title: Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.
abstract: OBJECTIVE
  Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.
  
  
  METHODS
  A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded.
  
  
  RESULTS
  In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ≥70 years old with Davies comorbidity scores of ≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02).
  
  
  CONCLUSIONS
  In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.
authors.affiliation: Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and w.verberne@antoniusziekenhuis.nl.
authors.forename: Wouter R
authors.initials: WR
authors.lastname: Verberne
authors.affiliation: Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and.
authors.forename: A B M Tom
authors.initials: AB
authors.lastname: Geers
authors.affiliation: Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and.
authors.forename: Wilbert T
authors.initials: WT
authors.lastname: Jellema
authors.affiliation: Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and.
authors.forename: Hieronymus H
authors.initials: HH
authors.lastname: Vincent
authors.affiliation: University Medical Center Utrecht, Julius Center for Health Sciences, Utrecht, The Netherlands.
authors.forename: Johannes J M
authors.initials: JJ
authors.lastname: van Delden
authors.affiliation: Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and.
authors.forename: Willem Jan W
authors.initials: WJ
authors.lastname: Bos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000072700:Conservative Treatment; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D011379:Prognosis; D006435:Renal Dialysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate
keywords: Humans; Kidney Diseases; Renal Replacement Therapy; Retrospective Studies; aged; chronic kidney failure; comorbidity; conservative management; renal dialysis; survival analysis