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Figure.
One-Year, Unadjusted Survival Curves
One-Year, Unadjusted Survival Curves

Mortality for age (A), comorbidity (B), predialysis functional status (C), and setting of dialysis initiation (D) across the study.

aSample size at time of dialysis initiation.

Table.  
Mortality Rates Stratified by Patient Characteristics (N = 391)
Mortality Rates Stratified by Patient Characteristics (N = 391)
1.
Moss  AH.  Renal Physicians Association Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Rockville, Maryland: Renal Physicians Association; 2010.
2.
2017 USRDS Annual Data Report: Epidemiology Of Kidney Disease in the United States. Bethesda, MD: Renal Physicians Association 2017.
3.
Kurella Tamura  M, Covinsky  KE, Chertow  GM, Yaffe  K, Landefeld  CS, McCulloch  CE.  Functional status of elderly adults before and after initiation of dialysis.  N Engl J Med. 2009;361(16):1539-1547. doi:10.1056/NEJMoa0904655PubMedGoogle ScholarCrossref
4.
Couchoud  CG, Beuscart  J-BR, Aldigier  J-C, Brunet  PJ, Moranne  OP; REIN registry.  Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease.  Kidney Int. 2015;88(5):1178-1186. doi:10.1038/ki.2015.245PubMedGoogle ScholarCrossref
5.
Yu  MK, Wong  SPY, Liu  CF, Hebert  PL, O’Hare  AM.  Clinical presentation at initiation of maintenance dialysis and subsequent survival: A retrospective cohort study.  Hemodial Int. 2019;23(1):106-116.PubMedGoogle ScholarCrossref
6.
Kucirka  LM, Grams  ME, Lessler  J,  et al.  Association of race and age with survival among patients undergoing dialysis.  JAMA. 2011;306(6):620-626. doi:10.1001/jama.2011.1127PubMedGoogle ScholarCrossref
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    Research Letter
    April 22, 2019

    One-Year Mortality After Dialysis Initiation Among Older Adults

    Author Affiliations
    • 1Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
    • 2Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
    • 3Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
    • 4Section of Palliative Care, Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California
    • 5Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 6Harvard Medical School, Boston, Massachusetts
    JAMA Intern Med. 2019;179(7):987-990. doi:10.1001/jamainternmed.2019.0125

    Shared decision making about dialysis, a potentially burdensome or harmful treatment for older adults, requires accurate estimates of prognosis.1 More than 120 000 people in the United States initiated chronic dialysis in 2015, half of whom were older than 65 years.2 The 1-year mortality rate after dialysis initiation for these older adults, based on the United States Renal Data System (USRDS) registry, is currently approximately 30%.2 However, the USRDS does not include all patients who start dialysis—most notably omitting those who die before an outpatient dialysis provider enters them into the registry. Therefore, USRDS-based mortality estimates are not generalizable to all patients who initiate dialysis. Registry data also lack detailed information on functional and cognitive status, which can significantly affect treatment decisions and outcomes. Thus, existing data2,3 may not provide optimal support for real-time decision making about dialysis initiation in older adults. To address these knowledge gaps, we used data from the Health and Retirement Study, a nationally representative, longitudinal survey of older adults, to describe mortality within the first year after dialysis initiation.

    Methods

    Using Health and Retirement Study data from April 3, 1998, to December 21, 2014, linked to Medicare claims and the National Death Index, we identified all patients 65.5 years and older with fee-for-service Medicare and an initial claim for dialysis. Data analysis was performed from January 5, 2017, to December 19, 2018. The institutional review board at Icahn School of Medicine at Mount Sinai approved this study and granted a waiver of informed consent.

    We calculated mortality at 30, 180, and 365 days after dialysis initiation and estimated 1-year Kaplan-Meier survival curves by age, comorbidity, predialysis functional status, and dialysis initiation setting. To identify characteristics independently associated with mortality at each time, we built parsimonious multivariate, complementary log-log regression models. A P value less than .05 determined with unpaired, 2-tailed testing was considered significant. Analyses were conducted in SAS, version 9.4 (SAS Institute Inc) and Stata, version 15 (Stata Corp).

    Results

    Among 391 Medicare beneficiaries initiating dialysis, 68 patients (17.4%) were 85 years or older, 89 patients (22.8%) required assistance with 1 or more activities of daily living, 267 patients (68.3%) had 4 or more comorbidities, and 286 patients (73.1%) started dialysis in the hospital (Table). Death occurred in 88 patients (22.5%) within 30 days after starting dialysis, 173 (44.2%) within 180 days, and 213 (54.5%) within 365 days. At 1 year, 65 of 89 patients (73.0%) with activity of daily living dependence, 48 of 68 patients (70.6%) 85 years or older, and 178 of 286 patients (62.2%) initiating dialysis as inpatients had died (Figure). After multivariate adjustment, factors significantly associated with higher 1-year mortality included activity of daily living dependence (hazard ratio [HR], 1.88; 95% CI, 1.36-2.61; P ≤ .001), age 85 years or older (HR, 1.85; 95% CI, 1.23-2.80; P = .003), inpatient dialysis initiation (HR, 2.17; 95% CI, 1.49-3.15; P ≤ .001), and having 4 or more comorbidities (HR, 1.50; 95% CI, 1.07-2.09; P = .02).

