Kidney Week

Abstract: TH-OR43

Impact of Conservative Management vs. Dialysis on the Survival of US Veterans with Advanced CKD

Session Information

• Hemodialysis Care: Quality, Vascular Access, and Emerging Threats
  November 02, 2023 | Location: Room 120, Pennsylvania Convention Center
  Abstract Time: 04:48 PM - 04:57 PM

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Rhee, Connie, University of California Irvine School of Medicine, Irvine, California, United States

Connie Rhee, MD, MS

• Narasaki, Yoko, University of California Irvine School of Medicine, Irvine, California, United States

Yoko Narasaki,

• Crowley, Susan T., Yale University, New Haven, Connecticut, United States

Susan T. Crowley,

• Kovesdy, Csaba P., The University of Tennessee Health Science Center, Memphis, Tennessee, United States

Csaba P. Kovesdy,

• Mukamel, Dana B., University of California Irvine School of Medicine, Irvine, California, United States

Dana B. Mukamel,

• You, Seungsook, University of California Irvine School of Medicine, Irvine, California, United States

Seungsook You,

• Novoa-Vargas, Alejandra, University of California Irvine School of Medicine, Irvine, California, United States

Alejandra Novoa-Vargas,

• Yoon, Ji Hoon, University of California Irvine School of Medicine, Irvine, California, United States

Ji Hoon Yoon,

• Nguyen, Danh V., University of California Irvine School of Medicine, Irvine, California, United States

Danh V. Nguyen,

• Kalantar-Zadeh, Kamyar, Harbor-UCLA Medical Center, Torrance, California, United States

Kamyar Kalantar-Zadeh,

Background

Given that dialysis patients may experience high early mortality rates, healthcare utilization, and withdrawal, particularly in those of older age and multi-morbidity, there has been interest in conservative management (CM) as an alternative treatment strategy for advanced CKD patients. Among a national cohort of US Veterans, we compared the impact of CM vs. dialysis on survival.

Methods

Using linked national VA, USRDS, and Medicare data, we examined Veterans with advanced CKD (≥2 eGFRs <25 separated by ≥90 days) categorized according to receipt of CM vs. dialysis (non-receipt vs. receipt of dialysis within 2-yrs of the 1^st eGFR <25), with the latter group parsed into later dialysis (LD) vs. earlier dialysis (ED) (eGFRs <15 vs. ≥15 at dialysis transition, respectively). We compared survival in CM vs. dialysis patients matched by propensity score (PS) in a 1:1 ratio to address confounding by indication using Cox models.

Results

Among 91,598 patients who met eligibility criteria, 3628 CM patients were PS-matched to 3628 ED patients, while 9833 CM patients were PS-matched to 9833 LD patients. In PS-matched models, both ED and LD were each associated with higher mortality vs. CM: HRs (95%CIs) 1.25 (1.19-1.32) and 1.08 (1.05-1.12), respectively. Similar findings were observed in sensitivity analyses doubly-adjusted for PS covariates. When examining survival trajectories after the index eGFR date, ED and LD demonstrated worse survival vs. CM after 2-years and 4-years, respectively.

Conclusion

In a national cohort of US Veterans, earlier transition to dialysis was associated with worse survival compared to CM. Later transition to dialysis was also associated with worse survival vs. CM, albeit to a lesser degree. Further studies are needed to examine the impact of CM vs. dialysis transition on other hard endpoints and patient-centered outcomes.

Funding

• NIDDK Support