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Prognostic stratification in older adults commencing dialysis.

Katharine L Cheung¹, Maria E Montez-Rath², Glenn M Chertow²

¹Division of Nephrology, University of Vermont College of Medicine, Burlington. Katharine.L.Cheung@med.uvm.edu.

The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

|February 1, 2014

Summary

Prognostic models for older adults starting dialysis poorly predict 6-month mortality. Existing tools need improvement for better treatment decisions in end-stage renal disease patients.

Keywords:

Epidemiology.Multimorbidities Outcomes Renal

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Area of Science:

Nephrology
Geriatrics
Biostatistics

Background:

Accurate prognostic models are crucial for treatment decisions in elderly end-stage renal disease (ESRD) patients considering dialysis.
These models can help identify patients suitable for conservative care or hospice, optimizing care for older adults.

Purpose of the Study:

To compare the predictive accuracy of three existing prognostic instruments for 6-month mortality in older adults commencing dialysis.
To evaluate the performance of the Liu index, the French Renal Epidemiology and Information Network (REIN) score, and hospice eligibility criteria.

Main Methods:

A cohort study of 44,109 patients aged ≥ 67 years initiating dialysis in the US (2008-2009) was analyzed.
Three prognostic instruments were assessed for their discrimination of 6-month mortality using the concordance (c)-statistic.
Logistic regression was used to estimate the odds of death, with and without age adjustment.

Main Results:

23.3% of patients died within 6 months of dialysis initiation.
The combined Liu/hospice eligibility criteria score showed the best discrimination (c-statistic 0.68-0.70), though overall performance was limited.
Discrimination worsened with older age, particularly for the Liu and REIN scores. High specificity was observed for certain REIN (≥ 9) or hospice eligibility criteria (≥ 3) scores.

Conclusions:

Existing prognostic indices derived from administrative data demonstrate poor performance in predicting 6-month mortality for elderly ESRD patients starting dialysis.
There is a need for improved prognostic tools to guide clinical decision-making in this vulnerable population.