THE OUTCOME OF PATIENTS WITH CKD STAGE 5(ESRD) TREATED CONSERVATIVELY AT SHEFFIELD KIDNEY INSTITUTE (SKI) OVER THE LAST 103 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) ISSN (Print) 2313-4410, ISSN (Online) 2313-4402 © Global Society of Scientific Research and Researchers http://asrjetsjournal.org/ Prototypical Study Detecting the Outcome of Patients with CKD Stage 5 (ESRD) Treated Conservatively (PSCKD5C), at Sheffield Kidney Institute (SKI) over a Period of 5 Years Dr. Mohamed Al-helfawia*, Dr. Amal Whidab aMedical Tripoli Center-Department of Nephrology.Tripoli-Libya,kortoba 39-5, . MmedSci. Sheffield Kidney Institute. UK bHigh Institute of Sciences and Medical technology.AbuSalem.Tripoli-Libya,Kortoba 39-5, Msc. Department of Biomedical Sciences.UWIC. UK aEmail: helfawi_65@yahoo.com bEmail: amal.w.almasri@gmail.com Abstract Very few studies have investigated and made decisions regarding RRT in elderly patients, and their conclusions are rather discordant [1,2,3,4,5,6,7,8,9,10]. Treatment option for ESRD (End Stage Renal Disease) is to decide not to have dialysis or transplantation and to manage such a condition medically with blood pressure control, dietary restrictions, and adjustment of medical regimen. This is known as conservative management. The increase in the ESRD (end stage renal disease), primarily due to the increasing of Diabetes and age of the population. It is a serious medical and economic public health problem throughout the world, and it has become a health concern both medically and economically [11]. Keywords: CKD5; (Chronic kidney disease stage 5). CKD5; (Chronic kidney disease stage 5 treated conservatively). COPD; (Chronic obstructive pulmonary disease). CI ; (Confidential interval). CVD; (Cerebrovascular disease). DM ; (Diabetes Mellitus). eGFR; (Estimated Glomerular filtration rate). ESRD ; (End stage renal disease). IHD ; (Ischemic Heart disease). KDOQI ; (Kidney Disease Outcomes Quality Initiatives). PVD ; (Peripheral Vascular Disease). RRT ; (Renal Replacement Therapy). RRT ; (Renal Replacement Therapy). SD ; (Standard deviation). SK ; (Sheffield Kidney Institute). t test ; (Student t-test). X² ; (Chi-square test). ------------------------------------------------------------------------ * Corresponding author. http://asrjetsjournal.org/ American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 104 1. Introduction Patients undergoing treatment for CKD 5 (Chronic kidney disease stage 5) represent a group with higher mortality compared with the general population, even when adjusted for age, race, sex, and co-morbid conditions and I focused on 84 patients (40 of them died) treated conservatively at SKI (Sheffield Kidney Institute), another 84 dialysis patients have also included in the study as a control group over 5 years duration. These patients are at increased risk for various life-threatening complications, including atherosclerotic disease, left ventricular hypertrophy, malnutrition, and infection. Clinicians should have to make decision about RRT (Renal replacement therapy) versus Conservative therapy, and to study factors influencing the recommendation for palliative (non-dialysis) treatment in patients preferring not to dialyze. 2. Methods The statistical analysis expressed as numerical values and percentages for categorical variables and as a means (±SD) for continuous variables. Frequency and cross tables have been used and comparison between category 1 and category 2 were based on the X²(Chi-square test) for categorical data and t test (Student t-test) for continuous data. Survival methods were computed using life-table method namely the Kaplan-Meier survival curves. 3. Results/Conclusion (80 years) is the mean age of the patients treated conservatively compared with 70 years in Dialysis group. Improving quality of life, further intention towards medical managements and tracing the diseases that contribute to the decline in renal function might give rise to a better outcomes, the main survival time is around 2.7 years, the majority prefer conservative management rather than dialysis, 40% are progressors. Comorbidities affect the survival time of the Conservative as well as the Dialysis patients. Diabetes play a major role as a cause of renal failure and it is the most predictor variable for survival. High quality conservative care is a viable. 