Association of Age With Risk of Kidney Failure in Adults With Stage IV Chronic Kidney Disease in Canada

Abstract

Importance: With population aging, the burden of many age-related chronic conditions, including kidney failure, is increasing globally.

Objective: To investigate the risks of kidney failure and death in adults with incident stage IV chronic kidney disease (CKD).

Design, setting, and participants: This population-based cohort study obtained data recorded between July 30, 2002, and March 31, 2014, from the linked laboratory and administrative data set of Alberta Health in Alberta, Canada. All adults of the province of Alberta with stage IV CKD (estimated glomerular filtration rate [eGFR] of 15-30 mL/min/1.73 m2) were eligible for inclusion. Included individuals were followed up from study entry until the date of kidney failure, death, or censoring, whichever occurred first. Observations were censored at the date of emigration from the province, the study end date (March 31, 2017), or at 10 years after study entry. Data analyses were performed from January 2020 to June 2020.

Main outcomes and measures: The primary outcome was kidney failure, defined as the earlier of either renal replacement (dialysis or kidney transplant) initiation or severe kidney impairment (eGFR <10 mL/min/1.73 m2). Incidence of stage IV CKD in Alberta was examined over time, along with the association between age at study entry and the competing risks of kidney failure and death. Cumulative incidence functions (95% CIs) were estimated to summarize absolute risks over time across categories of age, accounting for sex, diabetes, cardiovascular disease, eGFR, and albuminuria.

Results: The study included 30 801 adults (mean [SD] age, 76.8 [13.3] years; 17 294 women [56.1%]) with stage IV CKD. Of these, 5511 developed kidney failure (17.9%) and 16 285 died (52.9%). The incidence rate of stage IV CKD increased sharply with advancing age; the absolute risk of kidney failure decreased with advancing age, and the risk of death increased, especially in those aged 85 years or older. Compared with the 5-year risk of death, the 5-year risk of kidney failure was higher in people younger than 65 years, similar in people aged 65 to 74 years, and lower for older age groups. For those aged 75 years or older, the risk of death was much higher than the risk of kidney failure: 6-fold higher among those aged 75 to 84 years (0.51 [95% CI, 0.5-0.52] vs 0.09 [95% CI, 0.08-0.09]) and 25-fold higher among those aged 85 years or older (0.75 [95% CI, 0.74-0.76] vs 0.03 [95% CI, 0.02-0.03]). The risk of death was higher than the risk of kidney failure by 24-fold among those aged 85 to 94 years (0.73 [95% CI, 0.72-0.74] vs 0.03 [95% CI, 0.02-0.03]) and by 149-fold among those aged 95 years or older (0.89 [95% CI, 0.87-0.92] vs <0.01 [95% CI, <0.01 to 0.01]).

Conclusions and relevance: This study found that, although the incidence rate of stage IV CKD increased with advancing age, the absolute risk of kidney failure decreased. Unlike other age-related conditions, the expected increase in the burden of kidney failure in the older adults may be less dramatic than expected.

Figure 1.. Yearly Incidence Rate of Stage IV Chronic Kidney Disease (CKD) and Renal Replacement in Alberta, Canada

Each color band represents 1 year. Shading of the color bands indicates successive years, from the first year (lightest) to the last year (darkest).

Figure 2.. Observed Probabilities Over Time

Stacked cumulative incidence functions by age in years are shown. The number-at-risk data are included in eFigure 2 in the Supplement. CKD indicates chronic kidney disease.

Figure 3.. Stratified 5-Year Risks

Cumulative incidence functions at 5 years by age, diabetes, and cardiovascular disease (CVD) are shown. For model-based 5-year risks by sex, see eFigures 8 and 9 in the Supplement. Error bars indicate 95% CIs.