Predicting Early Death Among Elderly Dialysis Patients: Development and Validation of a Risk Score to Assist Shared Decision Making for Dialysis Initiation

Abstract

Background A shared decision-making tool could help elderly advanced chronic kidney disease (CKD) patients decide about initiating dialysis. Since mortality may be high in the first few months after initiating dialysis, 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. Study Design Retrospective observational cohort, with development and validation cohorts. Setting & Participants US Renal Data System (USRDS) and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) end-stage renal disease (ESRD) patients with previous 2-year Medicare history who initiated dialysis January 1, 2009–December 31, 2010. Candidate Predictors Demographics, predialysis care, laboratory data, functional limitations and medical history. Outcomes All-cause mortality in the first 3 and 6 months. Analytical Approach Predicted mortality via logistic regression. Results The simple risk score (total score, 0–9) included age (0–3 points); low albumin, 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: 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. Limitations Patients who did not choose dialysis and who did not have 2 year Medicare history were excluded. Conclusions Routinely available information can be used by CKD patients, families and their nephrologists to estimate risk of early mortality after dialysis initiation, which may facilitate informed decision-making regarding treatment options.

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

“…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). 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).…”

“…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).…”

Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD—A Systematic Review

“…Overall functional performance was assessed in 13 studies, with eight using the Karnofsky Performance Scale (KPS) (19)(20)(21)(22)(23)(24)(25)(26), one using the basic Activities of Daily Living scale (27), two using the World Health Organization performance scale (28,29), and two using a composite variable for assistance with daily living (30,31). Eight studies reported on the prevalence of functional impairment in patients reaching ESRD measured as impaired overall functional performance, which ranged from 21% to 85% (19,20,23,(25)(26)(27)29,30).…”

“…Eight studies reported on the prevalence of functional impairment in patients reaching ESRD measured as impaired overall functional performance, which ranged from 21% to 85% (19,20,23,(25)(26)(27)29,30). In all 13 studies, reduced functional performance was associated with a higher risk of adverse health outcomes, both after starting dialysis and CKM.…”

Priority topics for European multidisciplinary guidelines on the management of chronic kidney disease in older adults

“…The focus for the European guidelines will be on identifying scores to distinguish between patients that may benefit from renal replacement therapy and those who may not [14,15]. How to integrate such scores in the decision to start dialysis (ranked 2 nd in our prioritization), and within a shared treatment decision-making process (ranked 10 th ) in general has been addressed by other guidelines [13,16].…”