4. Material and Methods Study site The Sheffield Kidney Institute (SKI) was founded in 1990, bringing together all the clinical and research activities in the field of nephrology in the city of Sheffield within a purpose built 60-bed unit. The SKI is situated at the Northern General Hospital Campus of the Sheffield Teaching Hospital Foundation Trust, where it provides a regional service within Sheffield and its surroundings (mid-land) in nephrology for a population approaching 1.7 million. It corporate all acute and chronic nephrology services. Patients Between Jan. 2006, and Jun. 2010, 168 patients have been collected from computerized saved data to be studied to know the finding of their conservative management, 98 patients under conservative management, 14 of them excluded from the study as they were not fit the KDOQI (Kidney Disease Outcomes Quality Initiatives) diagnostic criteria of CKD 5 (eGFR< 15 ml/min/1.73 m²). So the actual number of patients treated conservatively was 84 patients (45 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 105 males and 39 females), 40 of them died earlier over the period. The remaining 84 patients (55 males and 29 females) on regular dialysis 17 of them have also died during the study. The Mean age for the conservative and dialysis patients was (80 years, standard deviation 7), (70 years, standard deviation 8) respectively. Patients who have been under conservative managements continued to benefit from regular follow-up in close cooperation with the family doctor, symptoms present in patients with ESRD and which are generally not well managed, including pruritus, nausea, constipation, fatigue, neuropathy, cramps, pain, anxiety, depression and psychological concerns over dependence. It should be obvious therefore that supportive care is not solely of use at the end of life, but should be an adjunct to the management of patients at all stages of their illness. Supportive care should be available to patients at the time of diagnosis. It does not simply mean conservative care in dialysis and does not mean any treatment. Patient who has been offered conservative or supportive management (rather than dialysis) must be on regular follow up [12]. Identification of factors influencing the conservative group and it’s comparison with the dialysis one has influenced the therapeutic proposals and made the survival analysis taken into account effective factor for my study. Data Organization: The day of clinical and laboratory data collection and starting of study was defined as the first day of CKD 5 diagnosis at which the first value of eGFR(estimated glomerular filtration rate) was taken. Survival duration was measured as the number of years and months from the diagnosis until death or latest news. The dialysis category has been collected randomly over the same period of time (one patient for every 15 patients). Variables collected were: age(two groups,<70and >70/<80and>80 years), gender, ethnicity, time of diagnosis, Causes of ESRD, presence or absence of eight co morbid conditions (heart failure, ischemic heart disease, cerebrovascular disease, peripheral vascular disease, diabetes, chronic obstructive airway disease, dementia and cancer). 5. Statistical Analysis The statistical results are expressed as Numerical values and percentages for categorical variables and as a means (±SD) for continuous variables. Comparison between category 1 and category 2 were based on the X²(Chi-square test) for categorical data and t test (Student t-test) for continuous data. Survival curves from date of diagnosis of stage 5 CKD to last news (date at time of end point eGFR) were computed using life-table methods. I used Kaplan-Meier survival curves to compare survival in both categories in respect of (age, gender, ethnicity, heart failure, ischemic heart disease, cerebrovascular disease, peripheral vascular disease, diabetes, chronic obstructive airway disease, dementia and cancer).. Kaplan-Meier survival method with log- rank test has also been included in the analysis as it is useful for comparing survival curves in two or more groups. All data of the study has been collected from SKI (PROTON) data base which shows detailed programmed regular follow up in terms of exploring patients complaint, investigations, clinical examination, Doctors opinions and managements, part of the data collected from patients notes, there are missing data ignored from the statistical analysis which was performed using the SPSS 14.0 software package for PC computer. The practicing of all the above statistical analysis tests are the ideal components of this prototypical study (PSCKD5C). Performing such a study is intended for CKD5 as it carry a controverters in managements American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 106 between different institutes. 