Older adults who are frail with chronic kidney failure and who opt for continuing medical management rather than dialysis have only a slight reduction in survival time while spending significantly more days at home, reports a study in the Annals of Internal Medicine.
The study included data on 20,440 older adults (mean age, 77.9 years) with chronic kidney failure. All had an estimated glomerular filtration rate of <12 mL/min/1.73 m2 and were not referred for kidney transplantation. Patients were treated in the US Department of Veterans Affairs health system between 2010 and 2018.
Using data from this observational cohort, the researchers performed a target trial emulation, mimicking the design principles of a randomized clinical trial, to compare the outcomes of initiating dialysis versus continuing medical management. Patient survival and number of days spent at home, rather than in a hospital or other care facility, were compared between groups.
The median time to dialysis was 8 days in patients who initiated dialysis versus 3 years in those continuing medical management. Survival was 770 days in the group starting dialysis versus 761 days in those continuing medical management—a nonsignificant difference of 9.3 days. On an “intention to treat” analysis, dialysis was associated with less time at home—a significant difference of 13.6 days—compared with continued medical management. In a “per-protocol” analysis, starting dialysis was associated with increased survival, with a significant difference of 77.6 days, but 14.7 fewer days at home.
Older adults with kidney failure who are not referred for kidney transplantation face a difficult choice between starting dialysis or remaining on medical management.
Few studies have provided empirical data to guide this decision.
The clinical trial emulation suggests a modest increase in survival time for patients in this situation who start dialysis but with fewer days spent at home. The findings suggest “a more favorable risk-benefit profile of starting dialysis at an eGFR [estimated glomerular filtration rate] less than 12 mL/min/1.73 m2 among subgroups aged 80 years or older and those with more advanced kidney failure,” the researchers write. They discuss the study implications for clinical practice and policy [Montez-Rath ME, 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, published online August 20, 2024. doi: 10.7326/M23-3028].
