What is the clinical evidence from this study?

Study design: Cohort. Population: End-stage kidney disease (n=281). Intervention: Dialysis vs. Maximal conservative management. Primary outcome: Change in EQ-5D Index at 6 months (p=<0.01).

March 29, 2019Open Access

Quality of life after the initiation of dialysis or maximal conservative management in elderly patients: a longitudinal analysis of the Geriatric assessment in OLder patients starting Dialysis (GOLD) study

Q: What are the key findings of this study?

Dialysis maintained a stable quality of life in elderly patients with end-stage kidney disease, whereas maximal conservative management was associated with a small decline in quality of life over 6 months.

Key Result

Dialysis maintained a stable quality of life in elderly patients with end-stage kidney disease, whereas maximal conservative management was associated with a small decline in quality of life over 6 months.

Study Design

Type

Cohort (n=281)

Multicenter

Yes

Structured PICO

Does dialysis improve quality of life compared to maximal conservative management in elderly patients with end-stage kidney disease?

Population

281 elderly patients (≥65 years old) with end-stage kidney disease (ESKD) from 17 hospitals in the Netherlands, including 192 starting dialysis and 89 choosing maximal conservative management.

Intervention

Dialysis (hemodialysis or peritoneal dialysis)

Comparator

Maximal conservative management (MCM)

Outcome

Trajectory of quality of life (QoL) measured with the EQ-5D-3L (EQ-5D Index and overall self-rated health) at 6 months follow-uppatient reported

In elderly patients with ESKD, starting dialysis does not significantly improve quality of life but is associated with higher hospitalization rates compared to maximal conservative management, with no survival benefit in patients over 80 years old.

Main Result

Absolute Event Rate: 0.026% vs -0.047%

p-value: p=<0.01

Limitations

Lead-time bias, as conservative patients were likely included earlier in their illness trajectory (reflected by higher GFR).
The decision for conservative management may have been pending for a while before inclusion, potentially overestimating their quality of life.
Short follow-up period of six months with only two quality of life measurements.
The EQ-5D questionnaire may not capture all aspects of quality of life that matter most to the conservative care population.

Abstract

BACKGROUND: Maximal conservative management (MCM) may be an appropriate alternative option for dialysis in some elderly patients with end-stage kidney disease (ESKD). Evidence about the impact of dialysis or MCM on quality of life (QoL) in older patients is sparse. In the GOLD (Geriatric assessment in OLder patients starting Dialysis) Study the trajectory of QoL was assessed in patients starting dialysis or MCM. METHODS: Patients ≥65 years old were included just prior to dialysis initiation or after decision for MCM. Baseline data included demographics, frailty as measured with a geriatric assessment, comorbidity (CIRS-G) and QoL, measured with the EQ-5D-3 L (EQ-5D Index and overall self-rated health). Six months follow-up data included QoL, hospitalizations and mortality. Change of QoL was assed with paired t-tests. Cox-regression was used to assess survival of MCM and dialysis patients. RESULTS: , p < 0.01). Baseline QoL did not differ significantly between the groups. After six months, EQ-5D Index did not improve significantly in the dialysis group with mean ± standard error (SE) 0.026 ± 0.014 (p = 0.10; not clinically relevant), but a small but clinically relevant decline was seen in the conservative group: 0.047 ± 0.022 (p < 0.01; between group difference p < 0.01). Hospitalization occurred in 50% of dialysis patients vs. 24% of conservative patients (p < 0.01). In patients over 80 years old, no survival benefit could be found for dialysis patients starting dialysis vs. MCM. CONCLUSION: A small decline of QoL was found for conservative patients, while QoL did not change in dialysis patients. However, hospitalization rate was higher in patients starting dialysis. In patients over 80 years, no survival benefit was found.

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