Dialysis Extends Life in Older Adults with eGFR < 12 mL/min/1.73 m²

Older adults who could not get a kidney transplant and turned to dialysis instead when their glomerular filtration rate (eGFR) fell < 12 mL/min/1.73 m2 had moderate increases in life expectancy and less time at home, a recent study reported.¹

Starting dialysis when their kidney function fell below this threshold, rather than waiting, gave patients 1 more week of their life, investigators from Stanford Medicine discovered.²

People with kidney failure can only get a donated kidney if they are healthy enough for transplantation. Many older adults who have other health conditions, such as heart or lung disease or cancer, are not eligible to receive a donor. This is why older adults with kidney failure who are not referred for a transplant often turn to the option of dialysis.

Maria Montez Rath, PhD, from the division of nephrology at Stanford University School of Medicine, said in a statement that patients and their family members sometimes believe dialysis is their only option and that it will significantly extend their life. “They often say yes to dialysis, without really understanding what that means,” Montez Rath said.

However, another option is available for patients with kidney failure—medications. Medications can manage the symptoms of fluid retention, itchiness, and nausea. If patients take the medication, they can avoid the adverse events that come along with dialysis, which include cramping and fatigue. Dialysis also is time-consuming with a 3 – 4-hour visit to the clinic 3 times a week.

“It’s a pretty intensive therapy that entails a major lifestyle change,” said senior author Manjula Tamura, MD, a professor of nephrology, in the press release.

Investigators sought to compare survival and number of days at home between older adults who immediately started dialysis at an eGFR < 12 mL/min/1.73 m2 and those who waited ≥ 1 month before starting dialysis and in the meantime took medications.¹ The team conducted an observational cohort study using target trial emulation and leveraging data from the US Department of Veterans Affairs, 2010 – 2018.

The sample included 20,440 participants aged ≥ 65 years (mean age: 77.9 years) with chronic kidney failure and an eGFR < 12 mL/min/1.73 m2 who were not referred for transplant. Participants either had started dialysis within 30 days or were continuing medical management.

The mean time to start dialysis was 8 days in the group starting dialysis and 3 years in the group continuing medical management. Over 3 years, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days; 95% confidence interval [CI], - 17.4 – 30.1). On average, patients who started dialysis immediately lived 9 days longer than patients who waited.

Compared to the group delaying dialysis, the group starting dialysis immediately had 13.6 fewer days at home. Rather, they spent 13 more days in an inpatient facility (95% CI, 7.7 – 20.5). Moreover, compared to the groups delaying dialysis and foregoing dialysis entirely, the group who started dialysis immediately had a longer survival by 77.6 days (95% CI, 62.8 – 9.11) and 14.7 fewer days at home (95% CI, 11.2 – 16.5).

Age also played a difference on how dialysis impacted survival and days home. Patients aged 65 – 79 years who started dialysis immediately lived, on average, 17 fewer days and spent 14 more days in an inpatient facility. However, patients ≥ 80 years who started dialysis immediately lived, on average, 60 more days but spent 13 more days in an inpatient facility.

As for patients who never underwent dialysis, they died an average of 77 days earlier than those who started dialysis immediately but spent 14 more days at home.

“The study shows us that if you start dialysis right away, you might survive longer, but you’re going to be spending a lot of time on dialysis, and you’re more likely to need hospitalization,” Montez Rath said.²

Investigators noted the study was limited by potential unmeasured confounding due to the absence of symptom assessments at eligibility, as well as the limited generalizability to women and nonveterans.¹

Overall, even though the study suggests it is more helpful to start dialysis earlier, the findings also indicate it is best to wait until the eGFR drops further. However, patient preferences should be taken into consideration as dialysis may bring relief for some patients and a burden to others. In the press release, Tamura said it may be more beneficial if clinicians present dialysis to older adults as a treatment primarily intended to alleviate symptoms.²

“Currently, dialysis is often framed to patients as a choice between life and death,” she said. “When it’s presented in this way, patients don’t have room to consider whether the treatment aligns with their goals, and they tend to overestimate the benefits and well-being they might experience. But when treatment is framed as symptom-alleviating, patients can more readily understand that there are trade-offs.”

References

1. ^{Montez-Rath ME, Thomas IC, Charu V, et al. Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults With Kidney Failure: A Target Trial Emulation Study. Ann Intern Med. Published online August 20, 2024. doi:10.7326/M23-3028}
2. ^{For Some Older Adults with Kidney Failure, Dialysis May Not Be The Best Option. EurekAlert! August 19, 2024. https://www.eurekalert.org/news-releases/1054753. Accessed August 22, 2024.}