Quality of life after the initiation of dialysis or maximal conservative management in elderly patients: a longitudinal analysis of the Geriatric assessment in OLder patients starting Dialysis (GOLD) study.
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SUBMITTER: van Loon IN
PROVIDER: S-EPMC6440027 | biostudies-literature | 2019 Mar
REPOSITORIES: biostudies-literature
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Quality of life after the initiation of dialysis or maximal conservative management in elderly patients: a longitudinal analysis of the Geriatric assessment in OLder patients starting Dialysis (GOLD) study.
van Loon I N IN Goto N A NA Boereboom F T J FTJ Verhaar M C MC Bots M L ML Hamaker M E ME
BMC nephrology 20190329 1
<h4>Background</h4>Maximal conservative management (MCM) may be an appropriate alternative option for dialysis in some elderly patients with end-stage kidney disease (ESKD). Evidence about the impact of dialysis or MCM on quality of life (QoL) in older patients is sparse. In the GOLD (Geriatric assessment in OLder patients starting Dialysis) Study the trajectory of QoL was assessed in patients starting dialysis or MCM.<h4>Methods</h4>Patients ≥65 years old were included just prior to dialysis in ...[more]
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Project description:With aging of the general population, patients who enter dialysis therapy will more frequently have geriatric impairments and a considerable comorbidity burden. The most vulnerable among these patients might benefit from conservative therapy. Whether assessment of geriatric impairments would contribute to the decision-making process of dialysis initiation is unknown.A systematic Medline and Embase search was performed on December 1, 2015 to identify studies assessing the association between risk of mortality or hospitalization and one or more geriatric impairments at the start of dialysis therapy, including impairment of cognitive function, mood, performance status or (instrumental) activities of daily living, mobility (including falls), social environment, or nutritional status.Twenty-seven studies were identified that assessed one or more geriatric impairments with respect to prognosis. The quality of most studies was moderate. Only seven studies carried out an analysis of elderly patients (?70 years old). Malnutrition and frailty were systematically assessed, and their relation with mortality was clear. In addition, cognitive impairment and functional outcomes at the initiation of dialysis were related to an increased mortality in most studies. However, not all studies applied systematic assessment tools, thereby potentially missing relevant impairment. None of the studies applied a geriatric assessment across multiple domains.Geriatric impairment across multiple domains at dialysis initiation is related to poor outcome. However, information in the elderly is sparse, and a systematic approach of multiple domains with respect to poor outcome has not been performed. Because a geriatric assessment has proved useful in predicting outcome in other medical fields, its potential role in the ESRD population should be the subject of future research.
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Project description:Elderly patients represent a growing population among people suffering from ESRD. So far only limited data on actual survival benefits of elderly adults initiating dialysis have been published. Besides the high burden of preexisting comorbidities, dialysis treatment itself may be associated with a further deterioration in functional status in this population. We retrospectively analyzed the Austrian Dialysis and Transplant Registry and identified 8,622 patients who started maintenance hemodialysis after the age of 65 years between 2002 and 2009. We compared this data set to a cohort of 174 patients aged over 65 years with CKD stage 5 who progressed to an eGFR < 10ml/min/ and were managed conservatively in the same era. All patients who died of malignant disease were excluded from this analysis. The risk of mortality was analyzed using multivariable Cox proportional hazards models. Furthermore, a parametric model of time to event analysis was used for visualization of changing risk over time and precise calculation of time to equal risk assuming a Weibull distribution. Hemodialysis treatment was associated with a decreased risk for death with a HR of 0.23 (95% CI 0.18 to 0.29; p<0.001) compared to conservative treatment. The time to event analysis however showed, that although survival was initially superior in the hemodialysis group, hazards crossed thereafter. Time to equal risk was 2.9 months and 1.9 months for female and male patient aged 65, respectively, and decreased to one month in the very elderly aged 95. Elderly patients with ERSD did benefit from initiation of hemodialysis, as the conservative group showed a very high initial mortality rate. This survival benefit of dialysis treatment however did not persist beyond the first two months compared to survivors of the conservative group.
