Patients with advanced chronic kidney disease (CKD) who transition to early dialysis are at higher risk for death compared with those managed conservatively without dialysis, investigators concluded in a presentation during the American Society of Nephrology’s Kidney Week 2021.

Conservative dialysis-free management and late dialysis, however, are associated with similar mortality rates.

“While dialysis has been the dominant treatment paradigm in advanced CKD patients ineligible for or unlikely to receive kidney transplantation, our study’s findings support the growing emphasis on conservative non-dialytic management as an alternative patient-centered treatment strategy,” lead investigator Connie M. Rhee, MD, MSc, of the University of California Irvine, said in an interview with Renal & Urology News. “Shared-decision making; alignment of patient, care partner, and providers’ communications; and prioritization of patient choice are of paramount importance in selecting the optimal treatment approach for patients with advanced CKD.”


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Dr Rhee and colleagues studied a nationally representative cohort of 309,188 patients with advanced CKD identified using the OptumLabs Data Warehouse. They defined early dialysis as transitioning to dialysis at an estimated glomerular filtration rate (eGFR, in mL/min/1.73 m2) of 15 or higher and late dialysis as transitioning to dialysis at an eGFR less than 15.

Model-based mortality rates, in deaths per 1000 person-years of follow-up, were 140 for patients managed conservatively and 132 and 158 for those transitioning to dialysis late and early, respectively, Dr Rhee’s team reported.

The investigators observed a similar pattern when they conducted secondary analyses comparing conservative management with late vs intermediate vs early dialysis (eGFR less than 10, 10-15, and 15 or higher, respectively). Model-based mortality rates were 140 for patients receiving conservative management and 126, 141, and 158 for patients with late, intermediate, and early dialysis transition, respectively.

Dr Rhee’s team also examined mortality rates by age group (less than 65 years and 65 years or older) and found that all dialysis groups had higher mortality rates compared with conservative management.

“Multiple studies have shown that, in certain subpopulations, dialysis may not always exert the intended effect of increasing life nor restoring health, and also suggest that, in some patients, dialysis may not offer a survival advantage and is associated with worse health-related quality of life, decline in physical function, loss of independence, and greater symptom burden,” Dr Rhee said. Therefore, she added, there is a compelling need to determine which patients will benefit most from conservative management versus dialysis using precision-medicine based approaches. To address this question, Dr Rhee and colleagues are conducting the NIH-funded OPTIMAL study, a longitudinal observational investigation using both retrospective and prospective data sources.

In a separate analysis, Dr Rhee’s team found differential relationships in mortality rates between conservative management and dialysis across race or ethnicity and age. In this study, late, intermediate, and early dialysis initiation were defined as eGFR less than 5, 5-10, and 10 or higher, respectively. White patients with late, intermediate, and early dialysis initiation had higher mortality rates compared with conservative management across all age groups. Among Hispanic patients, conservative management and dialysis were associated with similar mortality rates across age groups. Black and Asian patients aged 75 years or older with conservative management vs late dialysis had similar mortality rates, whereas younger patients had a survival benefit with conservative management vs dialysis.

References

You AS, Kalantar-Zadeh K, Narasaki Y, et al. Mortality rates in a nationally representative cohort of advanced CKD patients treated with conservative management vs. dialysis. Presented at: Kidney Week 2021, November 2-7, 2021. Abstract PO1372.

You AS, Kalantar-Zadeh K, Narasaki Y, et al. Impact of race/ethnicity and age on survival in advanced CKD patients treated with conservative management vs dialysis. Presented at: Kidney Week 2021, November 2-7, 2021. Abstract PO2327.