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Invited Commentary
January 22, 2019

Active Medical Management for Patients With Advanced Kidney Disease

Author Affiliations
  • 1Department of Occupational Therapy, Tufts University, Medford, Massachusetts
  • 2Department of Community Health, Tufts University, Medford, Massachusetts
  • 3Research on Ethics, Aging, and Community Health, Tufts University, Medford, Massachusetts
  • 4Division of Geriatrics, Department of Medicine, University of California, San Francisco
  • 5Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affair Medical Center, San Francisco, California
JAMA Intern Med. 2019;179(3):313-315. doi:10.1001/jamainternmed.2018.6195

Choosing a treatment for older adults with advanced kidney disease has consequences. For many such patients, dialysis may confer limited survival benefit compared with conservative management, and often reduces quality of life and intensifies end-of-life care. A 2016 systematic review estimated the annual survival of elderly patients (>75 years) undergoing dialysis as 73.0%, compared with 70.6% for patients receiving conservative management.1 Others have found no survival advantage among patients older than 80 years who choose dialysis rather than conservative management.2 Nonetheless, many nephrologists in the United States do not present conservative management as an option for elderly patients with advanced kidney disease. Thus, few patients perceive the initiation of dialysis to be a choice.3 Clinical guidelines have long called for shared decision making in the initiation of dialysis, as the decision is sensitive to patient preferences. Although shared decision making is widely supported, it has not been widely adopted.

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