| S-EPMC5524398 | biostudies-other
Project description:BackgroundWhile some prediction models have been developed for diabetic populations, prediction rules for mortality in diabetic dialysis patients are still lacking. Therefore, the objective of this study was to identify predictors for 1-year mortality in diabetic dialysis patients and use these results to develop a prediction model.MethodsData were used from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a multicenter, prospective cohort study in which incident patients with end stage renal disease (ESRD) were monitored until transplantation or death. For the present analysis, patients with DM at baseline were included. A prediction algorithm for 1-year all-cause mortality was developed through multivariate logistic regression. Candidate predictors were selected based on literature and clinical expertise. The final model was constructed through backward selection. The model's predictive performance, measured by calibration and discrimination, was assessed and internally validated through bootstrapping.ResultsA total of 394 patients were available for statistical analysis; 82 (21%) patients died within one year after baseline (3 months after starting dialysis therapy). The final prediction model contained seven predictors; age, smoking, history of macrovascular complications, duration of diabetes mellitus, Karnofsky scale, serum albumin and hemoglobin level. Predictive performance was good, as shown by the c-statistic of 0.810. Internal validation showed a slightly lower, but still adequate performance. Sensitivity analyses showed stability of results.ConclusionsA prediction model containing seven predictors has been identified in order to predict 1-year mortality for diabetic incident dialysis patients. Predictive performance of the model was good. Before implementing the model in clinical practice, for example for counseling patients regarding their prognosis, external validation is necessary.
| S-EPMC3942369 | biostudies-literature
Project description:IntroductionIncreased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end-stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis.MethodsProspective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in-center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13-item Patient Activation Measure (PAM-13) survey at baseline (month 1 after commencement of dialysis) and follow-up (month 4). The survey yields a score (0-100) that corresponds to four levels (1-4), with higher scores or levels indicating higher activation.FindingsOne hundred eighty-two participants (139 center, 43 home) completed both baseline and follow-up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM-13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow-up, respectively; mean intraindividual change: -0.3 ± 17.3. The proportions of patients at levels 1-4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow-up, 50%, 64%, 52%, and 37% of participants at levels 1-4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in-center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11-11.37 and 9.02, 95% CI: 3.03-15.02, at baseline and follow-up, respectively).DiscussionAlthough aggregated group scores and levels remained stable, intra-individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.
| S-EPMC9546050 | biostudies-literature
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| S-EPMC5967428 | biostudies-literature
Project description:Very early withdrawal from treatment in patients undergoing peritoneal dialysis (PD) is an increasingly important, but poorly understood, issue. Here, we identified the reasons and risk factors for very early withdrawal from PD.Incident PD patients from The First Affiliated Hospital of Sun Yat-sen University above 18?years who started treatment between January 1 2006 and December 31 2011 were included. Cessation of PD therapy within the first 90?days after beginning dialysis was classified as very early withdrawal.Totally 1444 patients were enrolled. Of these, 71 (4.9%) withdrew from PD therapy during the first 90?days. Primary reasons for very early withdrawal included death (34 patients, 47.9%), transplantation (21 patients, 29.6%) and transfer to hemodialysis (14 patients, 19.7%). The leading reasons for death were cardiovascular and infectious disease, accounting for 41.2% (14 patients) and 23.5% (8 patients) of total deaths, respectively. Dialysate leakage (six patients, 42.9%) and catheter dysfunction (five patients, 35.7%) were the main reasons for transfer to hemodialysis. In multivariate analysis, predictors for very early PD withdrawal were older age (per decade increasing; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.03-1.45; p?=?.019), higher systolic blood pressure (per 10?mmHg increasing; HR, 1.35; 95% CI, 1.20-1.50; p?<?.001), lower hemoglobin (per 10?g/l increasing; HR, 0.67; 95% CI, 0.57-0.78; p?<?.001), lower high-density lipoprotein cholesterol (HR, 0.24; 95% CI, 0.10-0.54; p?=?.001) and lower residual urine volume (per 100?ml/d increasing; HR, 0.90; 95% CI, 0.84-0.95; p?=?.001).Death was the primary reason for very early withdrawal from PD. Risk factors for very early withdrawal from PD were older in age, had higher systolic blood pressure, lower hemoglobin, lower high-density lipoprotein cholesterol and lower residual urine volume.
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Project description:It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD).Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty).The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status.
| S-EPMC2789552 | biostudies-literature
Project description:A shared decision-making tool could help elderly patients with advanced chronic kidney disease decide about initiating dialysis therapy. Because mortality may be high in the first few months after initiating dialysis therapy, incorporating early mortality predictors in such a tool would be important for an informed decision. Our objective is to derive and validate a predictive risk score for early mortality after initiating dialysis therapy.Retrospective observational cohort, with development and validation cohorts.US Renal Data System and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ?67 years) patients with end-stage renal disease with a previous 2-year Medicare history who initiated dialysis therapy from January 1, 2009, to December 31, 2010.Demographics, predialysis care, laboratory data, functional limitations, and medical history.All-cause mortality in the first 3 and 6 months.Predicted mortality by logistic regression.The simple risk score (total score, 0-9) included age (0-3 points), low albumin level, assistance with daily living, nursing home residence, cancer, heart failure, and hospitalization (1 point each), and showed area under the receiver operating characteristic curve (AUROC)=0.69 in the validation sample. A comprehensive risk score with additional predictors was also developed (with AUROC=0.72, high concordance between predicted vs observed risk). Mortality probabilities were estimated from these models, with the median score of 3 indicating 12% risk in 3 months and 20% in 6 months, and the highest scores (?8) indicating 39% risk in 3 months and 55% in 6 months.Patients who did not choose dialysis therapy and did not have a 2-year Medicare history were excluded.Routinely available information can be used by patients with chronic kidney disease, families, and their nephrologists to estimate the risk of early mortality after dialysis therapy initiation, which may facilitate informed decision making regarding treatment options.
