Preparing renal replacement therapy in stage 4 CKD patients referred to nephrologists: a difficult balance between futility and insufficiency. A cohort study of 386 patients followed in Brussels

Background. KDOQI guidelines recommend preparation for renal replacement therapy (RRT) once stage 4 chronic kidney disease (CKD) is reached. Recent studies conducted in the general population and in patients referred to nephrologists have shown that CKD patients, especially the elderly, are much more likely to die than to reach RRT. We investigated whether futile preparation for RRT was performed in CKD patients referred to our nephrology department. Methods. We included all patients (n = 386) with stage 4 CKD and without prior RRT, seen at our outpatient clinic between 1 November 2004 and 30 April 2007. Demographics, clinical and laboratory data at inclusion were collected. Follow-up continued until 1 November 2007 or later (last appointment or study outcome). The primary outcome was death without requiring RRT, and secondary outcomes were RRT, going through our pre-dialysis education programme (PDEP) and undergoing the creation of an arterio-venous fistula (AVF). Factors predicting these outcomes were analysed. Results. During complete follow-up (average 23.4 months), 47 patients (12.1%) died without requiring RRT and 59 patients (15.3%) started RRT. The rate of death without requiring RRT in the overall cohort increased from 50 years onwards and exceeded that of RRT in incident patients aged >= 80 years. A structured PDEP was offered to 66.1% of patients starting RRT vs 14.9% of patients dying without requiring RRT and 13.9% of patients surviving without requiring RRT (P < 0.001). In addition, 53.3% of patients starting haemodialysis had a prior AVF creation vs 6.4% of patients dying without requiring RRT and 5.7% of patients surviving without requiring RRT (P < 0.001). Conclusions. The risk of death exceeds that of RRT in stage 4 CKD incident patients aged >= 80 years referred to our clinic. Futile preparation for RRT was relatively uncommon (14.9%). We were able to largely avoid futility at the expense of incomplete exposure of patients who eventually started RRT, to the structured PDEP, and of a relatively low (53%) level of AVF created prior to start of HD. Whether and how these figures can be improved will require further investigation.