Withdrawal of Renal Replacement Therapy: The Role of Palliative Care

Introduction: With aging populations and wider access to renal replacement therapy (RRT), more patients undergo dialysis, often with declining quality of life, leading to consideration of RRT withdrawal. Early integration of palliative care (PC) is essential to ensure a patient-centered approach. This study evaluates the clinical course of patients admitted to a university hospital PC unit who had RRT withdrawn. Methods: Retrospective observational study of all patients admitted to a hospital-based Palliative Care Unit (PCU) in Portugal with RRT suspension from September 2018 to February 2024. Patient demographics, clinical course, symptoms, complications, and management were analysed. Results: Twenty-seven patients were included (59% male; mean age 77.4 years). Almost all had ≥1 cardiovascular risk factor; common comorbidities included heart failure (51.9%), cerebrovascular disease (48.2%), and active neoplasia (48.2%). RRT was withdrawn in 77% due to irreversible consciousness impairment or hemodynamic instability. Nephrology (100%) and PC (92.3%) were the most involved specialties. Most patients (81.5%) had ≥3 symptoms, primarily asthenia (85.2%), anorexia (81.5%), dyspnea (70.4%), and pain (66.7%); many presented before RRT withdrawal. Post-withdrawal, constitutional symptoms increased. Mean PC follow-up was 13.4 days; median survival was 12 days. All but one patient died in the hospital. Conclusion: Short PC follow-up and limited patient involvement in RRT withdrawal decisions (22%) highlight the vulnerability of this population and late referral to palliative care. Earlier integration and proactive advance care planning are critical to optimizing patient-centered decision-making and symptom management.