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End-stage kidney disease on dialysis: an observational study of modality change from maximum conservative management
  1. Alvin Shrestha1 and
  2. Aine Burns2
  1. 1 Care of the Elderly, St George's University Hospitals NHS Foundation Trust, London, UK
  2. 2 UCL Centre for Nephrology, Royal Free Hospital, London, UK
  1. Correspondence to Dr Alvin Shrestha, Care of the Elderly, St George's University Hospitals NHS Foundation Trust, London SW170QT, UK; alvinshrestha{at}


Objectives A rising burden from end-stage kidney disease with poor outcomes in the frail, elderly population has seen the emergence of a non-dialytic option, also known as maximum conservative management (MCM). Despite an established MCM programme in our institution, it was anecdotally observed that some MCM patients would end up being dialysed short and long term. We explored treatment modality changes from MCM to renal replacement therapy (RRT), the reasons surrounding the change, and aimed to quantify survival in this cohort of patients.

Methods 44 patients were identified as being MCM, who changed modalities to RRT, from 2000 to 2015, using the Royal Free Hospital Renal Unit’s database. Electronic health records were reviewed retrospectively. Associations with 12-month mortality were explored and Kaplan-Meier method used to predict survival.

Results The most common modality change was to haemodialysis (81%), with one transplantation, and rest peritoneal dialysis. 28 patients commenced dialysis as unplanned starters, with the most common symptom being fluid overload. One-year survival was associated with increased age (75 vs 83, p=0.004, for alive vs dead) and had lower mean Charlson Comorbidity Index (6.2 vs 7.3, p=0.021). Median survival of 65 months following RRT initiation was predicted by the Kaplan-Meier method.

Conclusions Patients changed modalities from MCM to RRT due to symptoms, the most common being fluid overload. Despite an unplanned change to RRT, survival appears to be significant at 65 months in this study, indicating clinicians are continuing to offer RRT to patients appropriately.

  • chronic conditions
  • end of life care
  • renal failure
  • service evaluation

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  • X @alvinshrestha

  • Contributors AS collected the data and initiated the manuscript. AB supervised, gave guidance and reviewed the final report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.