Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease

Abstract

A significant number of elderly patients die during their first 3 months of dialysis. Because dialysis can impair the quality of both life and death, a personalized care plan based on both early prognosis and patient choices is required. We developed a prognostic screening tool to identify older patients in need of specific care based on a multidisciplinary approach. Our study included 24,348 patients aged 75 years and older from the French national renal epidemiology and information network (REIN) registry who began dialysis between 1 January 2005 and 30 September 2012. Our primary outcome was overall mortality during the first 3 months of renal replacement therapy. Multivariate logistic regression was used to construct a scoring system in a random half of the cohort (training set). This score, which included age, gender, specific comorbidities, albumin levels, and mobility, was then applied to the other half (validation set). In all, 2548 patients died during the first 3 months after dialysis initiation, 22% after dialysis withdrawal. Three risk groups were identified: low risk (score under 12 points, 3-month expected mortality under 20%), intermediate risk (score from 12 to 16, mortality between 20 and 40%, 9.5% of patients) and high risk (score 17 or more, mortality over 40%, 2.5% of patients). We developed a decision-making process that classifies patients according to their risk of early death in view of their potentially imminent need for supportive care or treatment.

The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review

“…Dependence in ADLs was associated with mortality in two of three studies (OR, 1.41; 95% CI, 1.08 to 1.85) (31,42). Impaired cognitive function, defined as severe behavioral disorder, was associated with mortality as well (25,26), but two smaller studies did not find this relation (29,31). Depressive symptoms were not associated with mortality is this population (29,31).…”

“…The sample size ranged from 40 to 272,024 patients, and the mean age ranged from 53 to 82 years old. Seven studies focused exclusively on elderly patients (mean age ranging from 67 to 82 years old) (18,25,26,29,33,34,42), and one study performed a subgroup analysis of elderly patients (31).…”

“…Depressive symptoms were present in 24%-55% of patients in the studies that applied a systematic assessment (20,23,27,35), whereas the prevalence of the International Statistical Classification of Diseases diagnosis depression ranged from 4% to 28% (23,29,39,41). Prevalence of cognitive impairment ranged from 6% to 13% in general (25,26,29,31,40) and was 41% in the very old (18). No studies assessed the relation between falls or social environment and poor outcome in the incident dialysis population.…”

“…However, when focusing on the database studies, which included the vast majority of patients, depressive symptoms were associated with mortality in two studies (OR, 1.30; 95% CI, 1.00 to 1.60 [41] and OR, 1.08; 95% CI, 1.01 to 1.14 [35]), and in one study, depression was associated with noncardiovascular mortality (HR, 1.94; 95% CI, 1.10 to 3.42 [20]). In elderly patients, impaired mobility was associated with 1-year mortality in an univariate analysis of a single publication (OR, 4.22; 95% CI, 1.87 to 9.57) (18), and total dependence for transfers was independently associated with 3-and 6-month mortality (OR, 6.53; 95% CI, 5.38 to 7.92 and OR, 1.7; 95% CI, 1.4 to 2.0, respectively) (25,26). Dependence in ADLs was associated with mortality in two of three studies (OR, 1.41; 95% CI, 1.08 to 1.85) (31,42).…”

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

“…Therefore, nephrologists taking care of ESKD patients are encouraged to discuss prognosis and have an approach to advance care planning based on the patients and family expectations and the goals of dialysis treatment [9–11]. The aim is to provide the best possible patient care and to maintain quality of life.…”