated by MDRD-4 equation.

- Patient had at least one value of eGFR in the range 10–15 mL/min/1.73 m2.

- All subsequent recorded values of eGFR <15 mL/min/1.73 m2.

Exclusion criteria:

N total at baseline:

Intervention: 689

Control: 155

Important prognostic factors²:

age ± SD:

I:58,5 ± 15,0

C: 77,5 ± 7,6

Describe intervention:

We aimed to offer patients a free choice of modality constrained only by clinical and social imperatives. After the diagnosis of progressive CKD, patients were referred by the nephrologists to a liaison team, led by a senior nurse and a renal counsellor. This referral usually took place when the patient had stage 4 CKD—but for a minority of patients this was sometimes later. The role of the team included assessment, education, counselling and support of the patient and family/carer before, during and after modality choice.

HD patients were treated exclusively using high-flux membranes, predominantly polysulphone. Around 40% of patients were treated by online haemodiafiltration (HDF). Bicarbonate was used exclusively as the buffer, and ultrapure water was standard. Target total two-pool Kt/V urea (Kt/VTotal) was 1.2 per session for thrice-weekly HD and HDF. PD patients were treated by continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis. Disconnect systems were used exclusively for CAPD. Minimum weekly Kt/VTotal target for both PD modes was 2.0.

Describe  control:

We aimed to offer patients a free choice of modality constrained only by clinical and social imperatives. After the diagnosis of progressive CKD, patients were referred by the nephrologists to a liaison team, led by a senior nurse and a renal counsellor. This referral usually took place when the patient had stage 4 CKD—but for a minority of patients this was sometimes later. The role of the team included assessment, education, counselling and support of the patient and family/carer before, during and after modality choice.

Patients opting for conservative management were offered ongoing support by the multidisciplinary team in liaison with community, primary care and hospice services. Full medical treatment was continued, which included the use of erythropoietin as appropriate to treat or prevent anaemia.

Length of follow-up:

Not mentioned

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I:

C:  > age (p<0,001), > higher comorbidity (P<0,001)

Not correlated:

Gender, ethnicity, diabetes mellitus, eGFR.

Carson 2009

Type of study:

Retrospective cohort

Setting:

Single-centre

Country:

UK

Source of funding:

Not mentioned

Inclusion criteria:

- Patients who started dialysis (RRT) and were ≥70 yr of age at the time of first dialysis.

- Patients who were identified through our Low Clearance Clinic.

Exclusion criteria:

-

N total at baseline:

Intervention: 173

Control:29

Important prognostic factors²:

Mean age:

I: 76,4

C: 81,6

Describe intervention:

All patients were reviewed by a multidisciplinary team that included a nephrologist, clinical nurse specialist, dietician, and social worker. Families were invited to participate in all discussions about dialysis initiation. The only difference in counseling received by the two groups was that patients who chose MCM were also visited once at their homes by the clinic social worker to offer additional support and opportunity for the patient and the family to discuss the treatment plan.

Hemoglobin was optimized for both groups using erythropoietin and intravenous iron, maintaining a target 110 g/L. BP and cholesterol management was similar for both MCM and RRT patients.

Describe  control:

All patients were reviewed by a multidisciplinary team that included a nephrologist, clinical nurse specialist, dietician, and social worker. Families were invited to participate in all discussions about dialysis initiation. The only difference in counseling received by the two groups was that patients who chose MCM were also visited once at their homes by the clinic social worker to offer additional support and opportunity for the patient and the family to discuss the treatment plan.

Hemoglobin was optimized for both groups using erythropoietin and intravenous iron, maintaining a target 110 g/L. BP and cholesterol management was similar for both MCM and RRT patients.

Length of follow-up:

Average of 26,7 months for intervention group and 12,9 months for control group.

Loss-to-follow-up:

Intervention:

N=10 (6%)

Control:

N=0 (0%)

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I:

C: > age (P<0,001),

Not correlated:

Gender, diabetes mellitus, hemoglobine, albumin, cholesterol, CCI score, ethnicity,

Murtagh 2007

Type of study:

Retrospective cohort

Setting:

Multi-centre

Country:

UK

Source of funding:

Not mentioned

Inclusion criteria:

- Patients >75 years

receiving dedicated multidisciplinary pre-dialysis care.

Exclusion criteria:

- Patients presenting late with

previously undiagnosed CKD or in whom a rapid unforeseen

deterioration in function has occurred.

N total at baseline:

Intervention: 52

Control: 77

Describe intervention:

Dedicated multidisciplinary pre-dialysis care is provided by a team of physicians, specialist nurses, counsellors and dieticians providing additional educational, dietary, social and psychological support to that available in the general clinic. Within all four units, all patients predicted to need dialysis within 18 months are directed from general nephrology care into this dedicated multidisciplinary predialysis care.

Describe  control:

Dedicated multidisciplinary pre-dialysis care is provided by a team of physicians, specialist nurses, counsellors and dieticians providing additional educational, dietary, social and psychological support to that available in the general clinic. Within all four units, all patients predicted to need dialysis within 18 months are directed from general nephrology care into this dedicated multidisciplinary predialysis care.

