Author/year | Aim/objectives | Population of interest | Main findings* | Conclusions/comments |
Joly et al 2003121 | Comparison of survival between CM and RRT in octogenarians; predictors of poor prognosis; most data obtained prospectively | All patients ≥80 with a creatinine clearance <10 mL/min (Cockcroft-Gault formula), not yet on dialysis; seen in a single French unit in 1989–2000 n=146 (CM: 37; RRT: 107) Age: CM: 84.1±2.9; RRT: 83.2±2.9 Later referral, poor functional status and diabetes were more common in CM cohort; no of comorbidities similar between both cohorts | Survival: less with CM (8.9 vs 28.9 months) Factors significantly associated with: 1-year mortality: poor nutritional status, late referral and functional dependence Mortality beyond the first year: peripheral vascular disease | In those >80, best 1-year survival is seen in those with early referral, normal BMI and good functional status (Most dialysis decisions here were taken by multidisciplinary team; all subsequently accepted by patients) |
Smith et al 200388 | Comparison of survival between CM and RRT, in a group of pre-dialysis patients in a single UK hospital, analysing outcomes according to initial choice and eventual treatment, prospective study | All pre-dialysis patients presenting for assessment/counselling regarding RRT options in a renal clinic, classified into two groups based on recommended therapy—CM or RRT; followed for 3 to 57 months; eventual treatment choice and outcomes studied n=321 (recommended: CM 63; RRT 258) Age: 61.5±15.4 (recommended: CM 71±12; RRT 59±15) RRT: 186 started treatment; rest died or chose CM CM: 11 switched to RRT eGFR: by derivation, <10 in both groups | Survival: Recommended CM: 6.3 vs 8.3 months if switched to RRT (not statistically significant) Cox PH: no survival benefit of RRT in those recommended for CM, regardless of eventual choice Likelihood of CM recommendation: older, sicker, diabetic, more functionally impaired, less likely to survive 1 year | In those older, more functionally impaired, more comorbidities and diabetes, who are recommended for CM, no survival benefit from RRT |
Murtagh et al 2007122 | Comparison of survival between CM and RRT in patients ≥75 from 4 UK renal units; retrospective study | All patients ≥75 receiving renal care, with survival calculated from the date of first recorded eGFR ≤15 n=129 (CM 77, RRT 52) Median age: CM 83; RRT 79.6 Comorbidities: similar CM cohort: older; but otherwise similar | After eGFR ≤15: Median survival time: less in CM (540 vs 588 days) 1-year survival rate: lower in CM (68% vs 84%) 2-year survival rate: lower in CM (47% vs 76%) Survival in those with high comorbidity: no statistical difference CM vs RRT | In those >75 with severe comorbidity, no significant survival advantage for RRT over CM |
Carson et al 200989 | Comparison of clinical outcomes (survival, hospitalisation) for patients who had ESRD and chose either CM or RRT | Patients older than 70 who either started RRT or attended CM clinic from 1997 to 2003 n=202 (CM 29; RRT 173) Age: CM 81.6; RRT 76.4 eGFR: median value at start of RRT was 10.8. For CM group, survival calculated from the time they were estimated to reach eGFR 10.8 Comorbidity scores: similar in both groups | CM cohort was older. Survival: less with CM (13.9 vs 37.8 months) Hospitalisation: less with CM during follow-up; CM cohort more likely to die at home or hospice than hospital (OR 4.15) | In those >70, RRT provided longer survival (by 2 years) than CM, but there were similar number of hospital-free days in both RRT and CM |
Chandna et al 2011123 | Comparison of survival between CM and RRT in patients with ESRD with high vs low comorbidity in UK clinic from 1990 to 2008 | All adults progressing to stage 5 CKD seen in clinic over 18 years; followed from the time of first recorded eGFR @10 to 15 n=844 (CM 155, RRT 689) Ages: CM 77.5±7.6; RRT 58.5±15 eGFR: 13.2±1.4 in both groups at study entry Comorbidity scales scored for every participant | CM was older and had greater comorbidities Survival (median) with low comorbidity: less in CM (29.4 vs 36.8 months) Survival, severe comorbidity: less in CM (20.4 vs 25.8 months) (non-significant difference in survival with severe comorbidity) | In those >75 with severe comorbidity, no significant survival advantage for RRT over CM |