6. Results Table 1: Comparison between conservative and dialysis statistical data Conservative Dialysis Age Mean 80 70 Std Deviation 7 8 Gender female Count 39 29 Col % 46.4% 34.5% Male Count 45 55 Col % 53.6% 65.5% Race White Count 55 74 Col % 93.2% 91.4% Non White Count 4 7 Col % 6.8% 8.6% Diabetes Mellitus No Count 62 58 Col % 73.8% 82.9% Yes Count 22 12 Col % 26.2% 17.1% Heart failure No Count 67 70 Col % 79.8% 100.0% Yes Count 17 Col % 20.2% I.H.D* No Count 59 46 Col % 70.2% 65.7% Yes Count 25 24 Col % 29.8% 34.3% C.V.D* No Count 69 64 Col % 82.1% 91.4% Yes Count 15 6 Col % 17.9% 8.6% P.V.D* No Count 67 57 Col % 79.8% 81.4% Yes Count 17 13 Col % 20.2% 18.6% COAD* No Count 69 59 Col % 82.1% 84.3% Yes Count 15 11 Col % 17.9% 15.7% Dementia No Count 78 70 Col % 92.9% 100.0% Yes Count 6 Col % 7.1% Cancer No Count 69 61 Col % 82.1% 87.1% Yes Count 15 9 Col % 17.9% 12.9% American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 107 During the years of observation period, 168 patients with CKD (Chronic kidney disease) stage 5 and calculated eGFR (Estimated glomerular filtration rate) of <15ml/min/1.73m² was followed in SKI by using MDRD (Modification of diet in renal disease) formula. Demographic and medical characteristics included in this study that compares conservative with dialysis groups are shown on( table 1. Table 2a, Table 2b): Frequency *IHD= ( Ischemic heart disease ). *CVD=(Cerebrovascular disease). *PVD=(Peripheral vascular disease).*COPD=(Chronic obstructive pulmonary disease). Table 2a: Age group 1: Crosstab Group belonging to Total conservative dialysis Agegroups1 Less than 70 years Count 7 40 47 % within Agegroups1 14.9% 85.1% 100.0% % within Group belonging to 8.3% 47.6% 28.0% More than 70 years Count 77 44 121 % within Agegroups1 63.6% 36.4% 100.0% % within Group belonging to 91.7% 52.4% 72.0% Total Count 84 84 168 % within Agegroups1 50.0% 50.0% 100.0% % within Group belonging to 100.0% 100.0% 100.0% Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Point Probability Pearson Chi-Square 32.170(b) 1 .0001 .0001 .0001 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 108 Table 2b: Age group2: Crosstab Group belonging to Total conservative dialysis Agegroups2 Less than 80 years Count 35 74 109 % within Agegroups2 32.1% 67.9% 100.0% % within Group belonging to 41.7% 88.1% 64.9% More than 80 years Count 49 10 59 % within Agegroups2 83.1% 16.9% 100.0% % within Group belonging to 58.3% 11.9% 35.1% Total Count 84 84 168 % within Agegroups2 50.0% 50.0% 100.0% % within Group belonging to 100.0% 100.0% 100.0% Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Point Probability Pearson Chi-Square 39.734(b) 1 .0001 .0001 .0001 Furthermore, factors including a patient's spiritual beliefs and the extent of the patient's social support network are important predictors of quality of life [13]. So there is controversy whether to choose conservative option or dialysis, the economic pressure for conservative treatments may prove hard to resist. Patients have also the right to have the legal choice (e.g. Patient self discrimination act) to refuse or accept medically indicated treatment. Patient therefore require careful counseling about the most appropriate treatment option, such issues should involve senior nurses, renal counselors and social workers assessing the patients in terms of understanding of their illness, functional capacity and dependency, and their family and social support, and to provide the prognosis and treatment options. The option not to dialyze should be part of the discussion with the patient and supported by a plan to offer support to individual and family, including community agencies, this is not rationing dialysis but rational dialysis, i.e. limiting the use of dialysis therapy in circumstances that render them detrimental, for instance, Patients with co morbidities that could not tolerate dialysis. Here comes the role of conservative management which aims to improve quality of life and treat uraemic symptoms, while