Maria E Montez-Rath, I-Chun Thomas, Vivek Charu, Michelle C Odden, Carolyn D Seib, Shipra Arya, Enrica Fung, Ann M O'Hare, Susan P Y Wong, Manjula Kurella Tamura
{"title":"开始透析与持续医疗管理对肾衰竭老年人存活率和居家时间的影响：一项目标试验模拟研究。","authors":"Maria E Montez-Rath, I-Chun Thomas, Vivek Charu, Michelle C Odden, Carolyn D Seib, Shipra Arya, Enrica Fung, Ann M O'Hare, Susan P Y Wong, Manjula Kurella Tamura","doi":"10.7326/M23-3028","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.</p><p><strong>Objective: </strong>To compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m<sup>2</sup> and those who continued medical management.</p><p><strong>Design: </strong>Observational cohort study using target trial emulation.</p><p><strong>Setting: </strong>U.S. Department of Veterans Affairs, 2010 to 2018.</p><p><strong>Participants: </strong>Adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m<sup>2</sup> who were not referred for transplant.</p><p><strong>Intervention: </strong>Starting dialysis within 30 days versus continuing medical management.</p><p><strong>Measurements: </strong>Mean survival and number of days at home.</p><p><strong>Results: </strong>Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).</p><p><strong>Limitation: </strong>Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans.</p><p><strong>Conclusion: </strong>Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m<sup>2</sup> who were not referred for transplant had modest gains in life expectancy and less time at home.</p><p><strong>Primary funding source: </strong>U.S. Department of Veterans Affairs and National Institutes of Health.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6000,"publicationDate":"2024-08-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults With Kidney Failure : A Target Trial Emulation Study.\",\"authors\":\"Maria E Montez-Rath, I-Chun Thomas, Vivek Charu, Michelle C Odden, Carolyn D Seib, Shipra Arya, Enrica Fung, Ann M O'Hare, Susan P Y Wong, Manjula Kurella Tamura\",\"doi\":\"10.7326/M23-3028\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.</p><p><strong>Objective: </strong>To compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m<sup>2</sup> and those who continued medical management.</p><p><strong>Design: </strong>Observational cohort study using target trial emulation.</p><p><strong>Setting: </strong>U.S. Department of Veterans Affairs, 2010 to 2018.</p><p><strong>Participants: </strong>Adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m<sup>2</sup> who were not referred for transplant.</p><p><strong>Intervention: </strong>Starting dialysis within 30 days versus continuing medical management.</p><p><strong>Measurements: </strong>Mean survival and number of days at home.</p><p><strong>Results: </strong>Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).</p><p><strong>Limitation: </strong>Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans.</p><p><strong>Conclusion: </strong>Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m<sup>2</sup> who were not referred for transplant had modest gains in life expectancy and less time at home.</p><p><strong>Primary funding source: </strong>U.S. Department of Veterans Affairs and National Institutes of Health.</p>\",\"PeriodicalId\":7932,\"journal\":{\"name\":\"Annals of Internal Medicine\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":19.6000,\"publicationDate\":\"2024-08-20\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Annals of Internal Medicine\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.7326/M23-3028\",\"RegionNum\":1,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"MEDICINE, GENERAL & INTERNAL\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Annals of Internal Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.7326/M23-3028","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"MEDICINE, GENERAL & INTERNAL","Score":null,"Total":0}
Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults With Kidney Failure : A Target Trial Emulation Study.
Background: For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.
Objective: To compare 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.
Design: Observational cohort study using target trial emulation.
Setting: U.S. Department of Veterans Affairs, 2010 to 2018.
Participants: Adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2 who were not referred for transplant.
Intervention: Starting dialysis within 30 days versus continuing medical management.
Measurements: Mean survival and number of days at home.
Results: Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).
Limitation: Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans.
Conclusion: Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home.
Primary funding source: U.S. Department of Veterans Affairs and National Institutes of Health.
期刊介绍：
Established in 1927 by the American College of Physicians (ACP), Annals of Internal Medicine is the premier internal medicine journal. Annals of Internal Medicine’s mission is to promote excellence in medicine, enable physicians and other health care professionals to be well informed members of the medical community and society, advance standards in the conduct and reporting of medical research, and contribute to improving the health of people worldwide. To achieve this mission, the journal publishes a wide variety of original research, review articles, practice guidelines, and commentary relevant to clinical practice, health care delivery, public health, health care policy, medical education, ethics, and research methodology. In addition, the journal publishes personal narratives that convey the feeling and the art of medicine.
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