FC063A PROSPECTIVE STUDY COMPARING OUTCOMES IN DIALYSIS VERSUS CONSERVATIVE CARE IN OLDER PEOPLE WITH END STAGE KIDNEY DISEASE

INTRODUCTION: The benefits of dialysis in older people with ESKD are not clear. We aimed to establish whether dialysis has survival advantage compared to conservative care (CC) in older people who were medically suitable for dialysis therapy. METHODS: This was a prospective observational study of CKD patients’ aged ≥75 years when eGFR first reached ≤15ml/min/1.73m2. Estimates of median survival and hazard ratios (HR) for death were compared between patients who chose dialysis versus those who chose conservative care from two time points: when first seen in pre-dialysis clinic (eGFR ≤15ml/min/1.73m2), and when initiation of dialysis was first considered (eGFR ≤10ml/min/1.73m2). Survival analysis was then repeated using propensity score matching. Propensity scores were determined using all collected clinical co-variates, and dialysis versus conservative care patients matched 1:1 with a calliper width of 0.01. Un-matched patients were excluded. Logistic regression was then used to calculate odds ratios for propensity score matched cohorts. Patients with co-morbidities likely to significantly reduce life expectancy were excluded (e.g. NYHA class 3 or 4 heart failure, malignancy, dementia). Comparative data on number of days spent in hospital during follow up were also collected. RESULTS: There were 204 patients (123 dialysis, 81 CC) with first eGFR ≤15ml/min/1.73m2 when aged ≥75 years. Of these, 115 went on to record an eGFR of ≤10ml/min/1.73m2 (73 dialysis, 42 CC). Patients who chose conservative care over dialysis were older (83.7 ± 2.2 years versus 78.9 ± 2.8 years, p <0.001), and more likely to live alone and have peripheral vascular disease. The median survival from eGFR first ≤15ml/min/1.73m2 for the dialysis and CC groups were 42 (95% CI =33–50) months and 31 (95% CI = 21-41) months, respectively. The HR for death in the dialysis group compared to CC adjusted for co- morbidities (age, PVD and living alone) was 0.61(95% CI = 0.41-0.91, p= 0.01). The median survival from eGFR first ≤10ml/min/1.73m2 for dialysis and CC group were 36 (25–47) months and 12 (0-5) months, respectively. The adjusted HR for death in the dialysis group compared to CC was 0.36 (95% CI = 0.21-0.62, p <0.001). The results from the propensity score matched analysis concurs with the results from the original Cox model. The median annualized number of hospital days (in-patient and outpatient) from eGFR ≤15mL/min/1.73m2 was 23 (IQR 10-86) for dialysis patients, and 10 (5-25) for CC. The median annualized number of hospital days (in-patient and outpatient) from eGFR ≤10mL/min/1.73m2 was 78 (IQR 18-125) for dialysis patients, and 21 (8-80) for CC. CONCLUSIONS: This study is novel in being both prospective and in excluding patients with co-morbidities which may limit suitability for dialysis. It indicates that dialysis increases survival in older patients, as the statistically significant difference in survival only appeared when eGFR was ≤10mL/min/1.73m2. This advantage may be offset in terms of quality of life by the increase in time spent at hospital for those patients who chose dialysis. Hence, a future focus on quality of life is needed to establish the true benefits of dialysis in older people.