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. 2021 Jan 20;16(1):e0244081.
doi: 10.1371/journal.pone.0244081. eCollection 2021.

Validation of prognostic indices for short term mortality in an incident dialysis population of older adults >75

Bjorg Thorsteinsdottir  1   2   3   4 , LaTonya J Hickson  4   5 , Rachel Giblon  3   6 , Atieh Pajouhi  1 , Natalie Connell  2 , Megan Branda  3   7 , Amrit K Vasdev  1 , Rozalina G McCoy  1   4 , Ladan Zand  5 , Navdeep Tangri  8   9 , Nilay D Shah  3   6
Affiliations

Validation of prognostic indices for short term mortality in an incident dialysis population of older adults >75

Bjorg Thorsteinsdottir et al. PLoS One. .

Abstract

Rational and objective: Prognosis provides critical knowledge for shared decision making between patients and clinicians. While several prognostic indices for mortality in dialysis patients have been developed, their performance among elderly patients initiating dialysis is unknown, despite great need for reliable prognostication in that context. To assess the performance of 6 previously validated prognostic indices to predict 3 and/or 6 months mortality in a cohort of elderly incident dialysis patients.

Study design: Validation study of prognostic indices using retrospective cohort data. Indices were compared using the concordance ("c")-statistic, i.e. area under the receiver operating characteristic curve (ROC). Calibration, sensitivity, specificity, positive and negative predictive values were also calculated.

Setting & participants: Incident elderly (age ≥75 years; n = 349) dialysis patients at a tertiary referral center.

Established predictors: Variables for six validated prognostic indices for short term (3 and 6 month) mortality prediction (Foley, NCI, REIN, updated REIN, Thamer, and Wick) were extracted from the electronic medical record. The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality.

Results: In our cohort of 349 patients, mean age was 81.5±4.4 years, 66% were male, and median survival was 351 days. The c-statistic for the risk prediction indices ranged from 0.57 to 0.73. Wick ROC 0.73 (0.68, 0.78) and Foley 0.67 (0.61, 0.73) indices performed best. The Foley index was weakly calibrated with poor overall model fit (p <0.01) and overestimated mortality risk, while the Wick index was relatively well-calibrated but underestimated mortality risk.

Limitations: Small sample size, use of secondary data, need for imputation, homogeneous population.

Conclusion: Most predictive indices for mortality performed moderately in our incident dialysis population. The Wick and Foley indices were the best performing, but had issues with under and over calibration. More accurate indices for predicting survival in older patients with kidney failure are needed.

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Conflict of interest statement

Dr.Tangri reports grants and personal fees from AstraZeneca Inc., personal fees from Otsuka Inc., personal fees from Janssen, personal fees from Boehringer Ingelheim and Eli Lilly, grants, and personal fees, and other from Tricida Inc., outside the submitted work. Study contents are the sole responsibility of the authors and do not necessarily represent the official views of NIH or the US government. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Flowchart of cohort development.
Fig 2
Fig 2. Percent of patients with each risk score value, by index.
Fig 3
Fig 3. Receiver operating characteristics (ROC) curves for each index.
Fig 4
Fig 4. Calibration plots by index.
a. Mortality at 3 months. b. Mortality at 6 months.
See this image and copyright information in PMC

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