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Background and Aims With the geriatric population increasing, the patients reaching stage 5 chronic kidney disease (CKD) are older, frailer and have multiple comorbidities. Technological advances in renal replacement therapy (RRT) and easier access to dialysis resulted in an expansion on geriatric dialysis population. Conservative management (CM) is an option that should be considered in this population, where is crucial to balance the survival and quality of life. Beside mortality, with this study we aim to evaluated patient-outcomes (hospitalization, falls and functional capacity) in older and frailer stage 5 CKD patients receiving hemodialysis (HD) and in CM. Method We conducted a single center retrospective study in older (≥ 75years), frailer (Clinical Frailty Scale – CFS ≥ 5) and with multiple comorbidities (modified Charlson comorbidity index – mCCI ≥ 5 and) stage 5 CKD patients, admitted in our Nephrology department between January 1, 2014 to December 31, 2020. The eGFR was calculated through Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) at the time of decision or at the time of starting HD. The comorbidities were stratified using the mCCI and frailty was assessed with CFS at the time of decision in CM group (CMG) and at the start of HD (HDG). We evaluated hospitalizations, falls, CFS one-year later and survival in each group. Survival analysis was performed using the Kaplan–Meier method and was calculated at the beginning of RRT or eGFR ≤ 15ml/min/1.73m2 in CMG. Differences between the two groups were tested with Mann-Whitney U method. Results A total of 76 patients with indication to start RRT were included: 61.8% (n=47) initiated HD and 38.2% (n=29) were in CM. The reasons for CM decision were deterioration of clinical condition (n=11), expected survival less than 6 months (n=8), patient option (n=5) and cognitive impairment (n=5). Clinical characteristics are presented in Table 1. The CMG was older [median, IQR: 88 (85.5-90.5) vs 80 (77.0 – 83.0), p < 0.001] and had a lower BMI [23.44 (21.08 - 25.08) vs 26.23 (23.26 – 29.20), p=0.006]. Both groups did not differ significantly in terms of sex, CKD etiology, comorbidity or frailty. A total of 66 patients died at the end of the study [CMG 100% (n= 29) vs 78.7% HDG (n=37)]. The overall survival has higher on the HDG compared to the CMG with a median survival rate of 503 days (Fig 1). One-year survival rate was 53.5% in HDG vs 24% CMG (p <0.001). The median (IQR) of number of hospitalizations per patient was greater in the HDG [4 (1.5-6.5) vs 3 (0.5-5.5) CMG]. In HDG 17% patients had at least one fall vs 3.4% in CMG. In both groups there was a general deterioration associated to a higher CFS at one-year follow up (p=0.003 HD group vs p=0.015 CMG). Conclusion In our study, hemodialysis was associated to improved survival in older and frailer stage 5 CKD patients compared to CM. However, this group had more hospitalizations, falls and poor functional status. These outcomes have a crucial impact on quality of life in this population and should be consider at the time of treatment decision. One of the limitations of our study was small sample size in both groups. In the future, we consider that is important to perform multicenter studies focused on patients-outcomes. We also think that it’s important to understand the patient and family perspective in terms of quality of life and symptom burden associated to each treatment option.

Summary Chronic kidney disease (CKD) is a silent worldwide epidemic responsible for a high clinical and socioeconomic burden. Beyond disease-related outcomes, there is an urgent need for clinicians to focus on implementation of validated patient-reported outcome measures (PROMs) in routine care practice. This updated concept of high-quality renal care implies a changing paradigm, with a focus on patient experiences and health-related quality of life (HRQL) measures. This is even more crucial in end-stage renal disease, where adequate dialysis should aim at a multidimensional approach instead of only analytical targets. It is vital to emphasize interventions that positively affect the quality of life of the patient with CKD beyond improving their survival. Although the importance of using HRQL measures is well established, there has been resistance to their use in routine care. There are numerous tools to assess HRQL, but not all are easy to apply. It is essential to overcome these possible barriers and better adequate the HRQL tools to the patients. The shorter and simpler instruments are more appealing, as well as the electronic health questionnaires. The EuroQol-5 Dimensions tool (EQ5D) is a standardized measure of health status, is simple and quick, and provides information that can be used in economic assessments of healthcare.In this era of limited health resources, cost analysis and economic evaluations are becoming increasingly relevant. In dialysis units, sustainability management should include a pathway of integrated care, including home and center dialysis, that values the better adjustment of prescriptions to the individual patient. The authors advocate using the EQ5D to support this pathway of quality in dialysis units toward global health gains. The EQ5D is a PROM with a view centered on patient and sustainable health services.

