Abstract
With population aging, the burden of many age-related chronic conditions, including kidney failure, is increasing globally. To investigate the risks of kidney failure and death in adults with incident stage IV chronic kidney disease (CKD). This population-based cohort study obtained data recorded between July 30, 2002, and March 31, 2014, from the linked laboratory and administrative data set of Alberta Health in Alberta, Canada. All adults of the province of Alberta with stage IV CKD (estimated glomerular filtration rate [eGFR] of 15-30 mL/min/1.73 m2) were eligible for inclusion. Included individuals were followed up from study entry until the date of kidney failure, death, or censoring, whichever occurred first. Observations were censored at the date of emigration from the province, the study end date (March 31, 2017), or at 10 years after study entry. Data analyses were performed from January 2020 to June 2020. The primary outcome was kidney failure, defined as the earlier of either renal replacement (dialysis or kidney transplant) initiation or severe kidney impairment (eGFR <10 mL/min/1.73 m2). Incidence of stage IV CKD in Alberta was examined over time, along with the association between age at study entry and the competing risks of kidney failure and death. Cumulative incidence functions (95% CIs) were estimated to summarize absolute risks over time across categories of age, accounting for sex, diabetes, cardiovascular disease, eGFR, and albuminuria. The study included 30 801 adults (mean [SD] age, 76.8 [13.3] years; 17 294 women [56.1%]) with stage IV CKD. Of these, 5511 developed kidney failure (17.9%) and 16 285 died (52.9%). The incidence rate of stage IV CKD increased sharply with advancing age; the absolute risk of kidney failure decreased with advancing age, and the risk of death increased, especially in those aged 85 years or older. Compared with the 5-year risk of death, the 5-year risk of kidney failure was higher in people younger than 65 years, similar in people aged 65 to 74 years, and lower for older age groups. For those aged 75 years or older, the risk of death was much higher than the risk of kidney failure: 6-fold higher among those aged 75 to 84 years (0.51 [95% CI, 0.5-0.52] vs 0.09 [95% CI, 0.08-0.09]) and 25-fold higher among those aged 85 years or older (0.75 [95% CI, 0.74-0.76] vs 0.03 [95% CI, 0.02-0.03]). The risk of death was higher than the risk of kidney failure by 24-fold among those aged 85 to 94 years (0.73 [95% CI, 0.72-0.74] vs 0.03 [95% CI, 0.02-0.03]) and by 149-fold among those aged 95 years or older (0.89 [95% CI, 0.87-0.92] vs <0.01 [95% CI, <0.01 to 0.01]). This study found that, although the incidence rate of stage IV CKD increased with advancing age, the absolute risk of kidney failure decreased. Unlike other age-related conditions, the expected increase in the burden of kidney failure in the older adults may be less dramatic than expected.
Highlights
The incidence rate of stage IV chronic kidney disease (CKD) increased sharply with advancing age; the absolute risk of kidney failure decreased with advancing age, and the risk of death increased, especially in those aged 85 years or older
Compared with the 5-year risk of death, the 5-year risk of kidney failure was higher in people younger than 65 years, similar in people aged 65 to 74 years, and lower for older age groups
This study found that, the incidence rate of stage IV CKD increased with advancing age, the absolute risk of kidney failure decreased
Summary
Because of lower birth rates and longer life expectancy, the proportion of older adults in the general population has been steadily increasing. By 1 estimate, the number of people older than 80 years will triple between 2019 and 2050, from 143 million to 425 million, worldwide. Chronic kidney disease (CKD), which is defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2, affects 10% to 16% of the general population worldwide and is associated with death and kidney failure. The prevalence of CKD increases with age (from 4% at younger than 40 years to 47% at 70 years or older5), as do more severe CKD stages characterized by lower eGFR and worse outcomes. As in other populations, among people with CKD, the prevalence of comorbidity and the risk of adverse health outcomes increase in parallel with age.7,8With population growth and aging, the number of people with chronic medical conditions is expected to rise worldwide. For example, the global number of people living with dementia more than doubled from 1990 to 2016,10 and approximately 60% of people aged 80 years or older have at least 3 chronic disorders. death is a competing risk for developing kidney failure, and some but not all older people with advanced CKD will live long enough to develop kidney failure. Chronic kidney disease (CKD), which is defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2, affects 10% to 16% of the general population worldwide and is associated with death and kidney failure.. Among people with CKD, the prevalence of comorbidity and the risk of adverse health outcomes increase in parallel with age.. With population growth and aging, the number of people with chronic medical conditions is expected to rise worldwide.. Death is a competing risk for developing kidney failure, and some but not all older people with advanced CKD will live long enough to develop kidney failure. Studies that assessed the association between age and kidney failure in people with CKD reported rates or relative hazards from which absolute risks cannot be obtained directly in the presence of competing events.. Studies that assessed the association between age and kidney failure in people with CKD reported rates or relative hazards from which absolute risks cannot be obtained directly in the presence of competing events. In addition, with few exceptions, previous studies were largely based on selected cohorts of people receiving nephrology care, who may differ in clinically important ways from those not receiving nephrology care. Given that treatments for kidney failure, including renal replacement with dialysis or kidney transplant, are resource intensive, data on the association of population aging with the burden of kidney failure are potentially valuable to policymakers
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