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Abstract: TH-PO794

Dialysis vs. Conservative Management for Patients 65 Years and Older With ESKD: A Propensity-Matched Cohort Study

Session Information

Category: Geriatric Nephrology

  • 1200 Geriatric Nephrology

Authors

  • Thorsteinsdottir, Bjoerg, Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • Swarna, Kavya Sindhu, Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • Rule, Andrew D., Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • Palsson, Runolfur, Landspitali, Reykjavik, Iceland
  • Albright, Robert C., Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • Kashani, Kianoush, Mayo Clinic Minnesota, Rochester, Minnesota, United States
  • O'Hare, Ann M., VA Puget Sound Health Care System Seattle Division, Seattle, Washington, United States
  • Hickson, LaTonya J., Mayo, Jacksonville, Florida, United States
Background

Several cohort studies have compared survival for older individuals with ESKD who pursue dialysis vs. conservative care. Results have been variable and methodologically challenged by systematic differences in age and comorbidity by treatment. We sought to account for differences in patient characteristics by using propensity score matching among members of a large claims-based database.

Methods

All patients in the OptumLabs Data Warehouse over 65 years old with at least one creatinine measure, and six months of coverage were identified. The median eGFR at dialysis start was 9 ml/min/1.73 m2. All patients who started dialysis within 3 days of reaching this eGFR threshold were propensity matched with patients with an eGFR in the same range who did not start dialysis. Overall survival was compared for the two groups with Cox regression and the subgroup age >80 years. Sensitivity analysis was performed using eGFR thresholds of 11 and 7 ml/min/1.73 m2, (representing the 25th and 75th percentiles) , and excluding patients with an AKI diagnosis.

Results

We identified 6017 patients who initiated dialysis during the observation period and 5814 who did not start dialysis. Those who started dialysis were younger (mean age 74.9 vs. 77.3 years), more likely to be men, more likely to be identified as Black or Hispanic and had a higher comorbid burden, especially CKD complications (i.e. anemia), cardiac and pulmonary disease, and less likely to have dementia, cancer and other neurological conditions.
In survival comparison before propensity matching, dialysis carried a hazard ratio (HR) of 0.67(CI 0.64-0.71) compared to no dialysis. After propensity matching of 2,566 patients from each group, the overall survival advantage was attenuated (HR 0.77; CI 0.71-0.83)) but persisted even for those over 80 years old (HR 0.65; CI 0.57-0.73).

Conclusion

Patients who do not receive dialysis are more likely to be older, white and have disabling or life limiting comorbidities. Even after propensity score matching, patients who started dialysis survived longer than those who did not, and this was true even for those aged 80 years or older. However, sicker patients who start dialysis more acutely at higher GFR levels may be underrepresented in our cohort.

Funding

  • NIDDK Support