Outcomes in dialysis versus conservative care for older patients: A prospective cohort analysis of stage 5 Chronic Kidney Disease

Abstract

Background The benefits of dialysis in older people with ESKD are not clear. We prospectively evaluated whether dialysis has survival advantage compared to conservative care (CC) in older people who were medically suitable for dialysis therapy. Methods This was a prospective observational study of CKD patients aged 75 years when eGFR first reached 15ml/min/1.73m2. Hazard ratios (HR) for death were compared between patients who chose dialysis versus conservative care (CC) from when first seen in pre-dialysis clinic (eGFR 15ml/min/1.73m2), and when initiation of dialysis was first considered (eGFR 10ml/ min/1.73m2). Patients with co-morbidities likely to significantly reduce life expectancy such as advanced heart failure, advanced dementia, and malignancy, were excluded. Results There were 204 patients (123 dialysis, 81 CC). 115 went on to record eGFR of 10ml/min/ 1.73m2 (73 dialysis, 42 CC). The median survival from eGFR first 15ml/min/1.73m2 for the dialysis and CC groups were 42 (33-50) months and 31 (21-41) months. The adjusted hazard ratio (HR) for death in the dialysis group compared to CC was 0.61 (0.41-0.61, p = 0.01). The median survival from eGFR first 10ml/min/1.73m2 for dialysis and CC group were 36 (25-47) months and 12 (0-5) months. The adjusted HR for death in the dialysis group compared to CC was 0.36 (0.21-0.62, p <0.001). Conclusion Dialysis confers a survival benefit in older patients medically suitable for dialysis. This study is novel in being both prospective and in excluding patients with co-morbidities which may limit suitability for dialysis and life expectancy. A future focus on quality of life is needed to establish the true benefits of dialysis in older people.