MO186MORTALITY IN FRAIL ELDERLY WITH CHRONIC KIDNEY DISEASE – WHAT CAN MAKE US CHOOSE BETWEEN HEMODIALYSIS AND A CONSERVATIVE APPROACH?
Authors: Freitas Joana 
Published: May 2021

Abstract

Background and Aims
The prevalence of Chronic Kidney Disease (CKD) is increasing worldwide including a significant number of frail elderly patients. This reflects the need to create tools that could help the nephrologists to choose between the best renal replacement treatment and a conservative approach. The identification of prognostic factors and their correlation with mortality could be crucial.
The aim of this study was to identify and compare some variables that could be associated with mortality in CKD patients whether receiving hemodialysis or in a conservative approach.

Method
The authors realized a single center retrospective study in older (≥ 75years) and frail patients admitted in Nephrology department between in the last seven years. Baseline characteristics were collected from electronic medical records. Three groups were characterized: group 1 (G1) represents non deceased patients in hemodyalisis (HD), group 2 (G2) represents deceased patients in HD and group 3 (G3) represents deceased patients treated with a conservative approach.
The comorbidities were stratified according with modified Charlson comorbidity index (mCCI) ≥ 5; the frailty according to Clinical Frailty Scale (CFS) ≥ 5). The eGFR was calculated through Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) at the time of admission. The nutritional status (based in Body Mass Index and seric albumin), ferritine value as a marker of inflammation and the number of hospitalizations during 2014-2020 were analyzed. Quantitative variables are described with their mean and compared with Student´s T-test. A p-value &lt;0.05 was considered statistically significant. SPSS Statistics version 23 (Chicago, IL) was used for all statistical analyses.

Results
A total of 398 patients with CKD stage 4 and 5 presented with dyalitic indication or conservative approach (CA) at time of admission were included: 72 (18.1%) were in CA group. Clinical characteristics are presented in Table 1.
We analyzed the difference between patients who were still alive (G1) versus patients who died during this observational period of seven years, accordingly with which treatment modality (CA or HD).
We found no significant differences regarding gender and CKD etiology between groups. There were significant differences in age (G1: median age 77 vs G2:median age 76, p value &lt; 0,001; G1: median age 77 vs G3:median age 82, p value &lt;0,001).
In our study, deceased population had a higher degree of frailty (G1: 2,5 vs G2:5,2, p value &lt; 0,001; G1: 2,5 vs G3:5,7, p value 0,015), a higher Charlson comorbidity score (G1:3 vs G2: 4,3, p value 0,000018; G1: 3 vs G3:5,7, p value &lt;0,001), a poorer nutritional status (Body Mass Index: G1:25,7 vs G2:22,8, p value &lt; 0,001; G1:25,7 vs G3:23,2, p value &lt;0,001 and lower albumin levels: G1: 3,86 vs G2:3,23, p value 0,00001; G1: 3,83 vs G3:3,23, p value &lt;0,001 ), higher ferritine levels (G1:258 vs G2:436, p value &lt;0,001; G1: 258 vs G3:386, p value &lt; 0,001).
The number of emergency admissions were higher in deceased groups (G1:0,3 vs G2:1,2, p value &lt; 0,001; G1:0,3 vs G3:0,8, p value &lt; 0,001).

Conclusion
We concluded that G2 and G3 had more comorbidities and more frailty, as we expected.
Knowledge of the factors associated with mortality could be of value in shared decision-making and useful to help improve outcomes in CKD population.
In the absence of a model completely capable of predicting mortality among patients who initiate hemodialysis versus patients undergoing conservative treatment, the analysis of these variables can contribute to a better selection of patients who will really benefit from a conservative treatment approach. Further studies are needed to validate a prognostic tool to choose the better treatment for elderly frail patients.