fully supporting the patient and answering all their questions [13]. On the other hand, it is the duty of physicians to identify the clinical fitness and any comorbid conditions through the clinical follow up and decide whether to American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 109 commence conservative management or not. In circumstances where there are discrepancy (patient refusal) between the doctor and the patient opinions in SKI, both sides must be taken into consideration and one decision is sorted out to be medically satisfactory after discussion, the patient must be willingly agreed and satisfied. Reason for choice of Conservative managements: All of the choices are joint decision between the patient and the doctor despite that most of the patients in SKI prefers the Conservative option rather than renal replacement therapy for a number of reasons mentioned below: 1. Frail and Comorbid patients. 2. Social reasons. 3. Quality of life. 4. Refuse RRT. 5. The demented patients the only option is Conservative. 6. Patients with sever disability (Rheumatoid arthritis) cold not tolerate prolonged hours under Dialysis. Among the conservative group, 40% of Conservative patients considered to be progressors (their eGFR>1 ml/min/1.73m²) while 60% are non-progressors as their (eGFR <1 ml/min/1.73m²).Percentage change of renal function deterioration over the last 5 years among the (conservative group ) is 20% fall per year as shown in figure 1 and table 3: Figure 1 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 110 Table 3: The mean percentage change of eGFR (start or mean as baseline). Group belonging to N Mean Std. Deviation Std. Error Mean percent progression (start as baseline) conservative 78 -19.7835 34.23240 3.87606 percent progression (mean as baseline) conservative 78 -30.0270 44.17960 5.00235 Table 4: Paired samples test. Paired Differences t df Sig. (2- tailed) Group Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference Lower Upper 1 2.308 3.922 .444 1.423 3.192 5.196 77 .000 2 -7.465 10.793 1.164 -9.779 -5.151 - 6.414 85 .000 Most of the patients submitted to conservative or dialysis measures underwent regular follow up at SKI out patient department for every 2, 4, 6 weeks or longer according to the patient clinical conditions, 40 patients were lost (died) over the period of study in the conservative group. Over this period, the mean survival time is 33.9 months (95% confidential interval, 25 to 42) and the median is 27.4 months (95% confidential interval, 22 to 32) in patients treated conservatively (P =0.0001) . Looking at the Kaplan-Meier survival curve shown below, figure 1. Generally, I found that dialysis patients live longer than conservative one (a round 7 years and more than 3 years respectively). There is a dramatic deterioration in renal function in the conservative group compared with a gradual decline in renal function in dialysis group. 50% survival is 3 years for the conservative patients while more than 7 years in the dialysis group (P value 0.001), after this period, most of the dialysis patients (a round 50%) still survive while most of the conservative patients have died already. That means the cumulative Hazard increases with time which is much more obvious with the Conservative patients, figure 3. Overall comparisons of statistical significance are shown in figure 7 and 8: American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 111 Figure 2: Kaplan-Meier survival curve Comparing the survival function between Conservative and Dialysis Patients. Figure 3: Kaplan-Meier survival curve comparing the cumulative Hazard between Conservative and Dialysis Patients Table 4: Overall Statistical Comparisons between Conservative and Dialysis groups.Test the equality of survival distributions for the different levels of both groups. Chi-Square df Sig. Log Rank (Mantel- Cox) 41.391 1 .000 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 112 Survival time function depends on many factors. For instance, the medical causes of CKD 5(Table 7), age of patients and the associated co morbidities that the patients had. It is obvious from the survival analysis of each comorbidity, the most statistical significant condition is Diabetes (P value=0.002), others are not significant. Table 5: Causes of Renal Failure in the Conservative group: Serial no. Cause of Renal Failure No.of Pt. Percent 1 