title: The impact of dialysis therapy on older patients with advanced chronic kidney disease: a nationwide population-based study.
abstract: BACKGROUND
  Older 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.
  
  
  METHODS
  This 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.
  
  
  RESULTS
  During 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.
  
  
  CONCLUSIONS
  In 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.
authors.affiliation: Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan. b001089010@tmu.edu.tw.|School of Medicine, National Yang-Ming University, Taipei, Taiwan. b001089010@tmu.edu.tw.
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Shih
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei, Taiwan. ytchen0117@gmail.com.|Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan. ytchen0117@gmail.com.
authors.forename: Yung-Tai
authors.initials: YT
authors.lastname: Chen
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei, Taiwan. okokyytt@gmail.com.|Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan. okokyytt@gmail.com.|Institutes of Physiology and Clinical Medicine, National Yang-Ming University, Taipei, Taiwan. okokyytt@gmail.com.
authors.forename: Shuo-Ming
authors.initials: SM
authors.lastname: Ou
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei, Taiwan. WuCYang3103@gmail.com.|Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan. WuCYang3103@gmail.com.
authors.forename: Wu-Chang
authors.initials: WC
authors.lastname: Yang
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei, Taiwan. ludwigvantw@gmail.com.|National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan. ludwigvantw@gmail.com.|Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan. ludwigvantw@gmail.com.
authors.forename: Shu-Chen
authors.initials: SC
authors.lastname: Kuo
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei, Taiwan. dctarng@vghtpe.gov.tw.|Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan. dctarng@vghtpe.gov.tw.|Institutes of Physiology and Clinical Medicine, National Yang-Ming University, Taipei, Taiwan. dctarng@vghtpe.gov.tw.
authors.forename: Der-Cherng
authors.initials: DC
authors.lastname: Tarng
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D003657:Decision Making; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D009313:National Health Programs; D006435:Renal Dialysis / Q000191:economics / Q000706:statistics & numerical data; D051436:Renal Insufficiency, Chronic / Q000191:economics / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D013624:Taiwan