Hemodialysis International 2014; 18:583–584
Editorials
Elderly patients starting outpatient dialysis not at excessive mortality risk
A November 2013 presentation by Mayo Clinic physicians at the American Society of Nephrology Annual Meeting in Atlanta, GA, found that elderly patients bore an excessive risk of dying within the first year of starting dialysis.1 These dramatic findings emphasized the critical nature of the shared decision-making process for dialysis initiation.2 The study involved 379 patients ≥75 years of age who, between the years 2007 and 2011, started any form of dialysis during a Mayo hospitalization. Overall, more than half of these patients died within 1 year of starting dialysis. However, it is important to note that 76% required dialysis following an acute event or surgical procedure, including 60% of the total population who began dialysis while in the intensive care unit (ICU); mortality at 1 year was 73% for ICU patients and 41% for other hospitalized patients. Importantly, 1-year mortality was only 11% among patients who initiated dialysis as outpatients. Patient data from DaVita HealthCare Partners Inc., facilities were examined retrospectively to see whether the Mayo Clinic finding could be supported. Patients qualifying for the analysis were aged 75 years or greater (n = 9510), who within 30 days of first dialysis, began in-center hemodialysis at a DaVita® clinic between January 1, 2007, and December 31, 2008. To implicitly exclude patients who initiated dialysis for acute kidney injury and subsequently recovered, only those patients who remained on dialysis through at least dialysis day 90 were studied. Patient death was studied longitudinally for
Correspondence to: S. M. Brunelli, MD, MSCE, Davita Clinical Research, 825 S 8th Street, STE 300, Minneapolis, MN 55404-1208, USA. E-mail: [email protected] Support and Financial Disclosure: A.R.N. and M.K. are employees of DaVita HealthCare Partners Inc. S.M.B. is an employee of DaVita Clinical Research®, a wholly owned subsidiary of DaVita HealthCare Partners Inc. This analysis was funded by DaVita HealthCare Partners Inc. There are no conflicts of interest.
up to 1 year or until censoring for transfer of care, change in dialysis modality, or kidney transplant. A total of 9405 patients contributed 7319 patient-years at-risk, during which 1942 deaths were observed. The corresponding all-cause mortality rate was 26.5 deaths/ 100 patient-years (95% CI 25.4–27.7). Kaplan-Meier examination of the data showed that fewer than 25% of the patients died by 1 year (Figure 1). This finding is perhaps comparable to the Mayo results when considering that patients initiating chronic dialysis for end-stage renal disease (ESRD) are split between those who initiate as inpatients (although rarely in the ICU) and those who initiate as outpatients. The current examination is limited by survivor bias (patients had to survive 90 days to be included). Also, our study considered only patients initiating in-center
Figure 1 Survival estimates for DaVita HealthCare Partners Inc. Patients aged 75 and older. The cumulative incidence of all-cause mortality among 9405 patients ≥75 y of age who initiated in-center hemodialysis at DaVita HealthCare Partners Inc., over a 2-y period is shown. Kaplan-Meier analysis demonstrated that fewer than 25% of the patients died by 1 y of dialysis.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12167
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Editorials
hemodialysis; results likely would be more favorable among patients initiating peritoneal dialysis.3 Our findings support those of the Mayo authors: elderly patients who initiate chronic dialysis electively for ESRD evidence survival rates comparable to those in other age groups. To guide decision making in elderly patients beginning dialysis, further studies are needed that clearly distinguish between those patients who initiate urgently/emergently for acute kidney injury and those who start electively for ESRD.
ACKNOWLEDGMENTS We extend our sincere appreciation to the teammates in more than 1800 DaVita® clinics who work every day to take care of patients and also to ensure the extensive data collection on which our work is based. We thank DaVita Clinical Research® (DCR®), and specifically acknowledge Michele G. Scheid and Donna E. Jensen, PhD, of DCR for
584
editorial assistance. DCR is committed to advancing the knowledge and practice of kidney care.
Steven M. BRUNELLI, MD, MSCE, Allen R. NISSENSON, MD, Mahesh KRISHNAN, MD, MPH, MBA DaVita Clinical Research, Minneapolis, Minnesota, USA
REFERENCES 1 Thorsteinsdottir B, Larson HLW, Hickson LJ, Feely MA, Williams AW. Starting dialysis at age 75 years or older— Outcomes data to help in shared decision making. J Am Soc Nephrol. 2013; 24:46A. 2 Pivert K. Starting dialysis after 75: New outcomes data for shared decision-making. Kidney News. 2013; 5:1–2. 3 United States Renal Data System. Annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. 2013. Available from: http://www.usrds.org/ atlas.aspx (accessed date: October 10, 2013).
