Conservative Management vs. Dialysis and Cognitive Function in Veterans with Advanced CKD Using Competing Risks Approaches

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Background: While dialysis has been the dominant treatment paradigm in advanced CKD patients progressing to ESKD, there is growing interest in conservative management (CM) as an alternative patient-centered treatment strategy for advanced CKD in certain subgroups (elderly, multi-morbid). We examined the association of CM vs. dialysis transition with cognitive dysfunction in Veterans with advanced CKD. Methods: Using linked national VA, USRDS, and Medicare data, we examined Veterans with advanced CKD (≥2 eGFRs <25 separated by ≥90 days) categorized according to receipt of CM, defined as those who did not receive dialysis within 2-yrs of the index eGFR (1st eGFR <25), vs. receipt of dialysis within 2-yrs of the index eGFR. We compared the risk of incident dementia, mild cognitive impairment (MCI), and either dementia or MCI (combined dementa/MCI) ascertained by diagnostic codes in CM vs. dialysis patients matched by propensity score (PS) in a 1:1 ratio to address confounding by indication using unadjusted and doubly-adjusted Fine-Gray subdistribution hazard models to account for all-cause death as a competing risk. Results: Among 90,017 patients who met eligibility criteria, there were 15,844, 3406, and 16,858 patients who developed dementia, MCI, and combined dementia/MCI, respectively. In the unadjusted PS-matched models, transition to dialysis was associated with higher risk of incident dementia, MCI, or combined dementia/MCI compared to CM: SHRs (95%CIs) 1.36 (1.28-1.45), 1.34 (1.18-1.52), and 1.32 (1.24-1.40), respectively. Similar findings were observed in sensitivity analyses doubly-adjusted for PS covariates. Conclusion: In a national cohort of US Veterans, transition to dialysis was associated with higher risk of dementia and MCI compared to CM in analyses that accounted for death as a competing risk. Further studies are needed to determine the mechanistic pathways underlying the differential risk of cognitive dysfunction across advanced CKD treatment strategies. Funding: NIDDK Support

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