Clinical significance of hemodialysis quality of care indicators in very elderly patients with end stage kidney disease

Abstract

Introduction: Improvement in life expectancy has increased the number of very elderly patients undergoing hemodialysis. However, it is not clear which quality measures for hemodialysis should be employed in this population. Therefore, in this paper we investigated the association between major adverse cardiovascular and cerebrovascular events (MACCE) indicators of hemodialysis quality in very elderly patients. PATIENTS AND METHODS: Data regarding a total of 29,692 patients undergoing maintenance hemodialysis (median age 61 years, 41.5% females) who participated in a national hemodialysis quality assessment program were analyzed. They were divided into < 80 years and ≥ 80 years age groups. The primary and secondary outcomes were MACCE and all-cause mortality, respectively. The association between the outcomes and some of the most widely used standard hemodialysis quality-of-care indicators, including spKt/V, hemoglobin, serum calcium, serum phosphate, and albumin levels, was evaluated. To explore the association between Cox proportional hazard models were constructed. Model 1 was adjusted for age and sex. Model 2 included additional demographic characteristics, such as Charlson Comorbidity Index (excluding diabetes), diabetes, cause of ESKD, dialysis vintage, BMI, and pre-dialysis systolic blood pressure. Model 3 was further adjusted for the main medications. To evaluate the relationship between MACCE risk and quality assessment indicators as a continuous variable, cubic spline analyses were conducted.

Results: During a median follow-up of 3.7 years, MACCE occurred at a higher rate in the ≥ 80-years group than in the < 80-years group (282.0 vs. 110.1 events/1000 person-years). Multivariate Cox regression analysis revealed that spKt/V, serum calcium and phosphate, and hemoglobin levels were associated with MACCE and all-cause mortality risk in patients aged < 80 years. However, these indicators showed no significant relationship with MACCE and all-cause mortality in patients aged ≥ 80 years. Low serum albumin levels were significantly associated with increased MACCE and all-cause mortality risks, regardless of age.

Conclusion: In conclusion, hemodialysis quality-of-care indicators including spKt/V, serum calcium and phosphate levels, and hemoglobin were not related to MACCE or all-cause mortality in very elderly hemodialysis patients. However, lower serum albumin levels were associated with poor outcomes, regardless of patient age. Assuring nutritional status rather than improving hemodialysis management adequacy may be more beneficial for improving outcomes in very elderly hemodialysis patients. Further prospective evaluations are needed to confirm these findings.