Abstract
Prognosis provides critical knowledge for shared decision making between patients and clinicians. While several prognostic indices for mortality in dialysis patients have been developed, their performance among elderly patients initiating dialysis is unknown, despite great need for reliable prognostication in that context. To assess the performance of 6 previously validated prognostic indices to predict 3 and/or 6 months mortality in a cohort of elderly incident dialysis patients. Validation study of prognostic indices using retrospective cohort data. Indices were compared using the concordance ("c")-statistic, i.e. area under the receiver operating characteristic curve (ROC). Calibration, sensitivity, specificity, positive and negative predictive values were also calculated. Incident elderly (age ≥75 years; n = 349) dialysis patients at a tertiary referral center. Variables for six validated prognostic indices for short term (3 and 6 month) mortality prediction (Foley, NCI, REIN, updated REIN, Thamer, and Wick) were extracted from the electronic medical record. The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality. In our cohort of 349 patients, mean age was 81.5±4.4 years, 66% were male, and median survival was 351 days. The c-statistic for the risk prediction indices ranged from 0.57 to 0.73. Wick ROC 0.73 (0.68, 0.78) and Foley 0.67 (0.61, 0.73) indices performed best. The Foley index was weakly calibrated with poor overall model fit (p <0.01) and overestimated mortality risk, while the Wick index was relatively well-calibrated but underestimated mortality risk. Small sample size, use of secondary data, need for imputation, homogeneous population. Most predictive indices for mortality performed moderately in our incident dialysis population. The Wick and Foley indices were the best performing, but had issues with under and over calibration. More accurate indices for predicting survival in older patients with kidney failure are needed.
Highlights
Optimal shared decision making is predicated on informed and evidence-based conversations between the patient, caregiver, and clinician
The cohort included all adults aged 75 years and older who initiated any type of renal replacement therapy (RRT) from January 1, 2007, through December 31, 2011 in the Mayo Clinic Dialysis Services (MCDS) which provides all RRT services in our health system and serves a general population of 385,000 patients in Southeast Minnesota, Northern Iowa, and Southwest Wisconsin, through 8 community based HD facilities as well as inpatient HD
We identified 11 indices validated for use at RRT initiation, predicting short term survival (3– 6 months), through a systematic review of mortality prediction indices [16]
Summary
Validation study of prognostic indices using retrospective cohort data. Dr Shah has received research support through Mayo Clinic from the Food and Drug Administration to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938); from the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI); from the Agency for Healthcare Research and Quality (R01HS025164, R01HS025402, R03HS025517); from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH; R56HL130496, R01HL131535), National Science Foundation; and from the Patient Centered Outcomes Research Institute (PCORI) to develop a Clinical Data Research Network (LHSNet). The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality
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