Become an AAHPM Member to view PC-FACS
Design and Participants: This observational cohort study used the US Department of Veterans Affairs’ healthcare databases (2010-2018) to emulate a hypothetical randomized trial of dialysis as destination therapy for adults 65 years or older with kidney failure not referred for transplantation. Survival and days at home were compared between starting dialysis (within 30 days of trial entry) at an estimated glomerular filtration rate less than 12 mL/min/1.73 m2 vs CMM; patients CMM could either start dialysis after 30 days or never. Analyses (intention to treat) used logistic regression.
Results: Participants (N=20,440) were aged mean 78 years (SD=8.8); 62% White and 28% Black; and 2% female. The median time to dialysis was 8 days in the group starting dialysis and 3 years in CMM. Over a 3-year horizon, the dialysis group survived 770 days and CMM group survived 761 days (difference=9.3 days [95% CI=17-30 days]). Compared to CMM, dialysis was associated with longer survival by 60 days (3.5-109) but 13 fewer days at home (0.2-29) among adults 80 years or older. However, among those 65-79 years old, survival time favored CMM by 17 days (9.4-43), with those starting dialysis also spending 14 fewer days at home (6.6-21). Compared to the CMM group, the dialysis group had 14 fewer days at home (7.7-21). In per protocol analysis, dialysis was associated with improved survival vs CMM and forgoing dialysis (hazard ratio=0.74 [0.71-0.79]); compared to CMM and forgoing dialysis completely, starting dialysis had longer survival by 78 days (63-91) and 15 fewer days at home (11-17).
Commentary: Prognostication in organ failure is challenging because of its complex trajectory. In the case of renal failure, the availability of dialysis makes prognostication further complicated. In this study, initiation of dialysis had very small (~2 months) gains in life expectancy compared to CMM. Moreover, prior research has shown survival benefits from dialysis are frequently offset by increased time in healthcare settings, and it may not necessarily lead to functional recovery.4
It is crucial for providers and patients to carefully consider whether and when to initiate dialysis, ensuring it aligns with the patient’s goals and values. This is particularly important for older adults, as dialysis involves tradeoffs such as time commitments, frequent appointments, and potential complications that may lead to emergency department (ED) visits or hospitalizations.
Bottom Line: In older adults with chronic kidney failure, dialysis provides modest gains in life expectancy but at the expense of increased time spent in healthcare settings than at home.
Reviewer: Ayano Kiyota, MD PhD FAAFP FAAHPM, University of Michigan Medical School, Ann Arbor, MI
References:
1. Johansen KL, Chertow GM, Foley RN, et al. US Renal Data System 2020 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2021;77:A7-A8. doi:10.1053/j.ajkd.2021.01.002.
2. Wachterman MW, O’Hare AM, Rahman O-K, et al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019;179:987-990. doi:10.1001/jamainternmed.2019.0125.
3. Carson RC, Juszczak M, Davenport A, et al. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol. 2009;4:1611-1619. doi:10.2215/CJN.00510109.
4. Kurella Tamura M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539-1547. doi:10.1056/NEJMoa0904655.
Source: Montez-Rath ME, Thomas I-C, Charu V, et al. Effect of starting dialysis versus continuing medical management on survival and home time in older adults with kidney failure: a target trial emulation study. Ann Intern Med. 2024;177(9):1233-1243. doi:10.7326/M23-3028.
Access this article on PubMed.