Dialysis Discontinuation, Prognosis, and Shared Decision-Making

Dialysis discontinuation (withdrawal) generally refers to the intentional cessation of dialysis in patients with end-stage kidney disease (ESKD), a decision often made collaboratively by the patient, their family, and the healthcare team, considering the patient's overall medical condition, quality of life, and personal preferences. Practices for dialysis discontinuation vary around the world and many factors such as social, economic, religion, cultural and ethical are involved (1Chen J.H.C. Lim W.H. Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice.Nephrology. 2022; 27: 551-555Crossref Scopus (3) Google Scholar,2Davison S.N. Levin A. Moss A.H. Jha V. Brown E.A. Brennan F. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.Kidney International. 2015; 88: 447-459Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Reasons for dialysis withdrawal include medical factors (comorbidities, dialysis access difficulties), psychosocial factors (mental health burden, financial limitations, lack of social supports), and alternative dialysis approaches (palliative dialysis or time-limited dialysis trial) (1Chen J.H.C. Lim W.H. Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice.Nephrology. 2022; 27: 551-555Crossref Scopus (3) Google Scholar). For hemodialysis (HD), common reasons for withdrawal include multiple HD access failure, acute medical complications (hypotension, cramps, life threatening arrhythmias), chronic debilitating problems, chronic failure to thrive/frailty, logistic and financial reasons (3Bhojaraja M. Singhai P. Sunil Kumar M. Sreelatha M. Withdrawal from Dialysis: Why and When?.Indian J Palliat Care. 2021; 27: S30-S32Crossref Scopus (5) Google Scholar). Data from Neu and Kjellstrand’s seminal study which evaluated dialysis discontinuation in 155 of 1,766 patients with end-stage kidney disease (ESKD), found that dialysis withdrawal accounted for the 22% of deaths. (4Neu S. Kjellstrand C.M. Stopping Long-Term Dialysis.N Engl J Med. 1986; 314: 14-20Crossref PubMed Scopus (0) Google Scholar) Currently, annual mortality for patients receiving dialysis is approximately 20%, and dialysis withdrawal is a common cause of death for patients worldwide (2Davison S.N. Levin A. Moss A.H. Jha V. Brown E.A. Brennan F. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.Kidney International. 2015; 88: 447-459Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). In the Netherlands, dialysis withdrawal increased as cause of the death, from 18.3% in 2004 to 26.6% in 2015-2019 (5van Ovelen M. Abrahams A.C. Bos W.J.W. Hoekstra T. Hemmelder M.H. Dam Mt et al.Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation.Nephrol Dial Transplant. 2021; 36: 2112-2119Crossref Scopus (10) Google Scholar). Studies analyzing nephrologists’ attitudes and approaches to dialysis withdrawal have found that, in the US, nearly 90% of nephrologists had withheld dialysis at least once, and over 30% had withheld dialysis 6 times or more (6Cohen L.M. Germain M.J. Poppel D.M. Practical Considerations in Dialysis Withdrawal “To Have That Option Is a Blessing”.JAMA. 2003; 289: 2113-2119Crossref PubMed Scopus (0) Google Scholar). In Canada, withholding dialysis was reported in about 25% of referred patients. (6Cohen L.M. Germain M.J. Poppel D.M. Practical Considerations in Dialysis Withdrawal “To Have That Option Is a Blessing”.JAMA. 2003; 289: 2113-2119Crossref PubMed Scopus (0) Google Scholar) Dialysis withdrawal is more common among older compared to younger nondiabetic patients, and twice as common in nondiabetic patients with other degenerative disorders, patients receiving intermittent peritoneal dialysis (PD), and in patients living in nursing homes (4Neu S. Kjellstrand C.M. Stopping Long-Term Dialysis.N Engl J Med. 1986; 314: 14-20Crossref PubMed Scopus (0) Google Scholar). Additional risk factors include older age, female sex, increasing dialysis vintage, HD, and more recent year of death. (5van Ovelen M. Abrahams A.C. Bos W.J.W. Hoekstra T. Hemmelder M.H. Dam Mt et al.Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation.Nephrol Dial Transplant. 2021; 36: 2112-2119Crossref Scopus (10) Google Scholar) Although risk patterns for dialysis discontinuation are well described, gaps remain in understanding how and when to discontinue dialysis, and how to guide patients about their prognosis. Dialysis discontinuation should follow a shared decision-making model, a process whereby patients, clinicians, and often care partners consider the benefits and burdens of treatment, treatment goals, quality of life, patient preferences, and prognosis to achieve goal-concordant care. Prognosis is a key factor in shared decision-making, and in the context of dialysis withdrawal, previous studies have estimated that the average time to death following dialysis withdrawal is approximately 3 to 10 days (1Chen J.H.C. Lim W.H. Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice.Nephrology. 2022; 27: 551-555Crossref Scopus (3) Google Scholar). In this issue of KI Reports, So and Li’s study, “Prognostication After Dialysis Withdrawal” describes the median survival time after withdrawal of dialysis and identifies patient and dialysis-related factors significantly associated with prognosis. (7So S. Li K.C. Prognostication After Dialysis Withdrawal.Kidney International Reports. 