Temporal Trends in Decisions to Forgo KRT.

key pointsApproximately 6% of patients approaching kidney failure forgo dialysis, a proportion that has remained unchanged over the recent decade. Treatment with dialysis is more common in the United States than in other developed countries and even in not-for-profit US health systems. There is need to develop services, and the nephrology workforce to ensure conservative management is a viable treatment option.

backgroundAfter decades of rise, dialysis initiation rates are now declining. In parallel, conservative kidney management has emerged as an important therapeutic alternative to dialysis. However, contemporary trends in patients opting to forgo dialysis are poorly understood.

methodsThis retrospective cohort study included adults with advanced kidney disease as defined by ≥2 outpatient measures of eGFR ≤15 ml/min per 1.73 m 2 for ≥90 days, who were receiving care in a large US health system between 2012 and 2020. Patients were followed through death or December 31, 2022. Administrative codes were used to identify patients who received KRT during follow-up. For remaining patients, documentation in their clinical progress notes was reviewed to determine the KRT decision made closest to the end of follow-up. Descriptive analyses evaluated trends in the distribution of treatment decisions made in 3-year periods (2012-2014, 2015-2017, and 2018-2020) and stratified by age group (<65, 65-74, 75-85, and ≥85 years).

resultsAmong the 12,678 patients in the cohort (age 66±15 years, 49% non-Hispanic White, 52% male), 90% received KRT on the basis of either administrative codes or chart documentation, 4% had been discussing and/or preparing for KRT, and 6% decided against KRT over a median follow-up of 3 (1-5) years. The distribution of KRT decisions did not meaningfully change over time. The proportion of patients in 2012-2014, 2015-2017, and 2018-2020 who went on to be treated with KRT was 90%, 91%, and 90%, respectively. Across the same periods, 7%, 6%, and 6% of patients had forgone KRT, respectively. The distribution of KRT decisions remained stable for all age groups over time.

conclusionsForgoing KRT is uncommon. Over the recent decade, most patients approaching kidney failure receive or are preparing to receive KRT, underscoring its continued use as a default approach to kidney failure care.