    Discussion

    Drawing on nationally representative data, we found that 22.5% of Medicare beneficiaries initiating dialysis died within 30 days, 44.2% died within 6 months, and 54.5% died within 1 year—almost double the 1-year mortality rate reported for older adults in the USRDS registry.2 The oldest patients, non-Hispanic white patients, those with predialysis activity of living dependence or a high burden of comorbidity, and those who started dialysis in the hospital fared the worst.

    These results provide a complement to data from the USRDS registry. By more closely approximating real-world clinical situations in which it cannot be known whether patients will require chronic dialysis and whether they will survive long enough to enter the USRDS registry, these results may further support shared decision making regarding dialysis initiation. Our findings also may support the importance of age, race, comorbidity burden, functional status, and site of dialysis initiation in estimating subsequent mortality among older adults.1,3-6

    Several limitations must be considered. First, although drawing on a nationally representative cohort of older adults, the study’s subset of Medicare beneficiaries who initiated dialysis was small, offered limited power, and may not fully represent the population starting dialysis. Second, these data cannot describe survival among the counterfactual group of older adults with advanced kidney disease who did not start dialysis.

    The limited survival among older patients who initiated dialysis may help to frame prognostic expectations and support more informative discussions about dialysis initiation in older adults.

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    Article Information

    Accepted for Publication: January 13, 2019.

    Corresponding Author: Melissa W. Wachterman, MD, MSc, MPH, Section of General Internal Medicine, Veterans Affairs Boston Health Care 13 System, 150 S Huntington Ave, Bldg 9, Boston, MA 02130 (mwachterman@bwh.harvard.edu).

    Published Online: April 22, 2019. doi:10.1001/jamainternmed.2019.0125

    Author Contributions: Mr Rahman and Dr Kelley had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Wachterman, O’Hare, Lorenz, Marcantonio, Kelley.

    Acquisition, analysis, or interpretation of data: Wachterman, Rahman, Lorenz, Alicante, Kelley.

    Drafting of the manuscript: Wachterman, Alicante.

    Critical revision of the manuscript for important intellectual content: O’Hare, Rahman, Lorenz, Marcantonio, Kelley.

    Statistical analysis: Wachterman, Rahman, Kelley.

    Obtained funding: Wachterman, Kelley.

    Administrative, technical, or material support: Lorenz, Alicante, Kelley.

    Supervision: Lorenz, Marcantonio, Kelley.

    Funding/Support: This work was supported by the National Palliative Care Research Center Junior Faculty Career Development Award and by National Institutes of Health grants K23AG049088, K24AG035075, R01NR013372, and R01AG054540. The Health and Retirement Study is funded by National Institute on Aging grant U01 AG009740 and the Social Security Administration and is performed at the Institute for Social Research, University of Michigan.

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The interpretation of these data is the sole responsibility of the authors and does not reflect the opinion of the Department of Veterans Affairs.

    Additional Contributions: Nancy Keating, MD, MPH (Department of Health Care Policy, Harvard Medical School), played a significant role in study design decisions, interpretation of results, and review of the manuscript; Stuart Lipsitz, ScD (Division of General Internal Medicine, Brigham and Women’s Hospital), provided critical guidance on study methodology and statistical analyses; Diane Steffick, PhD (University of Michigan), provided advice regarding Medicare coding; Evan Bollens-Lund, MA (Icahn School of Medicine at Mount Sinai), assisted with several statistical coding questions; and Carly Meyer, BA (Harvard Medical School), assisted with administrative tasks related to drafting of the manuscript, including data entry and figure creation. There was no financial compensation.

    References
    1.
    Moss  AH.  Renal Physicians Association Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Rockville, Maryland: Renal Physicians Association; 2010.
    2.
    2017 USRDS Annual Data Report: Epidemiology Of Kidney Disease in the United States. Bethesda, MD: Renal Physicians Association 2017.
    3.
    Kurella Tamura  M, Covinsky  KE, Chertow  GM, Yaffe  K, Landefeld  CS, McCulloch  CE.  Functional status of elderly adults before and after initiation of dialysis.  N Engl J Med. 2009;361(16):1539-1547. doi:10.1056/NEJMoa0904655PubMedGoogle ScholarCrossref
    4.
    Couchoud  CG, Beuscart  J-BR, Aldigier  J-C, Brunet  PJ, Moranne  OP; REIN registry.  Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease.  Kidney Int. 2015;88(5):1178-1186. doi:10.1038/ki.2015.245PubMedGoogle ScholarCrossref
    5.
    Yu  MK, Wong  SPY, Liu  CF, Hebert  PL, O’Hare  AM.  Clinical presentation at initiation of maintenance dialysis and subsequent survival: A retrospective cohort study.  Hemodial Int. 2019;23(1):106-116.PubMedGoogle ScholarCrossref
    6.
    Kucirka  LM, Grams  ME, Lessler  J,  et al.  Association of race and age with survival among patients undergoing dialysis.  JAMA. 2011;306(6):620-626. doi:10.1001/jama.2011.1127PubMedGoogle ScholarCrossref
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