Length of follow-up:

Not mentioned

Loss-to-follow-up:

No loss-to-follow-up mentioned.

Incomplete outcome data:

Mentioned that there was no missing data.

Outcome measures and effect size:

Factors significant correlated

I:

C: > age (P<0,001)

Not correlated:

Gender, ethnicity, glomerulonephritis, pyelonephritis, diabetes mellitus, renovascular disease, hypertension, polycystic kidneys, comorbidity.

Yong 2009

Type of study:

Prospective cross-sectional study

Setting:

Single-centre

Country:

Hong Kong, China

Source of funding:

Not mentioned.

Inclusion criteria:

- PD or HD patients who were dialysed for at least

3 months.

- Patients on palliative care with a creatinine

clearance of <15 mL/min.

- Patients of age over 18 years

and with adequate command of Chinese language.

Exclusion criteria:

- Patients with cognitive impairment or known

psychiatric illness were excluded.

N total at baseline:

Intervention: 134

Control: 45:

Important prognostic factors²:

age ± SD:

I: 58,2 ± 11,4

C: 73,1 ± 7,1

Describe intervention:

In our hospital, a program jointly delivered by the renal team and the palliative care team is in place, so that patients who chose not to dialyse will receive renal palliative care.

Patients who presented with chronic renal failure (CRF) and their families were interviewed by the health care team to explain the prognosis, risks and benefits of RRT, and the option of medical care without dialysis but with palliative care.

The Renal Unit serves patients on chronic PD and HD.

Describe  control:

In our hospital, a program jointly delivered by the renal team and the palliative care team is in place, so that patients who chose not to dialyse will receive renal palliative care.

Patients who presented with chronic renal failure (CRF) and their families were interviewed by the health care team to explain the prognosis, risks and benefits of RRT, and the option of medical care without dialysis but with palliative care.

The Palliative Care Unit provides a comprehensive range of services including inpatient, outpatient, home care and day care.

Renal palliative care not only involved the management of medical problems but also addressed the ESRD-related symptoms and psychosocial and spiritual issues, with focus on maximizing the QOL of patients and supporting their caregivers.

Length of follow-up:

Not mentioned

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > high education (P<0,001)

C: > age (P<0,001), > public housing (P=0,007), > CCI score (P=0,05),

Not correlated:

Gender,  living with family, friends or alone, religion.

Shih 2014

Type of study:

Retrospective cohort

Setting:

Nation-wide multi-centre

Country:

Taiwan

Source of funding:

This study was supported by grants to Dr. D.C. Tarng from the National Science

Council (NSC 99-2314-B-010-002-MY3 and NSC 102-2314-B-010-004-MY3), Taipei

Veterans General Hospital (V102 C-129), and Ministry of Education’s aim for the Top University Plan.

Inclusion criteria:

- Patients with advanced CKD

- ≥70 years

Exclusion criteria:

Patients with histories of cancer.

- patients receiving

chronic dialysis or kidney transplantation before or

during the 30 days after the index date.

- patients with

follow-up periods <30 days.

N total at baseline:

Intervention: 6292

Control: 2049

Important prognostic factors²:

age ± SD:

I: 78,6 ± 7,1

C: 82,0 ± 6,4

Describe intervention:

Chronic Dialysis, no further explanation.

Describe  control:

Conservative care, no further explanation.

Length of follow-up:

Median follow-up of 2,7 years, with a minimum of 30 days.

Loss-to-follow-up:

Not mentioned

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > male (P=0,042), > diabetes mellitus (P0,08), > dyslipedemia (P<0,001),

C: > age (P=0,001), > CCI (P=0,003), > hypertension KD (P=0,015), > atrial fibrillation (P=0,005), > Valvular heart disease (P<0,001), > parkinsonism (P<0,001)

Not correlated:

Monthly income, glomerulonephritis, vasculitis, hereditary diseases, diabetes, hypertension, autoimmune disease, drug abuse

Costs included in article

Joly 2003

Type of study:

Retrospective cohort

Setting:

Single center

Country:

France

Source of funding:

Not mentioned.

Inclusion criteria:

- Patients with chronic renal failure and creatinine clearance below 10 ml/mn per 1.73 m2;

- ≥80 years;

Exclusion criteria:

-  Patients with acute reversible renal failure in the absence of previous advanced chronic renal failure;

- patients who started dialysis somewhere else and patients who

reached 80 yr of age after dialysis was started were not included;

N total at baseline:

Intervention: 107

Control: 37

Important prognostic factors²:

age ± SD:

I: 83,2 ± 2,9

C: 84,1 ± 2,9

Describe intervention:

Chronic Dialysis proposed.

Describe  control:

Conservative care proposed.

Length of follow-up:

>24 months

Loss-to-follow-up:

No loss-to-follow-up.

Incomplete outcome data:

Not mentioned

Outcome measures and effect size:

Factors significant correlated

I: > Karnofsky score (p=0,03), > phosphate (p=0,013)

C: > social isolated (p=0,003), > late referral (p=0,014), > diabetes (p=0,008),

Not correlated: age, gender, ethnicity, EPO, BMI, Etiology, Comorbidity, Hemoglobin, potassium, bicarbonate,

Proposed treatment