Dialysis Adoption by US Veterans Outpaces Other Nations

A greater proportion of veterans in the United States with advanced chronic kidney disease (CKD) initiate dialysis than observed in other developed nations, according to researchers.

The vast majority (85.5%) of stage 5 CKD patients in the new study received or were about to initiate renal replacement therapy (RRT). More than half of elderly patients older than 85 years with a high comorbidity burden followed suit, despite a poor prognosis.

“Our findings signal more liberal use of dialysis in our study cohort as compared with other developed countries, with differences being especially striking for older age groups,” investigator Susan PY Wong, MD, of the University of Washington in Seattle, stated in a press release.

Dr Wong and colleagues cited a Canadian study by Brenda R. Hemmelgarn, MD, and colleagues estimated that far fewer renal failure patients—51.4%, including just 6.8% elderly patients—were treated with RRT (JAMA 307:2507–2515, 2012). Similarly, a study by Claire Sparke and her team found that about 51.2% of patients from New Zealand and Australia, including less than 5.0% of elderly patients, initiate RRT (Am J Kidney Dis 61: 413–419, 2013). 

For the current study, the investigators retrospectively identified 28,568 patients receiving treatment from the US Department of Veteran Affairs who had an estimated glomerular filtration rate (eGFR) below 15 mL/min/1.73m². Using linked administrative data from the US Renal Data System, Veteran Affairs, and Medicare, they further determined that 19,165 patients received RRT during 2000 to October 1, 2011.

The team focused on the remaining 9403 patients to gauge how often those with advanced CKD do not start RRT and the clinical context of this decision. They performed an in-depth review of medical records for a random sample of 2252 patients (25%), two thirds of whom went on to receive RRT.

A chart review identified an additional 7.5% who received dialysis that was not recorded in administrative data. Another 10.9% of patients were contemplating or preparing for dialysis but had not yet started. Only 14.5% chose to forgo dialysis.

By age, 96.2% of those younger than 45 and 53.3% of those older than 85 years old opted for RRT. Comorbidity burden, assessed by Gagne comorbidity score, did not appear to impact these decisions.

“Our findings underscore the relevance of shared decision making for dialysis to ensure that treatment decisions uphold the priorities and preferences of individual patients and are grounded in realistic expectations about prognosis and the expected benefits and harms of this treatment,” Dr Wong and colleagues concluded in the Clinical Journal of the American Society of Nephrology.

“This practice contrasts with many known observational studies that show that the benefit of dialysis for these patients is questionable in terms of quality of life and survival,” Jennifer Scherer, MD, of NYU School of Medicine in New York, and Alvin Moss, MD, of West Virginia University, added in an accompanying editorial. These study findings are a “call to action to the nephrology community…”

Since the study involved veterans, it may not reflect the broader US population, including women. However, the researchers noted that dialysis initiation within versus outside the Veterans Administration health system is typically more conservative.

Sources

1. . 1. Wong SPY, Hebert PL, Laundry RJ, Hammond RW, Liu CF, Burrows NR, and O’Hare AM. Decisions about Renal Replacement Therapy in Patients with Advanced Kidney Disease in the US Department of Veterans Affairs, 2000–2011. Clin J Am Soc Nephrol. [Epub ahead of print].

2.    2. Scherer JS and Moss AH. Practice Change Is Needed for Dialysis Decision Making With Older Adults with Advanced Kidney Disease. Clin J Am Soc Nephrol. doi: 10.2215/CJN.08770816. [Epub ahead of print].

3.    3. Study Reveals More Liberal Use of Dialysis in the US Compared With Other Developed Nations [press release]. American Society of Nephrology; September 22, 2016.