Annals of Internal MedicineEffect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults with Kidney Failure: A Target Trial Emulation Study

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This study compared the outcomes of starting dialysis versus continuing medical management in older adults with kidney failure who were not referred for transplant. The research provides important insights into the impact of treatment choices on survival and home time for this patient population.

Study Design:

• Observational cohort study using target trial emulation
• Setting: US Department of Veterans Affairs, 2010 to 2018
• Participants: 20,440 adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2, not referred for transplant
• Mean age: 77.9 years (SD, 8.8)
• Intervention: Starting dialysis within 30 days vs. continuing medical management
• Measurements: Mean survival and number of days at home over a 3-year horizon

Key Findings:

• Median time to dialysis start: 8.0 days in dialysis group, 3.0 years in medical management group
• Survival: 770 days for dialysis group vs. 761 days for medical management group (difference: 9.3 days; 95% CI, −17.4 to 30.1 days)
• Home time: Dialysis group had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days)
• Compared to completely forgoing dialysis: Dialysis group had 77.6 days longer survival (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days)

HCN Medical Memo
When counseling older patients with kidney failure about treatment options, consider discussing both the potential for modest survival gains with dialysis and the impact on quality of life, particularly time spent at home. Individualized decision-making should take into account patient preferences, comorbidities, and overall health status.

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