Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy

Abstract

Background: Elderly patients with end-stage renal disease and severe extra-renal comorbidity have a poor prognosis on renal replacement therapy (RRT) and may opt to be managed conservatively (CM). Information on the survival of patients on this mode of therapy is limited.

Methods: We studied survival in a large cohort of CM patients in comparison to patients who received RRT.

Results: Over an 18-year period, we studied 844 patients, 689 (82%) of whom had been treated by RRT and 155 (18%) were CM. CM patients were older and a greater proportion had high comorbidity. Median survival from entry into stage 5 chronic kidney disease was less in CM than in RRT (21.2 vs 67.1 months: P < 0.001). However, in patients aged > 75 years when corrected for age, high comorbidity and diabetes, the survival advantage from RRT was ~ 4 months, which was not statistically significant. Increasing age, the presence of high comorbidity and the presence of diabetes were independent determinants of poorer survival in RRT patients. In CM patients, however, age > 75 years and female gender independently predicted better survival.

Conclusions: In patients aged > 75 years with high extra-renal comorbidity, the survival advantage conferred by RRT over CM is likely to be small. Age > 75 years and female gender predicted better survival in CM patients. The reasons for this are unclear.

Fig. 1

Kaplan–Meier survival curves from entry into stage 5 CKD for patients treated by RRT (n = 689) and by conservative kidney management (n = 155).

Fig. 2

Comparison of Kaplan–Meier survival curves by modality (RRT vs conservative kidney management) in patients > 75 years. The panel on the left depicts the relationships in those with low comorbidity and that on the right in those with high comorbidity.

Fig. 3

Cox proportional model survival curve of patients aged > 75 years—CM vs RRT—adjusted for age, gender, ethnicity, the presence of diabetes and the presence of high comorbidity. Median survival in RRT patients is better by < 4 months, which is not statistically significant (P = 0.43).

Fig. 4

Cox proportional model survival curve of conservatively managed patients aged > 75 years vs younger patients—adjusted for gender, ethnicity, the presence of diabetes, the presence of high comorbidity and eGFR at the start of the study. Survival of older patients is significantly better than that of younger patients (P = 0.009).