Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD

Abstract

Appropriate patient selection and optimal timing of dialysis initiation among older adults with advanced CKD are uncertain. We determined the association between dialysis versus medical management and survival at different ages and levels of kidney function. We assembled a nationally representative 20% sample of United States veterans with eGFR<30 ml/min per 1.73 m between 2005 and 2010 (=73,349), with follow-up through 2012. We used an extended Cox model to determine associations among the time-varying exposures, age (<65, 65-74, 75-84, and ≥85 years), eGFR (<6, 6-<9, 9-<12, 12-<15, and 15-<29 ml/min per 1.73 m), and provision of dialysis, and survival. Over the mean±SEM follow-up of 3.4±2.2 years, 15% of patients started dialysis and 52% died. The eGFR at which dialysis, compared with medical management, associated with lower mortality varied by age (<0.001). For patients aged <65, 65-74, 75-84, and ≥85 years, dialysis associated with lower mortality for those with eGFR not exceeding 6-<9, <6, 9-<12, and 9-<12 ml/min per 1.73 m, respectively. Dialysis initiation at eGFR<6 ml/min per 1.73 m associated with a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 ml/min per 1.73 m, the estimated difference in median life expectancy was <1 year for these patients. Provision of dialysis at higher levels of kidney function may extend survival for some older patients.

Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease

“…Therefore, as the authors of the REIN score also point out, the transportability of these models to advanced CKD patients who have yet to decide on a treatment strategy is unsure [ 28 ]. Multiple studies have compared survival in patients treated with dialysis and CC from an aetiological perspective and demonstrated a limited survival benefit of dialysis in patients with higher age and more comorbidities [ 8 , 14 , 29 ]. However, no mortality prediction model for patients on CC has previously been developed.…”

“…In order to foster shared decision-making and personalized treatment, patients should be provided with accurate information on their prognosis for each treatment strategy [ 5 , 8 ]. There is a large range in survival time of patients on both dialysis and CC.…”

“…Clinically speaking this is the most relevant time of prediction, as it could provide an individual patient with their hypothetical prognosis on both dialysis and CC. Such a prediction tool could be employed as a decision aid at the time of treatment choice and be of value in patient discussions when considering potential benefits and burdens of both treatment options [ 8 , 12 ].…”

The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review

“…Bowling et al [89] conducted a cohort study in 357,632 CKD patients aged � 70 years and showed that median survival time decreased with progression in either age or CKD stage; patients aged � 85 years had the lowest survival ranging from 1.9 (CKD stage 4) to 3.2 years (CKD stage 2). Tamura et al [90] estimated survival among 73,349 older ESRD patients (� 60 years) initiating dialysis at different kidney function levels. The study revealed that median survival was diminished upon initiating dialysis at higher GFRs as well as with older age.…”

DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA): rationale and design

“…When taking into account a dropout rate of 10%, 99 patients on CC and 394 on dialysis are needed, a total of 493 patients. Based on a study from the United States, we expected one third of patients to progress from stage one to two within 3 years, so a cohort of 1500 patients will be needed [ 49 ].…”