Hemodialysis International 2014; 18:583–584
Editorials
Elderly patients starting outpatient dialysis not at excessive mortality risk
A November 2013 presentation by Mayo Clinic physicians at the American Society of Nephrology Annual Meeting in Atlanta, GA, found that elderly patients bore an excessive risk of dying within the first year of starting dialysis.1 These dramatic findings emphasized the critical nature of the shared decision-making process for dialysis initiation.2 The study involved 379 patients ≥75 years of age who, between the years 2007 and 2011, started any form of dialysis during a Mayo hospitalization. Overall, more than half of these patients died within 1 year of starting dialysis. However, it is important to note that 76% required dialysis following an acute event or surgical procedure, including 60% of the total population who began dialysis while in the intensive care unit (ICU); mortality at 1 year was 73% for ICU patients and 41% for other hospitalized patients. Importantly, 1-year mortality was only 11% among patients who initiated dialysis as outpatients. Patient data from DaVita HealthCare Partners Inc., facilities were examined retrospectively to see whether the Mayo Clinic finding could be supported. Patients qualifying for the analysis were aged 75 years or greater (n = 9510), who within 30 days of first dialysis, began in-center hemodialysis at a DaVita® clinic between January 1, 2007, and December 31, 2008. To implicitly exclude patients who initiated dialysis for acute kidney injury and subsequently recovered, only those patients who remained on dialysis through at least dialysis day 90 were studied. Patient death was studied longitudinally for
Correspondence to: S. M. Brunelli, MD, MSCE, Davita Clinical Research, 825 S 8th Street, STE 300, Minneapolis, MN 55404-1208, USA. E-mail: [email protected] Support and Financial Disclosure: A.R.N. and M.K. are employees of DaVita HealthCare Partners Inc. S.M.B. is an employee of DaVita Clinical Research®, a wholly owned subsidiary of DaVita HealthCare Partners Inc. This analysis was funded by DaVita HealthCare Partners Inc. There are no conflicts of interest.
up to 1 year or until censoring for transfer of care, change in dialysis modality, or kidney transplant. A total of 9405 patients contributed 7319 patient-years at-risk, during which 1942 deaths were observed. The corresponding all-cause mortality rate was 26.5 deaths/ 100 patient-years (95% CI 25.4–27.7). Kaplan-Meier examination of the data showed that fewer than 25% of the patients died by 1 year (Figure 1). This finding is perhaps comparable to the Mayo results when considering that patients initiating chronic dialysis for end-stage renal disease (ESRD) are split between those who initiate as inpatients (although rarely in the ICU) and those who initiate as outpatients. The current examination is limited by survivor bias (patients had to survive 90 days to be included). Also, our study considered only patients initiating in-center
Figure 1 Survival estimates for DaVita HealthCare Partners Inc. Patients aged 75 and older. The cumulative incidence of all-cause mortality among 9405 patients ≥75 y of age who initiated in-center hemodialysis at DaVita HealthCare Partners Inc., over a 2-y period is shown. Kaplan-Meier analysis demonstrated that fewer than 25% of the patients died by 1 y of dialysis.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12167
583
Editorials
hemodialysis; results likely would be more favorable among patients initiating peritoneal dialysis.3 Our findings support those of the Mayo authors: elderly patients who initiate chronic dialysis electively for ESRD evidence survival rates comparable to those in other age groups. To guide decision making in elderly patients beginning dialysis, further studies are needed that clearly distinguish between those patients who initiate urgently/emergently for acute kidney injury and those who start electively for ESRD.
ACKNOWLEDGMENTS We extend our sincere appreciation to the teammates in more than 1800 DaVita® clinics who work every day to take care of patients and also to ensure the extensive data collection on which our work is based. We thank DaVita Clinical Research® (DCR®), and specifically acknowledge Michele G. Scheid and Donna E. Jensen, PhD, of DCR for
584
editorial assistance. DCR is committed to advancing the knowledge and practice of kidney care.
Steven M. BRUNELLI, MD, MSCE, Allen R. NISSENSON, MD, Mahesh KRISHNAN, MD, MPH, MBA DaVita Clinical Research, Minneapolis, Minnesota, USA
REFERENCES 1 Thorsteinsdottir B, Larson HLW, Hickson LJ, Feely MA, Williams AW. Starting dialysis at age 75 years or older— Outcomes data to help in shared decision making. J Am Soc Nephrol. 2013; 24:46A. 2 Pivert K. Starting dialysis after 75: New outcomes data for shared decision-making. Kidney News. 2013; 5:1–2. 3 United States Renal Data System. Annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. 2013. Available from: http://www.usrds.org/ atlas.aspx (accessed date: October 10, 2013).
Hemodialysis International 2014; 18:583–584
