Outcomes and Decision Stability in Older Adults following Structured Counseling on Dialysis versus Conservative Management for Kidney Failure: A Prospective Study.

BACKGROUND

The management of kidney failure in older adults has increasingly adopted patient-centered approaches, with conservative kidney management (CKM) recognized as a valid alternative to dialysis in selected cases. Structured counseling is commonly used to support informed decision-making and align treatment with patient goals. However, evidence on its structured application and impact on treatment decisions in this population remains limited. This study evaluates the clinical characteristics, treatment choices, decision stability, and outcomes of older adults with kidney failure who, after a structured counseling session ("Welcome Meeting") at La Paz University Hospital, chose either CKM or dialysis.

METHODS

This prospective, observational, single-center cohort study (April 2015 to December 2019) included participants aged >75 years with CKD-EPI <12 mL/min (<15 mL/min for those with diabetes), Charlson Comorbidity Index >5, and functional impairment (Barthel Index <95 or Palliative Performance Scale <60). All participants received a structured counseling session to support treatment decision-making. Participants then chose either dialysis or CKM. Predictors included treatment choice, clinical outcomes, symptom burden, and healthcare utilization. Decision stability was defined as sustained adherence to the initial treatment choice over the course of follow-up. Analyses were adjusted for potential confounders including age, sex, comorbidity, and functional status. Data were analyzed using SPSS version 27.

RESULTS

A total of 103 participants were included (mean age: 84.9 ± 5.5 years); 72% chose CKM and 28% opted for dialysis. CKM participants were older, more often female (p = 0.009), and had greater functional and cognitive impairment (p < 0.001). They also reported more weakness or lack of energy (p = 0.03), constipation (p = 0.03), and poor mobility (p < 0.001) at baseline. At the standardized follow-up assessment, depressive symptoms measured with the IPOS-Renal scale showed a significant reduction in the dialysis group (p = 0.043), while vomiting (p = 0.021) and sore or dry mouth (p = 0.049) increased significantly in the CKM group. Healthcare utilization was higher among dialysis participants. Of the 69 deaths, 65 occurred in the CKM group. Decision stability revealed only 5% of CKM participants switching later to dialysis, with no treatment transitions observed in the dialysis group.

CONCLUSION

After a structured counseling session, elderly kidney failure participants who chose CKM were older, female, and presented greater cognitive and functional impairment. This approach supported informed choices and was associated with a high adherence to the initial treatment decision. Further studies are needed to expand this line of research.