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.
BACKGROUND AND AIMS The number of elderly patients starting haemodialysis is increasing as a result of an aging population and age-related increases in the incidence of chronic kidney disease. Outcomes of elderly patients with end-stage kidney disease at urgent haemodialysis (UH) initiation are poorly studied. It is necessary to define predictors of adverse outcomes in these population. The aim of this study was to evaluate patterns and predictors of 1-year mortality of urgent-start haemodialysis in elderly patients. METHOD This is an observational, retrospective study including all elderly patients (>65 years) who started UH between 2014 and 2019. The follow-up period was 1 year after the start of UH. Demographic data, comorbidities, analytical parameters and vascular access were recorded. We analyzed global mortality by Kaplan–Meier survival curves and predictors of mortality at 1 year by multivariable Cox regression. In a secondary evaluation, predictors of mortality at 1 year by specific cause were studied through competing-risks multivariable regression. RESULTS A total of 166 patients (75.5 ± 6.3 years) were included and 45 patients (27%) died at 1-year follow-up. One-year mortality rate was 33/100 person-years [95% confidence interval (95% CI): 25–44] with the highest mortality rate in the first trimester (48/100 person-years, 95% CI: 31–75) (Figure 1A). The main cause of mortality was infection (mortality rate 14/100 person-years, 95% CI 9–22) followed by cardiovascular deaths (11/100 person-year, 95% CI 7–18) and cancer (5/100 person-years, 95% CI 2–11). There was a significant difference in the Kaplan–Meier survival probability between the patients with CFS ≥ 5 and CFS < 5 at 3 and 12 months (83% versus 98% and 59% versus 95%, respectively, P < 0.001); we also found differences in survival between patients with serum albumin levels < 3.2 g/dL and patients with serum albumin levels >3.2 g/dL, at 3 and 12 months (81% versus 94% and 57% versus 84%, respectively, P < 0.001) (Figure 2B and C). Patients who died at 1 year of follow-up were later referred to nephrology (P = 0.031), had lower serum albumin levels (P = 0.001), had a higher Clinical Frailty score—CFS—(P < 0.001) and a higher modified Charlson comorbility index—mCCI (P = 0.011). The 1-year mortality predictors that we identified were: CFS ≥ 5 (HR = 10.185; P < 0.001), mCCI ≥ 5 (HR = 2.190; P = 0.025), serum albumin levels < 3.2 g/dL (HR = 2.194, P = 0.013) and referral to nephrologist 4 months before UH (HR = 2.220; P = 0.012). In the first trimester, only CFS ≥ 5 was a predictor of mortality (HR = 8.468; P = 0.041). On the other hand, between 4 and 12 months, the following predictors of mortality were documented: CFS ≥ 5 (HR = 12.386; P = 0.001), serum albumin levels < 3.2 g/dL (HR = 2.420; P = 0.032) and body mass index (HR = 0.925; P = 0.027). Predictors of 1-year infection-related death were CFS ≥ 5 (sHR = 9.809; P = 0.024) and serum albumin levels < 3.2 g/dL (sHR = 4.258; P = 0.011). The predictors of cardiovascular-related death were CFS ≥ 5 (sHR = 8.150; P = 0.038) and ischemic coronary disease (sHR = 4.467; P = 0.009). The predictors of mortality by cancer were CFS ≥ 5 (sHR = 8.225; P = 0.032), serum albumin levels < 3.2 g/dL (sHR = 4.408; P = 0.029) and diagnosis of cancer in the previous 5 years (sHR = 5.631; P = 0.003). CONCLUSION This study showed a high mortality rate in elderly patients who started UH, especially during the first 3 months. Infectious diseases were the main cause of mortality followed by cardiovascular diseases. The CFS was a useful predictor of mortality in the global analysis and a predictor of mortality caused by infection, cancer or cardiovascular disease; all patients started UH, which can exacerbate the importance of frailty in defining outcomes. Serum albumin is a predictor of mortality by infectious causes, possibly reflecting the inflammatory activity and malnutrition of these patients. The relationship between BMI and outcomes needs further evaluation.
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