Treatment modality in older patients with end-stage kidney disease: Description and retrospective follow-up of a center's cohort.

BACKGROUND: Choosing a treatment for end-stage kidney disease (ESKD) is particularly challenging for older, frail patients, since dialysis can be burdensome and negatively impact their quality of life. Conservative care (CC) is a viable alternative for patients who may not benefit from dialysis. METHODS: We conducted a single-center, retrospective, observational, cohort study including patients aged over 80 years who attended an ESKD treatment modalities consultation between July 2015 and December 2021. Demographic and clinical characteristics were collected, including treatment modality choice, time to treatment initiation, and time until death. RESULTS: One hundred thirteen patients were included, with a median age of 84 years (IQR 82-86). Most patients (54.9%) opted for hemodialysis (HD), followed by CC (38.9%). Among those who chose HD, 65.6% began treatment, and 32.2% died before starting. In the CC group, 50% began CC consultations, and 34.1% died before initiation. Among patients who initiated treatment, those who chose and received hemodialysis showed longer observed median survival than those managed conservatively (3.5 vs 0.7 years; HR 3.8, 95% CI 2.02-7.2; p<0.001). However, these findings should be interpreted cautiously, as this observational comparison is highly susceptible to indication bias and residual confounding due to unmeasured differences in frailty, functional status, and baseline vulnerability. CONCLUSIONS: Most patients over 80 years of age chose HD over CC. Both treatment groups showed high early mortality, with nearly one-third of patients dying before starting their selected treatment modality. Among patients who initiated treatment, longer survival was observed among patients who chose and were treated with HD, although these comparisons are highly susceptible to residual confounding. These findings highlight the extreme vulnerability of older patients with ESKD and reinforce the importance of timely prognostic assessment and individualized treatment planning.