| S-EPMC4658211 | biostudies-literature
Project description:Initiating dialysis therapy in elderly patients with end-stage kidney disease (ESKD) is a challenging decision. We aimed to examine the mortality rates among elderly patients who underwent hemodialysis, peritoneal dialysis, or comprehensive conservative care. This retrospective cohort study included elderly patients (≥70 years) with ESKD who selected their treatment options from January 2008 to December 2018. Patients were categorized into three groups: hemodialysis, peritoneal dialysis, and comprehensive conservative care. The outcome of interest was all-cause mortality analyzed using flexible parametric survival models. Propensity score analysis with inverse probability treatment weighting technique was performed, incorporating age, Charlson Comorbidity Index score, and estimated glomerular filtration rate. The study included 719 elderly ESKD patients with mean age of 78.2 ± 4.9 years, 52.3% were male, and 60.1% died during the median follow-up period of 22.1 months. In a fully adjusted model, patients receiving comprehensive conservative care (n = 50) had higher mortality rates than those receiving hemodialysis (n = 317) (adjusted hazard ratio [HR] 5.60; 95% CI 2.26-13.84, p < 0.001). However, patients who received peritoneal dialysis (n = 352) had a similar mortality rate when compared to those who received hemodialysis (adjusted HR 1.38; 95% CI 0.78-2.44, p = 0.275). The higher mortality rate in the comprehensive conservative care group remained significantly higher than in the hemodialysis group among patients aged ≥80 years (adjusted HR 4.97; 95% CI 1.32-18.80, p = 0.018). Among elderly patients (≥70 years), treatment with dialysis was associated with longer survival rates. This survival advantage persisted in patients aged ≥80 years who chose hemodialysis or peritoneal dialysis over comprehensive conservative care.
| S-EPMC11370684 | biostudies-literature
Project description:BackgroundQuality of life (QOL) is important to patients with end stage renal disease and their partners. Despite the first 12?weeks being a critical time in the treatment pathway, limited research exists which examines how the transition onto dialysis impacts QOL. In this study we measured QOL in patients and their partners at pre-dialysis and over the first 12?weeks on dialysis to investigate QOL during this crucial period.MethodsPatients and their partners, recruited from 10 renal units in England, completed questionnaires at pre-dialysis (n?=?166 participants, 83 couples), 6?weeks (n?=?90 participants, 45 couples) and 12?weeks (n?=?78, 39 couples) after starting dialysis. On each occasion participants completed a QOL questionnaire (WHOQOL-BREF). Multilevel modelling accommodated the nested structure of couples with repeated measures within participants. Three-level random intercept models estimated changes in WHOQOL general QOL and its four domains (Physical, Psychological, Social and Environment). Two-level random intercept models assessed the relationship between baseline clinical and socio-demographic variables with changes in general QOL.ResultsPatients reported positive changes in general QOL from pre-dialysis to 6?weeks (??=?0.42, p?<?0.001, 95% CI 0.19, 0.65) and from pre-dialysis to 12?weeks (??=?0.47, p?<?0.001, 95% CI 0.24, 0.71). Partners' general QOL decreased significantly from pre-dialysis to 6?weeks (??=?-?0.24, p?=?0.04, 95% CI -0.47, -?0.01) but returned to its original level at 12?weeks. Patients reported improvements in the physical domain between pre-dialysis and 12?weeks (??=?6.56, p?<?0.004, 95% CI 2.10, 11.03). No other domains changed significantly in patients or partners. Only in patients were there significant associations between moderator variables and general QOL. High comorbidity risk level and diabetes were associated with poorer QOL at pre-dialysis whereas being female and having an arteriovenous fistula were linked with improvements in general QOL.ConclusionsPatients reported significant improvements in their general and physical QOL after starting dialysis. Partners' general QOL worsened after patients started dialysis but improved by 12?weeks. Both patients and partners may benefit from additional educational and counselling services in the lead up to, and immediately after starting dialysis, which could facilitate the transition onto dialysis and improve QOL in both.Study registrationThis study was adopted on the NIHR Clinical Research Network (UK). The details of this study are registered on the Research Registry website (www.researchregistry.com). The identifier for this study is researchregistry2574.
| S-EPMC7236460 | biostudies-literature