#3659 KIDNEY FAILURE MANAGEMENT IN THE ELDERLY: A PRELIMINARY SURVIVAL ANALYSIS
Authors: Zanetti Fiammetta , Fanton Giulia , Martino Francesca , Manani Sabrina Milan , Baretta Michele , Abaterusso Cataldo , Nordio Maurizio , Ronco Claudio , Zanella Monica 
Published: June 2023

Abstract

Background and Aims
Dialysis treatment (DT) is the most common approach for patients with kidney failure. However, this may not be optimal for geriatric individuals, as more than half of elderly patients who initiate DT die within the first year. As a result, current guidelines advocate for presenting comprehensive conservative management (CM) as an alternative option for vulnerable patients and their families. A recent meta-analysis (2022) revealed that DT had a median survival time of 20-67 months, compared to 6-31 months for CM, indicating that individuals who opt for DT may have higher survival benefits. This distinction, however, disappears in +80 y/o patients, suggesting that both therapies may yield similar outcomes in this population. The efficacy of CM, however, remains poorly recognized due to the difficulty in comparing the treatments and the heterogeneous nature of the studies conducted. Therefore, our study aimed to investigate and compare the survival of the elderly who elected to undergo either conservative therapy or dialysis.

Method
We present a preliminary analysis of a prospective observational study conducted across 3 Nephrology Units (Veneto, Italy). We enrolled 117 patients in the pre-dialysis or CM clinics, meeting the eligibility criteria: ≥75 y/o, eGFR&gt;15 ml/min/1.73 m2 (CKD-EPI formula), and had not already undergone DT or CM (personalized pharmacological therapy combined with a low-protein diet). At baseline, socio-demographic information, patient comorbidities, and blood and urine tests were collected through medical records and interviews. Additionally, the SF-36 questionnaire, the Barthel questionnaire, and the Mini-Mental State Examination assessed the quality of life, functional status, and global cognitive functioning. Survival was evaluated at 3 and 9 months after follow-up initiation, defined as the date of the first dialysis session or when the eGFR dropped below 10 ml/min/1.73 m2 in CM patients. The follow-up ended when patients reached the 9th month, died from any cause, switched treatments, discontinued medical follow-up, dropped out of the study voluntarily, or at the end of the project. To determine if any across-group differences existed at the baseline, non-parametric tests were used for continuous variables and the chi-square test for categorical variables. Kaplan-Meyer curve, Log Rank Test and Cox regression were performed for survival analysis.

Results
Of the 117 enrolled patients, 64 initiated the follow-up, 47 (59.6% M) in CM, and 17 (64.7% M) in DT. The patients in CM were older than those in DT (p = 0.028), with a median age of 82.5 (75.4-91.7) compared to 78.9 (75.6-87.9). At baseline, there were other statistically significant differences (p&lt;0.05) in median levels of BUN, creatinine, PTH, haemoglobin, and total cholesterol. Comorbidities were similar in both groups. During the follow-up, 11 patients died (17.2%), 10 in CM (21.3%) and 1 in DT (5.9%). One patient in CM had an unavailable death date and was, therefore, excluded from further analysis. Kaplan-Meier curves and Log Rank Test revealed no significant difference in survival (p = 0.25). The median survival time was undefined, as over 50% of subjects in both groups did not experience the event during follow-up. In CM, unadjusted survival rates at 3 and 9 months were 91.3% and 78.2%, respectively. The effect of the therapies resulted in not significant after adjusting for important prognostic covariates.

Conclusion
In this study, we found that middle-term survival in the elderly is comparable to DT and CM. Despite limitations, these results provide valuable information for clinical decision-making. Our results suggest that well-organized CM can be a reasonable option for elderly patients with kidney failure.