Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: A systematic review and meta-analysis.
OBJECTIVE
Elderly people comprise a large and growing proportion of the global dialysis population. Regional differences in rates of dialysis in the elderly suggest multiple factors influence treatment decision-making including beliefs about the relative benefits and harms of dialysis and supportive (non-dialysis) care. We therefore systematically reviewed the literature reporting survival of elderly patients treated with either treatment pathway.


METHODS
Systematic review and meta-analysis of cohort studies or randomized controlled trials identified in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials published before July 2014. Survival by treatment modality was calculated. Subgroup analyses by study design, study size, patient age and cohort era were conducted.


RESULTS
Eighty-nine studies published between 1976 and 2014 reported on 294 921 elderly end-stage kidney disease (ESKD) patients. There was a paucity of data for supportive care (724 patients or 0.2% of the total patients) and supportive care studies were susceptible to lead-time bias. One-year survival for elderly patients treated with undifferentiated dialysis was 73.0% (95% confidence interval (CI) 66.3-79.7%), 78.4% (95% CI 75.2-81.6) for haemodialysis and 77.9% (95% CI 73.8-81.9) for peritoneal dialysis. Supportive care patients had a 1-year survival of 70.6% (95% CI 63.3-78.0%). Residual heterogeneity remained within individual treatment modalities despite subgroup analyses.


CONCLUSIONS
While the available literature demonstrates a broadly similar 1-year survival in elderly ESKD patients, it does not allow a confident estimate of the relative survival benefits of dialysis or supportive care. This uncertainty needs urgent attendance by further prospective data, which avoid bias and allow comparisons of quality of life and survival.
The George Institute for Global Health, University of Sydney, Sydney, Australia.|Renal Department, Concord Repatriation General Hospital, Sydney, Australia.
Celine
C
Foote
The George Institute for Global Health, University of Sydney, Sydney, Australia.
Sradha
S
Kotwal
The George Institute for Global Health, University of Sydney, Sydney, Australia.|Renal Department, Concord Repatriation General Hospital, Sydney, Australia.|Concord Clinical School, University of Sydney, Sydney, Australia.
Martin
M
Gallagher
The George Institute for Global Health, University of Sydney, Sydney, Australia.|Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
Alan
A
Cass
Department of Renal Medicine, St George Hospital, Sydney, Australia.|Department of Medicine, University of New South Wales, Sydney, Australia.
Mark
M
Brown
The George Institute for Global Health, University of Sydney, Sydney, Australia.|Renal Department, Concord Repatriation General Hospital, Sydney, Australia.
Meg
M
Jardine
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D010530:Peritoneal Dialysis / Q000009:adverse effects / Q000401:mortality; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
aged; chronic; dialysis; kidney failure; palliative care; review; systematic