Study: Dialysis offers small survival advantage vs. supportive care for patients with ESKD
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Key takeaways:
- Older patients who chose dialysis vs. continuing medical management had a longer survival.
- Patients who choose dialysis vs. medical management spent less time at home.
Older adults with end-stage kidney disease had “modest gains” in life expectancy by starting on dialysis vs. choosing continuing medical management but spent less time at home, results from study show.
“Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home,” Maria E. Montez-Rath, MS, PhD, of the division of nephrology, department of medicine, at Stanford University School of Medicine, and colleagues wrote in a study published in Annals of Internal Medicine.
The researchers launched a target trial emulation study to examine whether outcomes from using medical management are comparable to choosing dialysis. Patients treated by the U.S. Department of Veterans Affairs from 2010 to 2018 who were aged 65 years or older with chronic kidney failure and had eGFR below 12 mL/min/1.73 m2 were reviewed.
Patients were started on dialysis within 30 days of the start of the study and were compared with a control group that received continual medical management.
Mean survival and number of days at home were reviewed.
Better survival
Results showed that among 20,440 adults (mean age, 77.9 years), “the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, –17.4 to 30.1 days]),” the researchers wrote. “Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home),” they wrote.
Clinicians can use results from the study to help patients make decisions about their modality options, the researchers wrote.
“Determining whether and when to intervene with an intensive therapy, such as dialysis, is a complex and dynamic decision,” they wrote. “Patients may implicitly assume that treatments prolonging survival concurrently improve independence or that gains in longevity outweigh the time one spends receiving inpatient care or intensive procedures. “By using the best available methods to account for bias and confounding, our study sheds light on the tradeoffs between survival and time spent at home experienced with starting dialysis,” they wrote.
Education on medical management
The authors also suggested the results should lead to better patient education about medical management as an alternative to dialysis. “These results have several implications for clinical practice and policy,” the authors wrote. “First, by focusing on the life-extending effects of dialysis, treatment decision-making for older adults with kidney failure often ignores or downplays the potential harms of dialysis, including exposure to invasive procedures, hospitalizations and time spent in health care settings,” they wrote. “Numerous studies have documented the consequences of poor-quality decision-making. Patients have unrealistic expectations about the benefits of treatment and experience high levels of regret and withdrawal from treatment soon after starting.
“In addition,” the authors wrote, “these results underscore the importance of a comprehensive and balanced approach to kidney disease education for patients who are not transplant-eligible.”
In an editorial accompanying the article, authors Victoria J. Riehl-Tonn, BN, of the Cumming School of Medicine, University of Calgary, and Sofia B. Ahmed, MD, MMSc, a member of the faculty of medicine and dentistry at the University of Alberta, wrote that the study by Montez-Rath and colleagues suggested that “[a]lthough older persons with [chronic kidney disease] CKD value longevity, reducing symptom burden and achieving maximal social and functional life participation may be more highly prioritized.
“Montez-Rath and colleagues’ findings highlight not only that dialysis initiation has important tradeoffs but also that older persons with advanced CKD are at high risk for death irrespective of dialysis initiation, underscoring the critical importance of ongoing discussion around goals of care among patients, their loved ones and caregivers, and healthcare providers,” the researchers wrote.
Perspective
Back to TopThe study by Montez-Rath and colleagues is one of the first from the United States focusing on use of dialysis vs. medical management of older adults with kidney failure. The authors should be commended for this study as it highlights an important decision and incorporates other health priorities beyond survival as outcomes. The short takeaway was that survival with dialysis exists, though the extent of this was modest and associated with decreased time spent at home.
Health priorities of adults with CKD have previously been shown to include factors other than survival, such as maintaining independence. While days at home were an outcome, the effect on this may have been underestimated as time spent at in-center dialysis, at least 3 hours three times a week, and transport time to and from treatments, was not included and can substantially add up during the course of months to years.
It is unclear the extent of support provided in this study to the group of patients who choose continuing medical management. In other countries, conservative management is more structured with an interdisciplinary practice, incorporating principles of palliative care in the support of patients and families to help with symptom management and care transitions.
Important conversations between patients, caregivers and providers should be sparked by this study when discussing management of advanced kidney disease. May other researchers continue to evaluate these outcomes, the best methods to aid in decision- making and how to best care for patients who opt for non-dialysis therapy.
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