U.S. Marine Corps veteran Richard Shea is tended to by Sheela George, an 8-year veteran RN in the VA North Texas Dialysis Clinic, as he completes another session of dialysis last year. A new study looked at the advantages and disadvantage of starting dialysis early in kidney failure. Photo from the North Texas VA Healthcare System.
PALO ALTO, CA — Older adults with reduced kidney function who start dialysis within 30 days and aren’t referred for transplant have modest gains in life expectancy and less time at home, according to a recent study.
The target trial emulation study published in the Annals of Internal Medicine compared survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m2 and those who continued medical management.1
Study authors are affiliated with the VA Palo Alto (CA) Health Care System and VA Puget Sound Healthcare System in Seattle.
Patients who progress to kidney failure at older ages and have other health conditions that prevent kidney transplant “face a complex decision between initiating dialysis and declining it for continued medical management. To make an informed decision, it’s crucial to have estimates of the benefits and burden of treatment, but there are limited data comparing treatment options. No trials have tested starting dialysis versus forgoing it and continuing medical management,” the study authors pointed out.
Through systematic reviews, researchers have determined that “reliable estimates of the benefits of dialysis can’t be obtained from existing data due to varied study designs. Also, patients might not realize that intensive treatments, such as dialysis, can result in many other medical interventions when complications arise. Home time, the amount of time patients spend at home rather than in a hospital or nursing facility, is increasingly used as a patient-centered endpoint in clinical trials of intensive treatments. However, few studies have compared the effects of dialysis and continued medical management on home time or other patient-centered outcomes and whether any increases in survival might come at the expense of home time,” according to the authors.
This study examined adults aged 65 and older with progressive chronic kidney failure with reduced kidney function, indicated by an eGFR of less than 12 ml/min/1.73m2 and who were not referred for a kidney transplant. The glomerular filtration rate (GFR) GFR is a key measure of kidney function, with lower values indicating more advanced kidney failure.
In this population, the authors emulated a clinical trial using VA electronic health records. They compared the effect of starting dialysis within 30 days of meeting eligibility versus waiting at least 30 days with the possibility of starting dialysis later, as well as the effect of starting dialysis within the next 30 days versus forgoing dialysis altogether and continuing medical management, explained Manjula K. Tamura, MD, MPH, director of the Geriatric Research and Education Clinical Center of the VA Palo Alto Health Care System.
The authors also measured mean survival and number of days at home.
“We found that starting dialysis within the next 30 days was associated with modest gains in life expectancy but also resulted in less time spent at home compared to (1) the group who waited at least 30 days and (2) the group who did not start dialysis and continued medical management,” Tamura told U.S. Medicine. “The trade-offs between life expectancy and time at home associated with starting dialysis soon after meeting eligibility were more favorable in patient subgroups with more advanced kidney disease and in those who were older.”
The authors “conducted this study to guide decisions about whether and when to start dialysis in older adults and provide a context that helps patients understand the trade-offs involved. Measuring home time offers insight into the downstream effects of a complex and intensive treatment like dialysis,” she suggested.
The analysis found that “among 20,440 adults (mean age, 77.9 years), the median time to dialysis start was eight days in the group starting dialysis and three years in the group continuing medical management. Over a three-year time period, the group starting dialysis survived 770 days, and the group continuing medical management survived 761 days, a difference of 9.3 days,” the study authors pointed out.
In addition, the authors concluded that, “compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home. Also, compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days and 14.7 fewer days at home.”
Shared Decision-Making
“It’s important for healthcare professionals who are treating older adults with advanced kidney failure to “engage patients in shared decision-making early in the process and consider referring them to clinical trials that test decision aids, incremental dialysis starts, and symptom management strategies to strengthen the evidence base for managing chronic kidney failure,” Tamura advised. She also noted that observational studies like this one have significant limitations.
“The most crucial limitation is the potential differences between the group that started dialysis and the group that continued medical management, such as whether patients were experiencing symptoms of kidney failure—factors we could not fully account for,” she said. “Ultimately, clinical trials are necessary to test these strategies and determine their effects on patient survival, quality of life and symptoms.”
The authors emphasized the study doesn’t “directly address the effectiveness of starting dialysis in symptomatic patients, so it remains unclear when dialysis should be started for symptom management in patients with kidney failure and which symptoms can be improved by dialysis treatment.”
This study also has limited generalizability to women and nonveterans, according to the authors.
The study authors suggested their results have several implications for clinical practice and policy. For instance, “treatment decision-making for older adults with kidney failure often ignores or downplays the potential harms of dialysis, including exposure to invasive procedures, hospitalizations and time spent in health care settings,” they wrote. “This study highlights the importance of a comprehensive and balanced approach to kidney disease education for patients who are not eligible for transplant. Alternative models of care should be tested for these patients, such as symptom management protocols to delay the onset of uremic symptoms, incremental dialysis initiation, dedicated treatment pathways for patients who do not wish to undergo dialysis, and concurrent dialysis and hospice.”
- Montez-Rath ME, Thomas IC, Charu V, Odden MC, Seib CD, Arya S, Fung E, O’Hare AM, Wong SPY, Kurella Tamura M. 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. 2024 Aug 20. doi: 10.7326/M23-3028. Epub ahead of print. PMID: 39159459.