Rate of Decline of Kidney Function, Modality Choice, and Survival in Elderly Patients with Advanced Kidney Disease

Abstract

Aim: In elderly, dependent patients with advanced chronic kidney disease, dialysis may confer only a small survival advantage over conservative kidney management (CKM). We investigated the role of rate of decline of kidney function on treatment choices and survival. Methods: We identified a retrospective (1995-2010) cohort of patients aged over 75 years, with progressive kidney impairment and an estimated glomerular filtration rate (eGFR) between 10 and 15 ml/min/1.73 m². All subsequently chose to be treated by either dialysis or CKM. Patients were followed for a minimum of 3 years. Results: Of 250 patients identified, 92 (37%) opted for dialysis and 158 (63%) for CKM. Mean age was 80.9 ± 4.0 years. eGFR was 13.3 ± 1.4 initially and 8.7 ± 3.0 ml/min/1.73 m² at follow-up. Both were similar in those on dialysis and CKM pathways. Rate of decline of eGFR was more rapid in those choosing dialysis (0.45 (interquartile range, IQR 0.64) vs. 0.21 (IQR 0.28) ml/min/1.73 m²/month, p < 0.001), and independently predicted choice of CKM. In patients with high comorbidity, choice of dialysis was associated with a non-significant adjusted survival advantage of 5 months. Inclusion in models of time dependent eGFR during follow-up (eGFR_td) - a reflection of the rate of decline of kidney function - showed it to be independently associated with mortality risk in those on the CKM (p < 0.001) but not on the dialysis pathway. CKM pathway patients at the 25th centile of eGFR_td had an adjusted survival of 7 months compared to 63 months for those at the 75th centile. Conclusions: Rate of decline of kidney function is a determinant of CKM choice in elderly patients and is associated with mortality risk in patients of the CKM pathway. These findings should inform counselling.

The impact of hypertension on chronic kidney disease and end-stage renal disease is greater in men than women: a systematic review and meta-analysis

“…This finding is supported by a recent pooled analysis of the Evaluating Prevention of Progression In Chronic kidney disease (EPPIC) trials, where women tend to start dialysis at an average eGFR value of 9 mL/min/1.73m 2 /year while men started at an average eGFR value of more than 11 mL/min/1.73m 2 /year [36]. This difference in the time to initiation of dialysis could be partly related to women having less access to nephrology care [32], they are less aware of their disease and the degree of its severity [37] or be more likely to choose conservative treatment [38][39][40][41].…”

Cohort study with patients older than 80 years with stage 5 chronic kidney failure on hemodialysis vs conservative treatment: Survival outcomes and use of healthcare resources

“…In the subgroup of patients older than 80 years of age in the study published in 2013 by Hussain et al, the RRT did not offer advantages of survival over CT. 14 In these studies, the age of the patients was lower than that of the patients in our sample. Later, in 2016, Chadna et al 16 published the results of a retrospective study of older patients, almost 80 years old, reporting that RRT survival adjusted for age, sex, race, comorbidity, and diabetes maintained a significant 11-month advantage, which, however, in the high comorbidity group it was not significant. As we mentioned, in our study, survival advantage in the Cox proportional hazards regression analysis is maintained after adjusting for age and comorbidity.…”

Prognóstico da doença renal crônica em uma população de baixo nível socioeconômico atendida no serviço de emergência de um hospital terciário, Brasil

“…As tabelas 2 e 3 mostram as razões de risco (RR) = "hazard ratio" (HR) por todas as causas e de acordo com as principais causas de morte (doença renal e por doença cardiovascular), nos modelos sem ajuste, ajustados por idade e sexo e nos modelos multivariados ajustados adicionalmente por escolaridade e diagnóstico de admissão. Ajustada por sexo e idade Referência (1,0) 2,42 (0,70-8,31) 3,75 (1,12-12,53) Ajuste multivariado Referência (1,0) 1,89 (0,51-6,98) 3,74 (1,06-13,23) 1 mês Bruta Referência (1,0) 4,61 (2,22-9,60) 2,95 (1,41-6,16) Ajustada por sexo e idade Referência (1,0) 4,07 (1,95-8,49) 3,82 (1,82-8,00) Ajuste multivariado Referência (1,0) 3,43 (1,37) 3,89 (1,34) 3 meses Bruta Referência (1,0) 2,03 (1,27-3,26) 1,44 (0,90-2,30) Ajustada por sexo e idade Referência (1,0) 1,81 (1,12-2,91) 1,92 (1,19-3,08) Ajuste A despeito dessas nuances em relação ao risco de morte de acordo com a TFG estimada, chama atenção em nossa amostra as altas taxas de mortalidade geral em curto prazo e, principalmente em até um ano, que excedem em muito as relatadas por outros países desenvolvidos -em torno de 20-30% em até um ano (Robinson et al, 2014;Silva-Gane et, 2012;Chandna et al, 2016;Astor et a.,2011), e mesmo em relação às estatísticas prévias brasileiras (Brazil, Brazilian Institute of Geography and Statistics -IBGE, 2013). …”

“…A maioria advém de amostras selecionadas de centros especializados de diálise em países desenvolvidos (Robinson et al, 2014;Silva-Gane et, 2012;Chandna et al, 2016;Asdtor et a.,2011;Matos et al, 2011).…”

“…O risco de mortalidade por todas as causas durante os 10 anos de seguimento foi de 32% (IC95%, 31-33%) dentre aqueles com TFGe estável, D I S C U S S Ã O enquanto que o RR foi de 50% (95% IC, 47% -52%) para uma variação na TFGe de -30%, 60% (95% IC, 56% -63%) para uma mudança de -40% e 77% (CI, 71% -82%) para uma variação de -57% (Chandna, 2016).…”