Renovascular disease 10 11.90% 2 Diabetes 18 21% 3 Obstructive Uropathy 10 11.90% 4 Malignancy/Myelomatosis 8 9.50% 5 Hypertension 14 16.60% 6 Renal Stones 6 7.10% 7 Others 18 21% Total 84 100% Cause of death in the Conservative group: There is no enough data demonstrating a clear cause of death in the Proton database, the patients notes as well as in the admission office of the Hospital as the majority of the patients had died out side Sheffield (Chesterfield, Rotherham, Doncaster and others). The following are some causes of death And those are the Causes in the Conservative group I have found: of death in the dialysis group: 1. IHD, MI, Heart failure 1. Bronchopneumonia. 2. Carcinoma liver. 2. Peripheral vascular disease. 3. Fracture nick of femur 3. Valvular Heart disease. 4.Ruptured Aortic aneurysm. 4. Sever Heart disease. 5.Chronic renal failure and its sequalae 5. Sepsis. .6. Cardiovascular complication of Diabetes. 6. Cancer. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 113 7.006.005.004.003.002.001.000.00 survival.time 1.0 0.8 0.6 0.4 0.2 0.0 Cu m Su rvi va l More than 70 years- censored Less than 70 years- censored More than 70 years Less than 70 years Agegroups1 Survival Functions 7.006.005.004.003.002.001.000.00 survival.time 1.0 0.8 0.6 0.4 0.2 0.0 Cu m Su rvi va l More than 80 years- censored Less than 80 years- censored More than 80 years Less than 80 years Agegroups2 Survival Functions Figure 4: Survival functions of the conservative patients belonging to the age group 1 and 2: 10.008.006.004.002.000.00 survival.time 1.0 0.8 0.6 0.4 0.2 0.0 Cu m Su rv iva l More than 70 years- censored Less than 70 years- censored More than 70 years Less than 70 years Agegroups1 Survival Functions group = dialysis 10.008.006.004.002.000.00 survival.time 1.0 0.8 0.6 0.4 0.2 0.0 Cu m S ur viv al More than 80 years- censored Less than 80 years- censored More than 80 years Less than 80 years Agegroups2 Survival Functions group = dialysis Figure 5: Survival functions of the Dialysis patients belonging to the age group 1 and 2Figure7: survival The curves for each Comorbid condition in the conservative patients: HF. P value=0.99, IHD. P value=0.79, CVA. P value=0.12, PVD. P value=0.08 DM. P value=0.002, COPD. American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 114 P value=0.38, Dementia. P value=0.32, Cancer. P value=0.98 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 115 100.0080.0060.0040.0020.000.00 survival time in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv al 1-censored 0-censored 1 0 DM Survival Functions 100.0080.0060.0040.0020.000.00 survival time in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv a l 1-censored 0-censored 1 0 PVD Survival Functions 100.0080.0060.0040.0020.000.00 survival time in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv al 1-censored 0-censored 1 0 COPD Survival Functions 100.0080.0060.0040.0020.000.00 survival time in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv a l 1-censored 0-censored 1 0 Cancer Survival Functions Figure 6: survival The curves for each Comorbid condition in the conservative patients: HF. P value=0.99, IHD. P value=0.79, CVA. P value=0.12, PVD. P value=0.08 DM. P value=0.002, COPD. P value=0.38, Dementia. P value=0.32, Cancer. P value=0.98 American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 116 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u r v iv a l 0-censored 0 Heart failure Survival Function 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv a l 1-censored 0-censored 1 0 IHD Survival Functions American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 117 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv al 1-censored 0-censored 1 0 CVA Survival Functions 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 Cu m S ur vi va l 1-censored 0-censored 1 0 PVD Survival Functions 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C um S ur vi va l 1-censored 0-censored 1 0 DM Survival Functions American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 118 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C um S ur vi va l 1-censored 0-censored 1 0 COPD Survival Functions 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv a l 0-censored 0 Dementia Survival Function 120.00100.0080.0060.0040.0020.000.00 time known to survive in months 1.0 0.8 0.6 0.4 0.2 0.0 C u m S u rv iv a l 1-censored 0-censored 