Abstract
BackgroundOlder patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis. Currently available data on this issue are limited because they were generated by small, short-term studies with statistical drawbacks. Further research is urgently needed to provide objective information for dialysis decision making in older patients with advanced CKD.MethodsThis nationwide population-based cohort study was conducted using Taiwan’s National Health Insurance Research Database. Data from 2000 to 2010 were extracted. A total of 8,341 patients ≥70 years old with advanced CKD and serum creatinine levels >6 mg/dl, who had been treated with erythropoiesis-stimulating agents were included. Cox proportional hazard models in which initiation of chronic dialysis was defined as the time-dependent covariate were used to calculate adjusted hazard ratios for mortality. The endpoint was all-cause mortality.ResultsDuring a median follow-up period of 2.7 years, 6,292 (75.4%) older patients chose dialysis therapy and 2,049 (24.6%) received conservative care. Dialysis was initiated to treat kidney failure a median of 6.4 months after enrollment. Dialysis was associated with a 1.4-fold increased risk of mortality compared with conservative care (adjusted hazard ratio 1.39, 95% confidence interval 1.30 to 1.49). In subgroup analyses, the risk of mortality remained consistently increased, independent of age, sex and comorbidities.ConclusionsIn older patients, dialysis may be associated with increased mortality risk and healthcare cost compared with conservative care. For patients who are ≥70 years old with advanced CKD, decision making about whether to undergo dialysis should be weighted by consideration of risks and benefits.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0169-3) contains supplementary material, which is available to authorized users.
Highlights
Older patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis
Using the initiation of chronic dialysis as a time-dependent variable in a Cox regression model, we found that dialysis therapy was associated with a nearly 40% increase in mortality risk, in patients ≥70 years old compared with those receiving conservative care
Our study demonstrated that dialysis therapy in older patients increased mortality risk by almost 40% compared with conservative care
Summary
Older patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis. Further research is urgently needed to provide objective information for dialysis decision making in older patients with advanced CKD. Older patients with chronic kidney disease (CKD) stage 5 comprise a rapidly growing emerging population that may face the dilemma of whether to undergo dialysis or receive conservative care [1]. The perceived financial burden of dialysis, as well as a high comorbidity rate, uncertainty about the treatment’s long-term benefit, and sense of life completion and acceptance of death, leads many older patients to forego dialysis [4]. The most critical concern of older patients with CKD stage 5 is whether dialysis provides benefits such as increased life expectancy and improved functional ability at the end of life [5,6]. Comprehensive physician–patient communication may help to achieve treatment goals and avoid unnecessary medical expenditure [8,9], independent and objective evidence of the comparative effectiveness of treatment options is still needed to guide older patients’ decision making about dialysis
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