Clinical and patient-reported trajectories at end-of-life in older patients with advanced CKD

Background We explore longitudinal trajectories of clinical indicators, patient-reported outcomes, and hospitalizations, in the years preceding death in a population of older patients with advanced chronic kidney disease (CKD). Methods The EQUAL study is a European observational prospective cohort study with an incident eGFR Results We included 661 decedents with a median time to death of 2.0 years (IQR 0.9-3.2). During the years preceding death, eGFR, Subjective Global Assessment score, and blood pressure declined, with accelerations seen at 6 months preceding death. Serum hemoglobin, hematocrit, cholesterol, calcium, albumin, and sodium values declined slowly during follow-up, with accelerations observed between 6 and 12 months preceding death. Physical and mental quality of life declined linearly throughout follow-up. The number of reported symptoms was stable up to 2 years prior to death, with an acceleration observed at 1 year prior to death. The rate of hospitalization was stable at around one hospitalization per person year, increasing exponentially at 6 months preceding death. Conclusions We identified clinically relevant physiological accelerations in patient trajectories that began similar to 6 to 12 months prior to death, which are likely multifactorial in nature, but correlate with a surge in hospitalizations. Further research should focus on how to effectively use this knowledge to inform patient and family expectations, to benefit the planning of (end-of-life) care, and to establish clinical alert systems.

Automated summary

This study explores the longitudinal trajectories of clinical indicators, patient-reported outcomes, and hospitalizations in older patients with advanced chronic kidney disease (CKD) before death. The results show that eGFR, Subjective Global Assessment score, and blood pressure decline, with accelerations observed 6 months before death. Serum hemoglobin, hematocrit, cholesterol, calcium, albumin, and sodium values decline slowly during follow-up, but with accelerations observed between 6 and 12 months before death. Physical and mental quality of life decline linearly, while the number of reported symptoms remains stable up to 2 years before death, accelerating at 1 year before death. The rate of hospitalization remains stable at around one hospitalization per person year, but increases exponentially 6 months before death.