Survival of Older Adults Choosing Dialysis or Conservative Kidney Management, Stratified by Suitability for Dialysis

Abstract

Rationale & Objective

Previous studies indicate survival benefit for dialysis over conservative kidney management (CKM), which attenuates in patients ≥80 years or with high comorbidity. Most studies did not differentiate dialysis suitability among those choosing CKM, potentially biasing outcomes. We aimed to describe survival outcomes in patients choosing dialysis, patients suitable for dialysis who chose CKM, and patients less suitable for dialysis who chose CKM.

Study design

Single-center cohort study.

Setting & Participants

We included patients aged ≥65 years with a documented treatment decision for dialysis or CKM between 2017 and 2024.

Exposure

Chosen treatment (dialysis or CKM). Patients choosing CKM were classified as suitable or less suitable for dialysis, based on the treating nephrologist’s.

Outcome

The primary outcome was all-cause mortality.

Analytical Approach

Descriptive, using Kaplan–Meier estimates and Cox proportional hazard models without adjustment for confounding.

Results

Median survival from treatment decision was 53 (dialysis), 32 (CKM, suitable for dialysis), and 18 months (CKM, less suitable for dialysis), with unadjusted hazard ratios of 2.11 (CKM, suitable for dialysis vs dialysis; 95% CI 1.59-2.80) and 3.23 (less suitable for dialysis vs dialysis; 95% CI 2.47-4.23). Among patients aged ≥80 years, hazard ratios were 1.89 (0.99-1.74) for CKM suitable for dialysis versus dialysis and 2.35 (1.31-4.64) for CKM less suitable for dialysis versus dialysis. Thirteen percent of patients who initially chose dialysis switched to CKM, whereas 1% transitioned from CKM to dialysis.

Limitations

Subjectivity in dialysis suitability assessment.

Conclusions

In this cohort of older patients with kidney failure, survival outcomes in patients choosing CKM suitable for dialysis were longer than previously reported. These findings highlight the importance of distinguishing dialysis suitability when evaluating survival outcomes in CKM and dialysis. This supports more individualized shared decision making in older adults with advanced kidney disease.

Plain-Language Summary

Older adults with advanced kidney disease often face a difficult decision whether to choose dialysis or conservative kidney management (CKM). Earlier studies did not clarify whether patients opting for CKM were medically eligible for dialysis, making results less applicable for people who face a genuine choice between treatments. This study described survival outcomes in people aged 65 years and older. People who chose dialysis lived about 53 months after making their treatment decision, people who chose CKM and were considered suitable for dialysis lived about 32 months, and people who chose CKM and were considered less suitable for dialysis lived about 18 months. These findings support individualized shared decision making and highlight the importance of considering dialysis suitability.