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Abstract: FR-PO893

Dialysis as Destination Therapy vs. Medical Management in a National Cohort of Older Adults with Kidney Failure: A Target Trial Emulation Study

Session Information

  • Geriatric Nephrology
    November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Geriatric Nephrology

  • 1300 Geriatric Nephrology

Authors

  • Montez-Rath, Maria E., Stanford University School of Medicine, Stanford, California, United States
  • Thomas, I-Chun, VA Palo Alto Health Care System, Palo Alto, California, United States
  • Charu, Vivek, Stanford University School of Medicine, Stanford, California, United States
  • Odden, Michelle, Stanford University, Stanford, California, United States
  • Seib, Carolyn Dacey, Stanford University School of Medicine, Stanford, California, United States
  • Tamura, Manjula, Stanford University School of Medicine, Stanford, California, United States
Background

For older adults who are not candidates for kidney transplantation, medical management is an alternative to lifelong dialysis, but little evidence is available to inform treatment decisions.

Methods

We emulated a target trial in which patients were randomized to dialysis versus medical management using electronic health record data between 2010 and 2018 from the U.S. Department of Veterans Affairs. We included adults aged 65 years or older with chronic kidney failure and an estimated glomerular filtration rate <12 ml/min/1.73m2 who were not candidates for kidney transplantation. We used causal inference methods to estimate restricted mean survival time difference using a weighted flexible parametric model and difference in home-time using weighted fractional regression at one and three years.

Results

We emulated a series of 99 trials using data from 16,363 adults with a mean age of 77 ± 9 and mean eGFR of 10 ± 2 who were predominantly male (2%) and white (64%). In intention to treat analyses, compared to medical management, dialysis was associated with an increase in one-year survival of 4 days (95% CI 2.0, 6.1), offset by 8 fewer days at home (95% CI -10, -7). At 3-years, compared to medical management, dialysis was associated with an increase in survival of 35 days (95% CI 23, 47), offset by 11 fewer days at home (95% CI -16, -4). Subgroup analyses showed that the survival benefit of dialysis was larger at older ages and at lower eGFR, and largely explained by an increase in survival in institutional settings (Figure).

Conclusion

Among older adults ineligible for transplantation, we found evidence of a modest survival benefit of dialysis compared to medical management, at the expense of fewer days at home. The findings suggest that medical management should be more widely considered as a patient-centered alternative to dialysis treatment and underscore the importance of engaging patients in shared decision-making.

Funding

  • Veterans Affairs Support