Hussain et al 201369 | Comparison of survival, hospital admissions and palliative care access between CM and RRT cohorts of older patients in a single UK unit; studied retrospectively | All patients aged >70 and eGFR <20, receiving advice regarding CM vs RRT during pre-dialysis education. Survival was calculated from three time points: when the eGFR was <20, <15 and <12 n=441 (CM 172, RRT 269) Age: CM 82±5.6; RRT 77±5 Comorbidity (CCI), WHO performance score worse in CM cohort; CM cohort more likely to be institutionalised | Survival from all three time points: less with CM Survival from eGFR <20 20.4 years less with CM Difference in survival between CM and RRT is reduced in those >80: when CCI score is high when performance score worsens Hospitalisation risk: more with RRT than CM (RR 1.6) Palliative care review: more with CM (85% vs 4% of patients) | In those >80, no survival advantage for RRT over CM In those >70, increasing performance score or increasing comorbidities reduces the survival advantage for RRT over CM |
Seow et al 2013124 | Comparison of change in health-related quality of life between CM and RRT in patients with advanced age and severe comorbidity | Pre-dialysis patients eGFR 8–12, who were >75 or had CCI >8, seen in single hospital Quality of life for assessed with KDQOL-SF v1.2, Chinese and English versions, administered by interviewer n=101 (CM 63, RRT 38) Age: CM: 78; RRT 71 eGFR: similar in both groups eGFR decline: faster in RRT group | PCS, MCS stable in CM group; no significant difference from RRT group RRT group: improved cognition function scale, but worse scores on effective kidney disease and burden of kidney disease scale | In those >75 with severe comorbidity, RRT did not improve kidney-specific symptoms or significantly improve QOL domains compared with CM |
Shum et al 201490 | Comparison of clinical outcomes (survival, hospitalisation, institutionalisation, EOL care) for Chinese patients with CKD stage 5 that chose either CM or PD | Adults ≥65; followed for at least 1.5 years from first dialysis assessment visit; retrospectively chosen from the period 2003–2010; n=199 (CM 42; PD 157) Age: CM 75.3±5.7; PD: 73.4±5.3 eGFR ≤15 for study inclusion | CM cohort was older, less likely to have home help with PD. Survival: less with CM (2.35 vs 3.75 years) Hospitalisation: more with CM cohort than PD cohort even after adjusting for age, comorbidity and functional status Institutionalisation: risks were similar EOL care: CM cohort more likely to receive renal palliative care; less bothersome interventions at EOL | In those >65, home-based PD provided greater survival than CM, with less hospitalisation and equal risk of institutionalisation |
Brown et al 201535 | Comparison of survival, symptom burden and quality of life between CM and RRT in older patients in a single Australian unit; studied prospectively | All patients receiving care in pre-dialysis, renal supportive care or emergency dialysis start pathways Symptoms, quality of life assessed using surveys n=467 (CM 122, RRT 345) Age: CM 82±9; RRT 67±14 eGFR at study entry: 16 in both groups | Survival: less with CM (20 vs 33 months) Survival in those >75: less with CM (19 vs 31 months) Mean survival from eGFR <15: less with CM (13 vs 20 months) Mean survival, eGFR <15, age >75: less with CM (aHR 4.4) mean survival, age >75, comorbidities (IHD or CHF) ≥2: not statistically different Symptom control: similar in both CM and RRT Quality of life changes: similar in both CM and RRT | In those >75, with cardiac plus other comorbidities, no survival advantages from RRT over CM |
