Dialysis Benefits in CKD Come With Trade-Offs

While older patients with chronic kidney failure who opt to start dialysis show a modest survival benefit over those choosing only medical management, an important trade-off is lengthier time spent in inpatient settings for those receiving dialysis, with the exception of patients older than 80 years and more severe kidney disease, new research shows.

“Decisions to start dialysis at this level of kidney function should consider the clinical factors that affect this trade-off and whether the expected outcomes of starting dialysis align with an individual’s values and goals,” concluded the authors of the study published this week in the Annals of Internal Medicine.

Patients with advanced kidney failure who are not eligible for a kidney transplant are often offered the option of dialysis, with the suggestion of a possible improvement in survival.

However, such discussions may leave patients with unrealistic expectations and only provide part of the picture of likely outcomes, the authors cautioned.

“Widely referenced estimates of survival after dialysis initiation are misleading to use in shared decision-making because these figures underestimate early mortality and run the risk of misattributing how long patients live to a beneficial effect of dialysis treatment,” they explained.

With no previous studies directly comparing patients with kidney failure who commenced dialysis with those who continued medical management, first author Maria E. Montez-Rath, PhD, and colleagues conducted an observational cohort study emulating a randomized trial, utilizing data from the US Department of Veterans Affairs.

The study included data on 20,440 adults from 2010 to 2018 who had chronic kidney failure, with an estimated glomerular filtration rate (eGFR) 2, and who were not referred for a transplant.

Outcomes were evaluated based on those who commenced dialysis within 30 days vs those who continued medical management.

The participants had a mean age of 77.9 years and were more than 98% male.

Of the patients, 8.1% initiated dialysis within a month at a median time of 8 days.

Over the 3-year study period, about 44% patients in the dialysis and medical management groups died.

Overall, the group starting dialysis within a month had a mean survival of 770 vs 761 days among the group choosing medical management, for a mean difference of just 9.3 days.

However, the group that started dialysis had a mean of 13.6 fewer days at home, defined as not receiving inpatient care in a hospital, skilled-nursing facility, nursing home, or rehabilitation facility, vs medical management.

A per-protocol analysis of those who started dialysis vs those who continued medical management forgoing dialysis completely did show the dialysis group had 77.6 days longer survival but still had 14.7 fewer days at home than the medical management group.

In stratifying by age, among those aged 80 years or older, starting dialysis within a month was associated with a mean of 60 days longer survival compared with medical management but 12.9 fewer days at home.

Conversely, among adults aged 65-79 years, the survival time in fact favored those continuing medical management by a mean of 16.6 days, while those starting dialysis still spent 14.4 fewer days at home.

Several subgroup analyses suggested that having a greater severity of kidney failure at entry into the trial was associated with more favorable survival when starting dialysis vs medical management.

However, starting dialysis earlier was nevertheless consistently associated with fewer days at home among most age and disease severity subgroups, the authors noted.

“In [the 80 and over] age group, we find a statistically significant survival benefit of starting dialysis within a month when eGFR Medscape Medical News.

“In the 65-80 age group, our findings are consistent with the IDEAL trial and suggest that it’s reasonable to defer dialysis until patients have more advanced symptoms and/or lower kidney function.”

Various Dialysis Factors Can Result in Inpatient Care

While the specific causes of longer inpatient care in dialysis groups were not evaluated, Tamura speculated on key reasons.

“First, patients might be hospitalized for care coordination when starting dialysis, especially if dialysis start hasn’t been planned for,” she said. In addition, “dialysis is associated with some complications that require inpatient care, such as blood stream infections.”

Furthermore, “patients who choose dialysis tend to receive more intensive care to manage their associated health conditions, and patients may not realize this when they sign up for dialysis.”

With previous data also suggesting longer survival with dialysis — without much context on other caveats — patients may feel pressured to receive dialysis, Tamura noted.

“I don’t want to oversimplify these situations because they are complex, but I’d say that patients often feel in retrospect that they didn’t have the choice to say no to dialysis.”

In the study, the authors further elaborated that “patients may implicitly assume that treatments prolonging survival concurrently improve independence or that gains in longevity outweigh the time one spends receiving inpatient care or intensive procedures.”

However, “except for certain older or sicker subgroups, the potential gain in length of life is more often spent in healthcare settings than at home,” they explained.

Patients’ Values Key in Shared Decision-Making

Commenting on the study, Sofia Ahmed, MD, a professor in the Faculty of Medicine & Dentistry, University of Alberta, in Edmonton, Alberta, Canada, said the findings underscore the complexities of addressing patients’ values while considering their overall health status.

“This is an ongoing and shared decision-making process — for some patients, this may mean initiation of dialysis, and for others, this may mean conservative management,” she told Medscape Medical News.

“At the end of the day, the goal is to provide the best care possible for the person living with kidney disease, and that is only achievable if the care incorporates a person’s values and preferences.”

Ahmed was coauthor of an editorial published concurrently with the study, which further noted that while it can be life-saving, “dialysis is also costly, access is inequitable, and outcomes are unsatisfactory.”

“In conjunction with a pressing need to develop treatments to prevent or delay kidney failure, novel, cost-effective, and accessible dialysis methods that improve patient outcomes are urgently required,” they added.

The study and editorial authors’ disclosures are detailed in the published paper.