#2677 A propensity score-matched analysis of kidney replacement therapy outcomes for older adults stratified by frailty severity

Abstract

Abstract Background and Aims Older people living with frailty who receive kidney replacement therapy (KRT) experience higher mortality and hospital readmission compared to their non-frail counterparts [1–3]. Shared decision making with older people regarding the optimal KRT modality (haemodialysis [HD], peritoneal dialysis [PD], or kidney transplant [TX]) can present challenges due to the lack of research comparing KRT modalities stratified by frailty severity. The Hospital Frailty Risk Score (HFRS), which uses routinely collected clinical data to categorise frailty severity, has been shown to predict outcomes in advanced chronic kidney disease (CKD) [4]. However, the HFRS has not been used to compare outcomes across KRT modalities. This single-centre project aims to explore outcomes between KRT modalities for older people stratified by HFRS frailty severity. Method Adults aged 60 years or older starting KRT at our institution between December 2012 and January 2022 were included. HFRS was calculated at first estimated glomerular filtration rate (eGFR) result below 15 mL/min/1.73 m2 and at start of KRT. Patients were stratified by KRT modality and their frailty severity (categorized as low, intermediate, or high according to their HFRS score). TX patients were then matched to 1:2 to HD patients and 1:1 to PD patients, based on patient age, HFRS category, and Charlson Comorbidity Index (CCI) at KRT start. Outcomes of interest were hospital readmission and mortality, both overall and within 1 year of KRT initiation. Descriptive statistics compared HD, PD, and TX groups. Results Twenty TX, 20 PD, and 40 HD matched patients were included. Age (HD vs PD vs TX: 68.5 vs 67.6 vs 68.3 years, p = 0.50), proportion of males (57.5% vs 70.0% vs 55.0%, p = 0.66), and CCI (15.0 vs 13.0 vs 13.0, p = 0.95) were similar between cohorts. Frailty, as assessed by the HFRS, worsened or remained the same for most patients in all 3 cohorts between first eGFR < 15 and KRT start (81.0% vs 93.0% vs 83.0%, p = 0.61). All patients were either of low (85.0% vs 80.0% vs 85.0%) or intermediate (15.0% vs 20.0% vs 15.0%) frailty status at time of KRT start and the proportion of patients in each category did not vary with modality (p = 0.92). Re-hospitalization within 1 year of starting KRT was similar between groups (32.5% vs 25.0% vs 10.0%, p = 0.12). Kaplan-Meier survival analyses also demonstrated similar survival among groups at 1 year (75.0% vs 95.0% vs 90.0%, log-rank p = 0.09), but better survival among TX patients overall (0.0% vs 66.1% vs 79.4%, log-rank p = 0.02). Overall and 1 year Kaplan-Meier survival for patients stratified by KRT modality and HFRS are shown in Fig. 1. Conclusion TX may optimize longer term survival for older people with low and intermediate frailty status and kidney failure. Furthermore, the HFRS appears to be a useful prognostic tool that could inform shared decision making with older patients regarding KRT modality choice.