Treatment for kidney failure may be less likely in older adults, study indicates
Older adults may not receive treatment for kidney failure as often as younger patients, according to a new study.
Older adults may not receive treatment for kidney failure as often as younger patients, according to a new study.
Researchers in Alberta, Canada, performed a community-based cohort study to determine whether age was associated with treatment for kidney failure in patients who had an outpatient estimated glomerular filtration rate (GFR) measured between May 1, 2002, and March 31, 2008. At baseline, included patients had a GFR of at least 15 mL/min/1.73 m2 and did not need renal replacement therapy. Patient age groups were 18 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 84 years, and 85 years or older; eGFR groups were 90 mL/min/1.73 m2 or higher, 60 to 89 mL/min/1.73 m2, 45 to 59 mL/min/1.73 m2, 30 to 44 mL/min/1.73 m2, and 15 to 29 mL/min/1.73 m2.
The study's main outcome measures were adjusted rates of treatment for kidney failure, defined as dialysis or kidney transplant; untreated kidney failure, defined as progression to an eGFR less than 15 mL/min/1.73 m2 with no renal replacement therapy; and death. Results were published in the June 20 Journal of the American Medical Association.
Overall, 1,816,824 adults with a mean age of 48.2 years were included in the study. Less than half (44.3%) of the patients were men. Over a median of 4.4 years of follow-up, 97,451 (5.36%) patients died, 3,295 (0.18%) had treated kidney failure, and 3,116 (0.17%) had untreated kidney failure. Rates of kidney failure treatment were higher in younger patients than in older patients across all strata of eGFR. In patients who had had an eGFR of 15 to 29 mL/min/1.73 m2 at baseline, treatment rates for kidney failure were more than 10-fold higher in the youngest compared with the oldest patients (P<0.001). In addition, older patients consistently had higher rates of untreated kidney failure; among those with an eGFR of 15 to 29 mL/min/1.73 m2 at baseline, rates were more than fivefold higher in the oldest compared with the youngest patients (P<0.001). Less variation by age was observed in overall kidney failure rates (treated and untreated disease combined).
The authors acknowledged that they did not have information on why patients decided not to begin dialysis or on long-term prognosis, among other limitations. Regardless, they concluded that a large proportion of elderly patients may have advanced kidney disease because of high rates of untreated kidney failure. They called for future studies to examine dialysis initiation and shared decision making in this population.
The authors of an accompanying editorial noted that the study had “considerable strengths” but also pointed out that it didn't provide information on any alternative treatments and that the results may not be generalizable to patients in the United States. They agreed, however, that the results do indicate a potentially large burden of untreated kidney failure in older patients.
“It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis,” the editorialists wrote. “Finding the right balance between overtreatment and undertreatment is challenging but necessary.”