Clinical Pearls

Advance Care Planning for End-Stage Renal Disease (ESRD)

Niharika Ganta, MD MPH; Amar Bansal, MD; Nina O’Connor, MD

Patients with end-stage renal disease (ESRD; advanced chronic kidney disease Stage V with an estimate glomerular filtration rate less than 15 mL/min) share several characteristics that make them an ideal population for increasing palliative care collaboration. ESRD patients have a high mortality rate, comparable to cancer, and high symptom burden with a majority of patients reporting at least three distressing symptoms such as pain, fatigue, and pruritus.¹

When managing ESRD, it is important to recognize that not all patients will benefit from dialysis. One recent systematic review of elderly ESRD patients reported a 1-year survival of 73% with any dialysis modality (95% confidence interval 66.3%–79.7%) versus 70.6% with supportive care (95% CI 63.3%–78.0%).² A recent retrospective cohort study of dialysis versus nondialytic management found no survival benefit with dialysis in patients ≥ 80 years of age or patients ≥ 70 years of age with multiple comorbidities.³ The same study found that elderly patients with cardiovascular disease are the least likely to derive survival benefit from dialysis.³