Octogenarians and Nonagenarians Starting Dialysis in the United States

6 February 2007 | Volume 146 Issue 3 | Pages 177-183

Background: The elderly constitute the fastest-growing segment of the end-stage renal disease (ESRD) population, but the epidemiology and outcomes of dialysis among the very elderly, that is, those 80 years of age and older, have not been previously examined at a national level.

Objective: To describe recent trends in the incidence and outcomes of octogenarians and nonagenarians starting dialysis.

Design: Observational study.

Setting: U.S. Renal Data System, a comprehensive, national registry of patients with ESRD.

Participants: Octogenarians and nonagenarians initiating dialysis between 1996 and 2003.

Measurements: Rates of dialysis initiation and survival.

Results: The number of octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13 577 persons in 2003, corresponding to an average annual increase in dialysis initiation of 9.8%. After we accounted for population growth, the rate of dialysis initiation increased by 57% (rate ratio, 1.57 [95% CI, 1.53 to 1.62]) between 1996 and 2003. One-year mortality for octogenarians and nonagenarians after dialysis initiation was 46%. Compared with octogenarians and nonagenarians initiating dialysis in 1996, those starting dialysis in 2003 had a higher glomerular filtration rate and less morbidity related to chronic kidney disease but no difference in 1-year survival. Clinical characteristics strongly associated with death were older age, nonambulatory status, and more comorbid conditions.

Limitations: Survival of patients with incident ESRD who did not begin dialysis could not be assessed.

Conclusions: The number of octogenarians and nonagenarians initiating dialysis has increased considerably over the past decade, while overall survival for patients on dialysis remains modest. Estimates of prognosis based on patient characteristics, when considered in conjunction with individual values and preferences, may aid in dialysis decision making for the very elderly.

Editors' Notes Context Numbers of very elderly persons starting dialysis are increasing in the United States. Contribution This study, using national registry data of patients with end-stage renal disease, showed that octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13 577 persons in 2003. Patients starting dialysis in 2003 had higher estimated glomerular filtration rates and less morbidity related to chronic kidney disease, but no difference in 1-year mortality rate (approximately 50%), compared with those starting dialysis in 1996. Older age, nonambulatory status, and more comorbid conditions were strongly associated with an increased risk for death. Implications Increasing numbers of the very elderly are receiving dialysis, while overall survival remains low. —The Editors

 

Author and Article Information

From the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, San Francisco, California, and the United States Renal Data System, Minneapolis, Minnesota.

Disclaimer: The data reported here have been supplied by the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the U.S. government.

Grant Support: Dr. Kurella was supported in part by the American Society of Nephrology–Association of Subspecialty Professors Junior Development award in Geriatric Nephrology, funded through Atlantic Philanthropies, the American Society of Nephrology, and the John A. Hartford Foundation. Dr. Chertow was supported in part by NIH and NIDDK (RO1 DK58411) and NIH and NIDDK (RO1 DK01005).

Potential Financial Conflicts of Interest: Grants received: G.M. Chertow (National Institutes of Health); Grants pending: G.M. Chertow (National Institutes of Health). Dr. Collins is the president of the National Kidney Foundation.

Requests for Single Reprints: Manjula Kurella, MD, MPH, Division of Nephrology, University of California San Francisco, UCSF Laurel Heights Suite 430, 3333 California Street; e-mail, manjula.kurella{at}ucsf.edu.

Current Author Addresses: Drs. Kurella and Chertow: Division of Nephrology, University of California, San Francisco, UCSF Laurel Heights Suite 430, 3333 California Street, San Francisco, CA 94118-1211.

Dr. Covinsky: Division of Geriatrics, University of California, San Francisco, San Francisco Veterans Affairs Medical Center, VAMC 181G, San Francisco, CA 94143.

Dr. Collins: United States Renal Data System, 914 South 8th Street, Suite D-206, Minneapolis, MN 55404.

Author Contributions: Conception and design: M. Kurella, G.M. Chertow.

Analysis and interpretation of the data: M. Kurella, K.E. Covinsky, G.M. Chertow.

Drafting of the article: M. Kurella, G.M. Chertow.

Critical revision of the article for important intellectual content: M. Kurella, K.E. Covinsky, A.J. Collins, G.M. Chertow.

Final approval of the article: M. Kurella, K.E. Covinsky, A.J. Collins, G.M. Chertow.

Statistical expertise: M. Kurella, G.M. Chertow.

Obtaining of funding: M. Kurella.

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