Dialysis is a life-prolonging treatment for many people with end-stage kidney disease. However, there has been an increasing focus on conservative care (i.e., without dialysis or transplantation), particularly for elderly patients with comorbidities who may gain little or no survival or quality of life benefit from commencing dialysis. To support informed and shared decision-making about initiating dialysis in the elderly population, an understanding of their prognosis and treatment goals is needed. One important consideration is mortality risk after dialysis initiation.
In a recent study published in AJKD, Thamer et al developed and validated predictive risk scores for early death in elderly patients on dialysis. The authors analyzed data from the United Stated Renal Data System (USRDS) and claims data from the Centers for Medicare and Medicaid Services, which included 69,441 patients aged 67 years or older who had initiated dialysis from 2009 – 2010. The authors developed a risk score 0-9 to predict all-cause mortality at 3 months and 6 months after initiating dialysis.
The risk score included age (70-84 years [1 point], 85-89 years [2 points], ≥ 90 years [3 points]), low albumin, assistance in daily living, residing in a nursing home, cancer, heart failure, and hospitalization for > 1 month [1 point each]. The highest scores (above 8) indicated an estimated 39% and 55% probability of death within the first 3 and 6 months, respectively. For a patient with a score of 3, the estimated probability of death at 3 and 6 months were 12% and 20%, respectively. The risk assessment tool has the potential to facilitated shared decision-making about dialysis initiation in elderly patients, but as the authors note, it is not intended as medical advice or to suggest treatment.
While the short-term mortality risk after commencement of dialysis is important, it should be considered in the broader context of the goals, priorities, and values of elderly patients who are at the crossroads of deciding between dialysis and conservative care. Various decision-aids for treatment modalities have been developed for patients with chronic kidney disease, such as the Kidney Research UK Dialysis Decision Aid booklet, but perhaps more resources that are targeted to the elderly population with end-stage kidney disease are needed.
Dr. Allison Tong
AJKD Blog Contributor