1 0 Cancer Survival Functions Figure 7: The survival curves for each Comorbid condition in the Dialysis patients: IHD. P value=0.718, CVA. P value=0.913, PVD. P value=0.070 DM. P value=0.988, COPD. P value=0.913, , Cancer. P value=0.304. It was clearly noted from the above survival analysis that, there was no much difference in the survival time of the Conservative patients aged >70 and those >80 compared with a longer survival time in case of Dialysis patients. Analyzing the survival curves related to co morbidity in the Conservative group showed that co morbidity has a clear impact on survival which is most pronounced in Diabetes, here 50% of Conservative patients with no American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 119 diabetes survive 4 years compared with 2 years in those who have got diabetes(P value=0.02). There is also a borderline statistical significance in those with CVD (P value= 0.08) as an impact of this co morbidity on survival (Figure: 3). In the other hand, dialysis patients with comorbidity have shown a lesser survival time compared with those with no comorbidity especially noticed in patients with PVD (P value 0.070). 7. Discussion No indication was given about patients with ESRD in terms not referred to a nephrology unit or were withheld from maintenance therapy, there is no formal barrier based on age for accepting older ESRD patients on a dialysis program in any Western country [1,2,7,9]. The mean age in the Conservative patients is 80 years compared to 70 years in the dialysis one, and they live shorter. The mean survival time in SKI is 33.9 months (95% confidential interval, 25 to 42) and the median is 27.4 months (95% confidential interval, 22 to 32) in patients treated conservatively (P =0.0001) which is 3 times more than Median survival 8.9 mo (95% CI, 4 to 10) of the conservative group (P < 0.0001) in Paris Necker University Hospital this which studied a smaller number of patients (37 Patients), the same Median survival in New Zealand. The decision to dialyze or commence the Conservative approach has an impact on survival. Dialysis in such patients risks death caused by Conservative medical treatment [13] in the renal unit, Lister Hospital, Steven age, UK, in which the median survival after dialysis in these patients is 8.3 months was not significantly longer than beyond date of dialysis initiation in palliative treated patients 6.3 months. One year survival is 80% in (SKI) compared with 71% in North Thames Dialysis Study. According to UK Renal Registry data 2015, Survival falls progressively with increasing age, 1 year after 90 days survival in 75- 79 year olds is 74٪ compared with 57 ٪ in those aged ≥ 85 years, and in New Zealand study is73.6% [14]. Most of the Conservative patients (38.4%) prefer Conservative treatment over Dialysis irrespective of the doctor opinion (32.9%), 40% having eGFR progression (Progressors) and the percentage change of their renal function is 20%. The highest mortality in the Conservative group was caused by diabetes which is the highest percentage. In concordance with most of the similar studies. Diabetes play a major role as a cause of renal failure, and considered to be the most predictor factor for survival of the Conservative patients (the same as in Lister Hospital, Stevenage, UK). In SKI this followed by Cerebrovascular diseases as well which is defined as a damage to the blood vessels in the brain, resulting in a stroke. The blood vessels can become blocked because of fat deposits, or a wandering blood clot, blocking the flow of blood to a part of the brain. Sometimes, the blood vessels may leak, break, or burst, resulting in a hemorrhagic stroke. People with diabetes are at higher risk of cerebrovascular disease . Generally, The Mean survival time as well as one year survival is best achieved http://en.wikipedia.org/wiki/Blood_vessel http://en.wikipedia.org/wiki/Brain http://en.wikipedia.org/wiki/Stroke http://en.wikipedia.org/wiki/Fat http://en.wikipedia.org/wiki/Blood_clot http://en.wikipedia.org/wiki/Diabetes American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 120 in SKI. 8. Limitation of the study 1. We need further solutions. 2. Subgroups of patients do poorly on dialysis but we have not identified them yet and Conservative management outcomes have shown difference among many studies despite of being minor but it is going to be of great concern. 