Survival of Older Adults Choosing Dialysis or Conservative Kidney Management, Stratified by Suitability for Dialysis

Rationale & Objective Previous studies indicate survival benefit for dialysis over conservative kidney management (CKM), which attenuates in patients ≥80 years or with high comorbidity. Most studies did not differentiate dialysis suitability among those choosing CKM, potentially biasing outcomes. We aimed to describe survival outcomes in patients choosing dialysis, patients suitable for dialysis who chose CKM, and patients less suitable for dialysis who chose CKM. Study design Single-centre cohort study. Setting & Participants We included patients aged ≥65 years with a documented treatment decision for dialysis or CKM between 2017 and 2024. Exposure Chosen treatment (dialysis or CKM). Patients choosing CKM were classified as suitable or less suitable for dialysis, based on the treating nephrologist's. Outcome The primary outcome was all-cause mortality. Analytical Approach Descriptive, using Kaplan-Meier estimates and Cox proportional hazard models without adjustment for confounding. Results Median survival from treatment decision was 53 (dialysis), 32 (CKM, suitable for dialysis), and 18 months (CKM, less suitable for dialysis), with unadjusted hazard ratios of 2.11 (CKM, suitable for dialysis vs dialysis; 95% CI 1.59; 2.80) and 3.23 (less suitable for dialysis vs. dialysis; 95% CI 2.47; 4.23). Among patients aged ≥80 years, hazard ratios were 1.89 (0.99; 1.74) for CKM suitable for dialysis vs dialysis and 2.35 (1.31; 4.64) for CKM less suitable for dialysis vs. dialysis. Thirteen percent of patients who initially chose dialysis switched to CKM, whereas 1% transitioned from CKM to dialysis. Limitations Subjectivity in dialysis suitability assessment. Conclusions In this cohort of older patients with kidney failure, survival outcomes in patients choosing CKM suitable for dialysis were longer than previously reported. These findings highlight the importance of distinguishing dialysis suitability when evaluating survival outcomes in CKM and dialysis. This supports more individualized shared decision-making in older adults with advanced kidney disease.