Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Abstract

Background and objectives: Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.

Design, setting, participants, & measurements: A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded.

Results: In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ≥70 years old with Davies comorbidity scores of ≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02).

Conclusions: In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.

Keywords: Humans; Kidney Diseases; Renal Replacement Therapy; Retrospective Studies; aged; chronic kidney failure; comorbidity; conservative management; renal dialysis; survival analysis.

Figure 1.

Flowchart of patients and outcomes. Twelve patients who initially opted for RRT changed to conservative management (CM), and two patients who initially opted for CM changed to RRT. Analyses were performed according to the original treatment choice.

Figure 2.

Kaplan–Meier survival curves comparing patients ages ≥70 years old treated with conservative management (CM) with patients on RRT using different starting points in survival calculation. (A) Time of treatment decision. (B) Time of first eGFR<20 ml/min per 1.73 m². (C) Time of first eGFR<15 ml/min per 1.73 m². (D) Time of first eGFR<10 ml/min per 1.73 m².

Figure 3.

Kaplan–Meier survival curves comparing both treatment groups with stratification of age using different starting points in survival calculation. (A and B) Time of treatment decision. (C and D) Time of first eGFR<20 ml/min per 1.73 m². (E and F) Time of first eGFR<15 ml/min per 1.73 m². (G and H) Time of first eGFR<10 ml/min per 1.73 m². CM, conservative management.

Figure 4.

Kaplan–Meier survival curves for both treatment groups ages ≥70 years old with stratification of comorbidity. (A) No and intermediate comorbidity are taken together and correspond to Davies comorbidity scores of 0–2. (B) Severe comorbidity corresponds to Davies comorbidity scores of ≥3. Only survival calculated from time of modality choice is shown. Similar results were observed using the other starting points. CM, conservative management.