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BACKGROUND AND AIMS Mortality in end-stage renal disease remains high, especially among the elderly with a higher burden of comorbidity and frailty. In this group, dialysis (HD) may not offer better survival compared with conservative management. Frailty defined by clinical frailty scale (CFS) and comorbidity by modified Charlson Comorbidity Index (mCCI) are known independent predictors of mortality. Our aim is to compare that has higher impact on early mortality in incident elderly HD patients. METHOD We conducted a retrospective cohort study of patients aged 65 years and over, who started HD as their first renal replacement therapy (RRT) between January 2014 and December 2019. CFS and mCCI, at time of HD start, were used to evaluate, respectively, frailty and comorbid disease burden. The primary outcome was death in the first 6 months of RRT. The optimal cut-off for our outcome was defined through the analysis of a receiver operating characteristic (ROC) curve. Survival curves were constructed using Kaplan–Meier method, with comparison between patients' groups being done by log-rank test. Multivariable Cox analysis was applied to assess independent predictors of early mortality. All p values are two-tailed, p value < 0.05 is considered to indicate statistical significance. RESULTS 166 patients were included, 107 (64%) started HD by central venous catheter. The median age, at time of haemodialysis start, was 75 years ± 6.3 years. The mortality at 6 months was 19% (n = 31). For both scales, the analysis of ROC curve, stablished the optimal cut-off to predict the event death at first 6 months of HD as ≥ 5points. The performance of CFS was superior to the mCCI (P = 0.031; Figure 1 top). In fact, the area under the curve is higher in CFS (0.739) versus the mCCI (0.620). A CFS ≥ 5 had a sensitivity/specificity of 94%/44% in prediction the primary outcome. On the other and, a mCCI ≥ 5 predicts the same outcome with a sensitivity/specificity of 26%/88%. The diagnostic odds ratio for CFS ≥ 5 was 11.6, compared with only 2.7 for mCCI ≥ 5. When confronted using the Kaplan–Meier method, both CSF < 5 versus CSF ≥ 5 and mCCI < 5 versus mCCI ≥ 5 presented different survival rates that proved to be statistically significant by log rank test (P < 0.001 and P = 0.020, respectively; Figure 1 medium and bottom). CFS was an independent predictor of 6 month mortality both as a categorical (CSF ≥ 5) (HR = 3.64; P = 0.004) and continuous variable (HR = 1.95; P < 0.01). mCCI didn't prove to be an independent predictor. Lastly, we constructed a model in which both scores interacted (as categorical variables), in this multivariable adjusted model mCCI/CFS < 5/≥5 and ≥ 5/≥5 were intendent predictors of mortality (HR = 6.141; P = 0.022) (HR = 10.58; P = 0.002). Interestingly, no events were observed in the mCCI ≥ 5/CFS < 5 group. CONCLUSION In this cohort of incident elderly HD patients, frailty defined by CFS was a stronger predictor of mortality than comorbidity defined by CCI. The group of mCCI/CFS (≥5/≥5) has a 10-time higher chance of dying than the reference group. Our data also suggest that simple scores can predict the risk of early mortality in incident HD patients and should be used to guide the decision-making process for elderly patients and to improve the quality of the information given to patients and families.