3. There is no randomized trial comparing dialysis versus conservative treatment as there are difficulties in data interpretation. 4. All studies are retrospective. 5. Difficulties in collecting data affects some results of the study. 9. Conclusion As it has already been shown from (PSCKD5C) that; 1. Stage 5 (ESRD) increases the mortality. 2. Transplant/Dialysis prolongs survival but only in some patients. 3. Elderly patients with significant co-morbid disease may not benefit renal replacement therapy (RRT). 4. The mean age in the Conservative group is 80 years compared with 70 years in Dialysis group 5. The mean Survival time is 33.9 months. 6. Majority of the patients prefer Conservative Managements rather than dialysis. 7. 40% of patients on Conservative managements have progressive decline in their renal function. 8. More than 2 years survival time in Conservative group is 50% compared with 8 years in Dialysis group. (Function progressives) 9. Percentage change of the renal function over the last 5 years in (SKI) shows 20% decline per year in their renal function. 10. Diabetes is a major cause of renal failure and most predictor factor determines the survival time followed by Cerebrovascular disease and hence the total number of mortality increased in association with these comorbidity conditions. 11. We are certainly sure that this study is mythological, informative, practical as well as a prototypical one which can be performed in any area in the world as informative and for further assessment and management of CKD which will improve the disease outcomes even further. In the main time it gives a clue regarding the way and the success of such that particular kidney institute. 12. Performing such a study is intended for CKD5 as it carry a controverters in managements between different institutes. References [1]. Dimkovic N, Oreopoulos DG: Chronic peritoneal dialysis in the elderly. Semin Dial 15:94-97, 2002 [2]. \Peri UN, Fenves AZ, Middleton JP: Improving survival of octogenarian patients selected for American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) (2018) Volume 44, No 1, pp 103-121 121 haemodialysis. Nephrol Dial Transplant 16:2201-2206, 2001 [3]. Vandelli L, Medici G, Perrone S, et al.: Haemodialysis therapy in the elderly. Nephrol Dial Transplant 11 Suppl 9:89-94, 1996 [4]. Neves PL, Sousa A, Bernardo I, et al.: Chronic haemodialysis for very old patients. Age Ageing 23:356-359, 1994 [5]. Issad B, Benevent D, Allouache M, et al.: 213 elderly uremic patients over 75 years of age treated with long-term peritoneal dialysis: a French multicenter study. Perit Dial Int 16 Suppl 1:S414-418, 1996 [6]. Vrtovsnik F, Porcher R, Michel C, et al.: Survival of elderly patients on peritoneal dialysis: retrospective study of 292 patients, from 1982 to 1999. Perit Dial Int 22:73-81, 2002 [7]. Chandna SM, Schulz J, Lawrence C, et al.: Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity. Bmj 318:217-223, 1999 [8]. Munshi SK, Vijayakumar N, Taub NA, et al.: Outcome of renal replacement therapy in the very elderly. Nephrol Dial Transplant 16:128-133, 2001 [9]. Harris SA, Lamping DL, Brown EA, et al.: Clinical outcomes and quality of life in elderly patients on peritoneal dialysis versus hemodialysis. Perit Dial Int 22:463-470, 2002 [10]. Byrne C, Vernon P, Cohen JJ: Effect of age and diagnosis on survival of older patients beginning chronic dialysis. Jama 271:34-36, 1994 [11]. Evans RW, Blagg CR, Bryan FA, Jr.: Implications for health care policy. A social and demographic profile of hemodialysis patients in the United States. Jama 245:487-491, 1981 [12]. Levy JB, Chambers EJ, Brown EA: Supportive care for the renal patient. Nephrol [13]. Smith C, Da Silva-Gane M, Chandna S, et al.: Choosing not to dialyse: evaluation of planned non- dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95:c40- 46, 2003 [14]. Madhan K: The epidemic of elderly patients with dialysis-requiring end-stage renal disease in New Zealand. N Z Med J 117:U912, 2004Dial Transplant 19:1357-1360, 2004. Abstract Very few studies have investigated and made decisions regarding RRT in elderly patients, and their conclusions are rather discordant [1,2,3,4,5,6,7,8,9,10]. Treatment option for ESRD (End Stage Renal Disease) is to decide not to have dialysis or trans... Data Organization: 5. Statistical Analysis Reason for choice of Conservative managements: