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Abstract:

Objective . Primary objective . To determine survival and survival predictive factors in advanced chronic renal failure ( ACRF ) patients not considered candidates for renal replacement therapy ( RRT ) . Secondary objectives . To describe : a ) the sociodemographic characteristics of the patients and the main caregiver ; b ) the aetiology and associated comorbidity of the nephropathy ; c ) the clinical variables of patients when they are included in the programme ; d ) the clinical outcome in terms of blood pressure ( BP ) , episodes of fluid overload , treatments received , frequency of hospitalisation , causes of hospitalisation , place and cause of death ; e ) the evolution of analytical parameters ; f ) the degree of information about diagnosis and prognosis given to the patient and family , and g ) care activity provided by the domiciliary palliative care support team ( DPCST ) during follow - up . Material and method . Design . Longitudinal descriptive study of a historical cohort . Scope . DPCST of Madrid areas 1 , 5 and 7 . Study subjects . Patients with ACRF not considered candidates for RRT . Selection criteria . 1 ) patients with ACRF considered and rejected for extra - renal depuration , and 2 ) the patient and/or caregiver and/or family had accepted follow - up by the DPCST and/or his or her Primary Care physician . Sample size . All clinical histories from the archives of the DPCSTs were selected , from 1997 up to December 2009 . Variables analysed . 1 ) Main answer : time of survival ; 2 ) secondary variables : 2 .1 ) sociodemographic characteristics of patient and caregiver : age and gender ; main caregiver : marital status , kinship ; 2 .2 ) variables related to the renal disease : the aetiology of the nephropathy , reason for exclusion from RRT , comorbidity ; 2 .3 ) clinical variables : degree of BP control during evolution of disease ; measurements from several visits were collected ; at initiation of programme , the presence or absence of the following was recorded : oedema , pain , constipation , pruritus , dyspnoea , insomnia , anxiety , sadness and cognitive deterioration ; number of episodes of fluid overload ; cause for exiting the programme ; place of death ; cause of death and symptoms observed in last days situation ; 2 .4 ) therapeutic variables : number of medications at beginning of programme , number of medications at time of exiting the programme , when cause of exit was death ; type of medications ; number of transfusions received ; 2 .5 ) variables of hospital admission : number of admissions ; causes of admission ; 2 .6 ) analytical variables : degree of control of analytical parameters during illness until death ; 2 .7 ) variables on the degree of information about diagnosis and prognosis ; 2 .8 ) variables of care activity : number of domiciliary visits to the patient . Results . N : 102 patients . Mean age : 76 .92 ( 9 .94 ) years . Aetiology ACRF : vascular 37 , unknown origin 32 , diabetic 15 . Comorbidity : low risk SCG 17 ; medium risk SCG 35 ; high risk SCG 50 . Median Charlson comorbidity index : 6 .88 ( 2 .5 ) . Cause for rejection for RRT : comorbidity 47 .5% , age 25 .7% , patient's decision 22 .8% , others 4% . Degree of information about diagnosis to patient and caregiver : 57 .9 and 94 .4% , respectively . Degree of information about prognosis to patient and caregiver : 11 .8 and 90% , respectively . Symptoms on first visit : dyspnoea 33 .3% , pruritus 30 .4% , insomnia 34 .3% , sadness 36 .3% , oedema 43 .1% . Average medications at beginning of follow - up : 10 . At the end : 11 . Number of transfusions : 5 . Number of hospital admissions : 50 ; caused by fluid overload : 35 , comorbidity : 12 , oliguria : 3 . Cause of death : ACRF 72 .9% , intercurrent illness 27 .1% . Place of death : home 39 , acute hospitalization ward 31 , palliative care ward 13 , emergency room 2 . Average of visits by DPCST : 11 .32 , median 6 .5 . Average survival : 4 months , survival at one year : 25% . Predictive survival factors : creatinine on first visit HZ 1 .106 ( 95% CI 1 .01 - 1 .20 ) , p= .024 ; age 71 - 80 years , HZ 4 .42 ( 95% CI 1 .60 - 12 .21 ) , age>81 years , HZ 2 .97 ( 95% CI 1 .16 - 7 .61 ) . The following were not associated with survival rates : BP , volume of diuresis , levels of sodium , potassium , calcium , phosphorus and haemoglobin . Conclusions . ACRF patients rejected for RRT receiving domiciliary follow - up by palliative care teams had an average survival of 4 months ; age and residual renal function were predictive factors for survival , whereas comorbidity , electrolyte levels , BP and diuresis were not . During follow - up , the most frequent cause of hospital admission was fluid overload . Most patients died because of disease progression , at home or in a palliative care medium - long term hospital ward . 
cognitive deterioration