• Maria E Montez-Rath, I-Chun Thomas, Vivek Charu, Michelle C Odden, Carolyn D Seib, Shipra Arya, Enrica Fung, Ann M O'Hare, WongSusan P YSPYDivision of Nephrology, Department of Medicine, University of Washington, and Hospital and Specialty Medicine Service and Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Sea, and Manjula Kurella Tamura.
• Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (M.E.M., E.F.).
• Ann. Intern. Med. 2024 Sep 1; 177 (9): 123312431233-1243.

BackgroundFor older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.ObjectiveTo compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m2 and those who continued medical management.DesignObservational cohort study using target trial emulation.SettingU.S. Department of Veterans Affairs, 2010 to 2018.ParticipantsAdults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2 who were not referred for transplant.InterventionStarting dialysis within 30 days versus continuing medical management.MeasurementsMean survival and number of days at home.ResultsAmong 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).LimitationPotential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans.ConclusionOlder adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home.Primary Funding SourceU.S. Department of Veterans Affairs and National Institutes of Health.

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