Abstract
Background and Aims
EDTA published data gathered between 2012 and 2016 showed greatly reduced survival in elderly prevalent dialysis patients as compared to similar aged individuals in the general population: a 70 year-old dialysis patient had a life expectancy of 5 years (instead of 16), an 80 year-old patient could expect to survive 3 years (instead of 9). This was due to the multiple comorbidities often present in elderly patients with advanced Chronic Kidney Disease (CKD). This burden of disease is further increased by dialysis itself, in particular by hemodynamic instability during treatment and by vascular access problems which often determine the need for central venous catheter insertion and for hospitalization. In 2007 the DODE study (a randomized, controlled, multicentric study in which our center took part) validated a conservative treatment of uremia based upon a Very Low Protein Diet supplemented with ketoanalogues (sVLPD): survival in patients on conservative management was similar to that of patients on chronic dialysis; also, no negative effect on nutritional status was observed. Our aim was to analyse clinical and epidemiologic data and outcomes of patients treated at our center with a sVLPD.
Method
We analized 222 selected from a group of approximately 300 patients with stage 5 CKD managed conservatively with a sVLPD (0.3 g/kg/day proteins). The inclusion criterion was active follow-up for at least six months; patients unable to maintain fluid and electrolyte balance with medical therapy were excluded. Except for one patient, all subjects were aged 75 years and older. Clinical and epidemiologic data were recorded at the beginning, during and at the end of follow-up.
Results
Mean age at the beginning of observation was 80 ± 7 years (51-96); 48% of patients were male (107), 52% were female (115). Median initial Renal Residual Function (RRF, ml/min) was 6,3 ± 2,1 ml/min, at the end of follow-up it was 5,3 ± 2,9 ml/min. The most common significant comorbidities were hypertension (84,5%), heart (61,4%) and vascular disease (48,6%); these and other significant comorbidities are illustrated in Fig. 1. Conservative management allowed to delay the initiation of dialysis by an average of one year; 24% of patients continued on the sVLPD for two year and some patients reached a duration of treatment of 7 years. Median duration of sVLPD is shown in Fig. 2. At the end of follow-up 40% of patients had begun chronic hemodialysis and 9% peritoneal dialysis, 8% were still on conservative management, 27% were deceased (Fig. 3).
Conclusion
The supplemented Very Low Protein Diet is an effective treatment which can delay the beginning of chronic dialysis in elderly stage 5 CKD patients with multiple comorbidities. It is a safe treatment and does not increase morbility and mortality. Current epidemiologic data (incident patients in dialysis: 170 pmp/year, 50% aged over 70 years old) support the use of this conservative strategy which can represent a valid alternative to dialysis in selected patients.
Long-term outcome on renal replacement therapy in patients who previously received a keto acid–supplemented very-low-protein diet
