Beyond Dialysis: Is Georgia Ready for Comprehensive Conservative Care for Elderly Patients with End-Stage Renal Disease?

Abstract

Background: Comprehensive conservative care (CCC) is increasingly recognized as a valid treatment option for frail elderly patients with end-stage renal disease (ESRD). However, despite international guideline recommendations, CCC implementation remains limited, particularly in healthcare systems where dialysis-centered care predominates. Cultural attitudes toward end-of-life care, inadequate supportive care infrastructure, and healthcare financing models may substantially influence treatment choices and patient trajectories.

Objectives: This study evaluated the feasibility and real-world implementation of comprehensive conservative care in elderly patients with ESRD in Georgia and identified clinical, cultural, and healthcare system-related barriers to its use.

Methods: This prospective, observational, comparative study included 64 patients aged ≥65 years with ESRD, frailty, and a high comorbidity burden who were treated between 2021 and 2023. We classified patients into Stable CCC, Stable Dialysis, or Transition Treatment groups based on their treatment trajectory during follow-up. We compared hospitalization, mortality, treatment trajectories, causes of death, and place of death across groups.

Results: During the 12-month follow-up, 30 of 64 patients (46.9%) died, with no significant difference in mortality between treatment groups. Hospitalization differed significantly across groups (p = 0.005), occurring in 21.1% of patients receiving Stable CCC, 62.9% of those receiving Stable Dialysis, and 70.0% of those in the Transition Treatment group. The Transition Treatment group had the highest hospitalization burden and the lowest probability of remaining hospitalization-free during follow-up. Place of death also differed significantly between groups (p = 0.016), with home deaths more frequent among patients receiving Stable CCC.

Conclusions: Implementation of comprehensive conservative care in Georgia remains constrained by cultural, structural, and healthcare system barriers. Patients in the Transition Treatment group had a higher hospitalization burden and predominantly hospital-based deaths, although these associations should be interpreted cautiously given the observational design and small sample size. Expanding nephropalliative care services, integrating advance care planning, improving physician education, and implementing healthcare policy reforms that support CCC may improve person-centered care for frail elderly patients with ESRD.