2024; Abstract Full Text Full Text PDF Scopus (0) Google Scholar) This retrospective cohort study of 239 patients from Australia (186 on hemodialysis (HD) and 53 on peritoneal dialysis (PD)), found similar prognosis overall, and no significant differences in survival time from last dialysis to death by dialysis modality (4 days for the PD group, 6 days for the HD group; p=0.72). However, among PD patients, withdrawal for psychosocial reasons was associated with a longer median survival time (p=0.002). For HD patients, variables associated with longer survival time included the reason for withdrawal (p=0.001), urine production (p=0.005), serum sodium levels (p=0.005), and smoking status (p=0.009). This study presents an important contribution in clarifying the prognosis for PD patients following dialysis withdrawal, and clarifying the differing reasons for patients withdrawing from HD and PD. In 2000, the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) comprised a working group and published the “Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis”. These guidelines included considerations for dialysis withdrawal, emphasizing a shared decision-making framework and best practices for end-of-life care (Figure 1) (6Cohen L.M. Germain M.J. Poppel D.M. Practical Considerations in Dialysis Withdrawal “To Have That Option Is a Blessing”.JAMA. 2003; 289: 2113-2119Crossref PubMed Scopus (0) Google Scholar,8Galla J.H. Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis.J Am Soc Nephrol. 2000; 11: 1340-1342Crossref PubMed Google Scholar). This process includes preparatory psychological counseling and support, a clear decision to stop dialysis, and palliative care, hospice, and spiritual supports aimed at helping patients achieve their goals of care and maintain dignity at the end of life. (6Cohen L.M. Germain M.J. Poppel D.M. Practical Considerations in Dialysis Withdrawal “To Have That Option Is a Blessing”.JAMA. 2003; 289: 2113-2119Crossref PubMed Scopus (0) Google Scholar) The “Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease” provides further endorses shared decision-making and offers guidance for dialysis withdrawal following ethical considerations which aim to balance principles of beneficence, nonmaleficence, and justice. (2Davison S.N. Levin A. Moss A.H. Jha V. Brown E.A. Brennan F. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.Kidney International. 2015; 88: 447-459Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar) The KDIGO guidance notes that clinicians must first attend to treatable factors, such as depression or pain, and reversible social issues that might influence the patient's decision to stop dialysis. They also note the importance of patient autonomy in deciding when and how to discontinue dialysis, and reliance on surrogate decision-makers in cases where patients lack capacity for medical decision-making. Access to suitable supportive or hospice care is essential following the decision to withdraw dialysis. With the aging from the population, and the increasing of people reaching ESKD, dialysis withdrawal is likely to become increasingly prevalent. Dialysis withdrawal is of particular concern and poses unique challenges for patients with dementia, as they are unable to make their own medical decisions. In the US, patients with ESKD have a 2–7-fold higher prevalence of cognitive impairment and dementia compared with the general population. Moreover, patients with dementia face adverse risks and poorer outcomes. A study using data from the US, Japan, France, Italy, Germany, Spain, and the UK, found that dementia has been associated with an increased risk of death [RR 1.48, 95% confidence interval (CI) 1.32–1.66] and dialysis withdrawal (RR 2.01, 95% CI 1.57–2.57). This underscores the importance of kidney clinicians engaging patients in early advance care planning discussions, including about dialysis initiation, and potentially routine screening for cognitive impairment as well (9Kurella M, Mapes DL, Port FK, Chertow GM. Correlates and outcomes of dementia among dialysis patients: the Dialysis Outcomes and Practice Patterns Study. Nephrology Dialysis Transplantation. ; 21(9): 2543-2548.Google Scholar). The decision to discontinue dialysis involves complex ethical considerations to ensure that patient wishes are honored. Cultural and religious beliefs may also influence the decision-making process and should be thoughtfully considered by the healthcare team. Kidney clinicians should engage patients early in discussions about the option to discontinue dialysis, the circumstances and factors that would influence their preference to continue, and the implications for their quality of life and prognosis. The initiation of dialysis presents a critical opportunity to discuss the possibility of withdrawal and document advance care plans, though unfortunately, this issue is rarely addressed. (1Chen J.H.C. Lim W.H. Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice.Nephrology. 2022; 27: 551-555Crossref Scopus (3) Google Scholar) Where possible, care partners, social work, and palliative care teams should be involved in these early discussions. Guidelines should be adapted for political, religious, or cultural issues in every country. DAM – declared no conflict of interest. KL - declared no conflict of interest. Prognostication After Dialysis WithdrawalKidney International ReportsPreviewDialysis withdrawal represents an increasingly common cause of death in patients receiving kidney replacement therapy internationally. Prognostic information about stopping dialysis guides clinicians counseling patients and families regarding end-of-life care. However, few studies examine prognostication after withdrawal. We aimed to determine median survival time after withdrawal of dialysis, and to determine which patient and dialysis-related factors are significantly associated with prognosis. Full-Text PDF Open Access

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