Prognostic stratification in older adults commencing dialysis.
BACKGROUND
Accurate prognostic models could inform treatment decisions for older adults with end-stage renal disease who are considering dialysis and might identify patients more appropriate for conservative care or hospice.


METHODS
In a cohort of patients aged ≥ 67 years commencing dialysis in the United States between January 1, 2008 and June 30, 2009, we compared the discrimination of three existing instruments (the Liu index; the French Renal Epidemiology and Information Network score; and hospice eligibility criteria) for the prediction of 6-month mortality. We estimated the odds of death associated with each prognostic index using logistic regression with and without adjustment for age. Predictive indices were compared using the concordance ("c")-statistic.


RESULTS
Of 44,109 eligible patients, 10,289 (23.3%) died within 6 months of dialysis initiation. The c-statistic for the Liu, Renal Epidemiology and Information Network, hospice eligibility criteria, and combined Liu/hospice eligibility criteria scores without and with age were 0.62/0.65, 0.63/0.66, 0.65/0.68, and 0.68/0.70, respectively. Discrimination was poorer at older ages, especially for the Liu and Renal Epidemiology and Information Network scores. Although sensitivity was poor, a Renal Epidemiology and Information Network score ≥ 9 or an hospice eligibility criteria ≥ 3 had relatively high specificity.


CONCLUSIONS
Existing prognostic indices based on administrative data perform poorly with respect to prediction of 6-month mortality in older patients with end-stage renal disease commencing dialysis.
Division of Nephrology, University of Vermont College of Medicine, Burlington. Katharine.L.Cheung@med.uvm.edu.
Katharine L
KL
Cheung
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Maria E
ME
Montez-Rath
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Glenn M
GM
Chertow
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Wolfgang C
WC
Winkelmayer
Department of Medicine, Veterans Affairs Palo Alto Health Care System, California. Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California.
Vyjeyanthi S
VS
Periyakoil
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California. Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, California.
Manjula
M
Kurella Tamura
D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D006435:Renal Dialysis; D018570:Risk Assessment
Epidemiology.; Multimorbidities; Outcomes; Renal