Verberne et al 201685 | Comparison of survival between CM and RRT in patients ≥70; retrospective study single Dutch hospital | All patients ≥70 receiving renal care in one centre, eGFR <20 Survival calculated from time of decision regarding RRT/CM n=311 (CM 107, RRT 204) Age: CM 82.5±4.5; RRT 75.9±4.4 eGFR: CM 15.3, RRT 13.1 eGFR decline: similar in both groups Comorbidities: similar | Survival: less with CM (0.5 vs 2.8 years at eGFR <10; 1.5 vs 3.1 years at eGFR <15) Survival in those over 80: no statistically significant advantage (1.4 vs 2.1 years, p=0.08) Survival in those with high comorbidity: benefit of RRT significantly reduced (1 vs 1.8 years, CM vs RRT) | In those >80, no significant survival advantages for RRT over CM |
Martinez Echevers et al 201686 | Comparison of survival between CM and RRT in older patients in a single Spanish unit; studied prospectively | All patients aged >70 receiving care in the advanced CKD clinic, with separate analyses in those with CKD stage 5 regarding CM vs RRT and survival Group with eGFR <15: n=162 (CM 93, RRT 69). Median age: CM 78; RRT 76 eGFR at study entry: 14 in both groups | Survival (overall study duration): less with CM (39 vs 65 months) Survival from eGFR <15: less with CM (21 vs 46 months) Survival in those >75: less with CM (p=0.003) Survival in those >80: no difference between CM vs RRT Survival in those with IHD: no difference between CM vs RRT Survival with high comorbidity CCI score: less with CM (p=0.009) | In those >80, no survival advantages from RRT over CM In those >70 with IHD, survival benefit of RRT is reduced |
Chandna et al 2016125 | Investigation of role of rate of kidney function decline on survival and treatment choices in older patients with ESRD seen in UK clinic from 1995 to 2010 | Patients over 75 years old progressing to eGFR 10–15, seen in renal clinics between 1995 and 2010 (second follow-up eGFR taken prior to dialysis start or prior to death (CM patients) to calculate the rate of decline of eGFR) n=250 (CM: 158; RRT: 92) Age: 80.9±4 (CM: 82±4.1; RRT: 79.1±3.1) Index eGFR: 13.3±1.4 in both groups Follow-up eGFR: CM: 8.8±3.2; RRT: 6±2.5 Median rates of eGFR decline (mL/min/month): CM: 0.21; RRT 0.45 (p<0.001) | CM cohort: similar age, more comorbidities, but slower rate of decline in eGFR Survival: less in CM (23.1 vs 38.2 months) Survival with high comorbidity: less in CM (20.3 vs 28.4 months; p<0.049) High rate of eGFR decline: worse survival in CM, minimal effect in RRT Predictors of RRT choice: Age >75, gender, comorbidity, rate of decline of eGFR (CM choice is more often taken in patients with low rates of decline) | In those >75 with high comorbidity, only marginal advantage of RRT Rapid rates of eGFR decline worsens survival in those >75 managed with CM |
Reindl-Schwaighofer et al 2017126 | Comparison of survival between CM and RRT in the same era, using Austrian registry data for haemodialysis patients; studied retrospectively | All patients >65 years starting haemodialysis between 2002 and 2009 in the Austrian dialysis and transplant registry were compared with patients managed conservatively, after the GFR declined <10; in a single hospital (aged >65, in 2002–2009); bootstrapping used for propensity scores n=CM 174; RRT (only HD) 8622 Age: CM 81.22±7.23; RRT 74.06±5.78 eGFR: CM <10; RRT not specified | CM cohort: 95% female, more comorbidities Survival: less with CM (1.1 months vs 26.9 months) Survival benefit: less with CM (HD HR for death 0.39) survival benefit beyond 2 months: better with CM (non-significant) | In those >65, with comorbidities, survival benefit for RRT did not persist beyond 2.9 months (females) or 1.9 months (males) compared with CM |
*CIs, IQRs and p values not included for all articles.
BMI, body mass index; CCI, Charlson comorbidity index; CHF, congestive heart failure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; EOL, end of life; ESRD, end-stage renal disease; HD, haemodialysis; IHD, ischaemic heart disease; MCS, mental component score; PCS, physical component score; PD, peritoneal dialysis; PH, proportional hazards.