In older adults with kidney failure, the decision to undergo maintenance dialysis is associated with increased hospital and ICU days and decreased use of inpatient palliative care, reports a study in JAMA Network Open.
Using Alberta health data, the researchers identified 968 older adults (65 or older) with kidney failure: 489 men and 479 women, median age 78.5 years. All had at least two consecutive outpatient estimated glomerular filtration rate (eGFR) measurements of less than 10 mL/min/1.73 m2 over at least 90 days—a level at which patients and physicians discuss and decide whether to pursue maintenance dialysis. Time-varying exposure to maintenance dialysis was analyzed for association with cumulative hospital days, with adjustment for covariates. A wide range of secondary outcomes were analyzed as well.
Maintenance dialysis was performed in 57.5% of patients. Those not receiving dialysis were more likely to be female, older (median age 83.6 years), to have higher comorbidity, and to reside in a long-term care facility.
Patients receiving maintenance dialysis spent more days in the hospital, incidence rate ratio (IRR) 2.47: the typical patient treated with dialysis had an additional 22 hospital days per year. There was no increase in the rate of hospital admissions, but patients in the maintenance dialysis group had a higher rate of ICU admissions: 98.37 versus 54.51 per 1000 hospitalizations, IRR 1.80.
Maintenance dialysis was also associated with a lower rate of inpatient palliative care: 3.92 versus 8.60 per 1000 hospital days, IRR 0.45. Of 627 patients who died during follow-up, those treated with dialysis were more likely to die in the hospital: 66.0% versus 48.4%, relative risk 2.93.
For older adults with kidney failure, time spent in the hospital is an important patient-oriented outcome that may affect the decision to initiate dialysis. There are few data on comparative outcomes for patients choosing dialysis or nondialysis care in this situation.
The new study shows increased intensity of care, including a substantial increase in hospital days, for older adults with kidney failure who receive maintenance dialysis. Dialysis is also associated with a lower rate of inpatient palliative care and an increased likelihood of dying in the hospital. The authors note that the findings in their Canadian cohort—including the 40% rate of treatment without dialysis—may not be generalizable to the United States and elsewhere [Tam-Tham H, et al. Association of initiation of dialysis with hospital length of stay and intensity of care in older adults with kidney failure. JAMA Network Open 2020; 3:e200222].