The proportion of the elderly people (over 65 years) has continued to increase among over half a million Americans with end-stage renal disease (ESRD). In 1990, 2000 and 2010, 39%, 44% and 44% of all prevalent dialysis patients, and 4%, 10% and 20% of all kidney transplant recipients were elderly. Consequent to the absolute increase of elderly individuals in the population pyramid, the prevalence and incidence of ESRD have also risen. Kidney transplantation is generally regarded as the treatment of choice in ESRD irrespective of age. However, there are no comparative data about the best choice of renal replacement therapy for the elderly ESRD patients, in whom such novel and fast-growing dialysis modalities as nocturnal and home hemodialysis (HHD) may offer same or even better survival advantages than deceased donor transplantation, the most common kidney transplantation in the elderly. Previous data suggest that the projected increases in life spans in transplant patients compared to conventional dialysis were 2.8 and 1.1 years for patients aged 65-69 and 70-74 years, respectively. Some recent studies show no difference in the adjusted survival between nocturnal HHD and deceased donor transplantation irrespective of age. We hypothesize that such contemporary dialysis treatments as HHD are associated with greater survival than deceased donor transplantation in most transplant-wait-listed elderly ESRD patients without a living donor and that a scoring system based on demographic and other recipient clinical and laboratory data can identify those elderly ESRD patients in whom such dialysis modalities are more or less advantageous. In this project, we will obtain, refine, and lin data from DaVita, one of the nation's largest dialysis providers, with a national transplant database known as the Scientific Registry of Transplant Recipients (SRTR). We will then study approximately 1,000 elderly (>65 years) incident HHD patients who started dialysis therapy in a DaVita clinic between 1/2007 and 12/2011 (5 years) and after merging their data with the SRTR database to create a propensity score matched (1:4) cohort of elderly cadaveric kidney transplant recipient (n=5,000). We will also create a propensity-matched cohort with living donor kidney transplant recipient. In addition, we will develop and examine a series of predictor scores for selection of living and cadaveric kidney transplantation in ESRD recipient over 65 years of age. Our scoring tools will predict the 1-, 3- and 5-year patient and kidney allograft survival as well as graft-loss censored mortality in the elderly population. This comparative effectiveness research application will innovatively utilize new methodological approaches including propensity score based analyses to assess and to quantify the true effectiveness of kidney transplantation versus certain dialysis modalities including HHD. This 2-year project will efficiently generate a wealth of time-sensitive information about the potential treatment of choice in elderly ESRD patients that will be of immediate clinical and

Public Health Relevance

and inform decision making by physicians, patients, providers, and payers. PUBLIC HEALTH RELEVANCE: The proposed research project aims to examine whether such contemporary dialysis treatments as home hemodialysis and nocturnal hemodialysis are associated with greater survival than cadaveric donor transplantation in most transplant-wait-listed elderly patients end stage kidney disease without a living donor. This project also aims to develop a scoring system to identify those elderly patients in whom these dialysis treatments are more or less advantageous and to identify elderly patients in whom kidney transplantation may have poorer outcomes than dialysis treatment modalities.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1)
Program Officer
Salive, Marcel
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University of California Irvine
Internal Medicine/Medicine
Schools of Medicine
United States
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Molnar, Miklos Z; Kovesdy, Csaba P; Kalantar-Zadeh, Kamyar (2018) The Authors' Reply. Transplantation 102:e87
Molnar, Miklos Z; Nguyen, Danh V; Chen, Yanjun et al. (2017) Predictive Score for Posttransplantation Outcomes. Transplantation 101:1353-1364
Molnar, Miklos Z; Ravel, Vanessa; Streja, Elani et al. (2016) Survival of Elderly Adults Undergoing Incident Home Hemodialysis and Kidney Transplantation. J Am Geriatr Soc 64:2003-2010
Molnar, Miklos Z; Ravel, Vanessa; Streja, Elani et al. (2016) Racial Differences in Survival of Incident Home Hemodialysis and Kidney Transplant Patients. Transplantation 100:2203-10
Obi, Yoshitsugu; Qader, Hemn; Kovesdy, Csaba P et al. (2015) Latest consensus and update on protein-energy wasting in chronic kidney disease. Curr Opin Clin Nutr Metab Care 18:254-62
Ahmadi, Seyed-Foad; Streja, Elani; Zahmatkesh, Golara et al. (2015) Reverse Epidemiology of Traditional Cardiovascular Risk Factors in the Geriatric Population. J Am Med Dir Assoc 16:933-9
Ahmadi, Seyed-Foad; Zahmatkesh, Golara; Streja, Elani et al. (2014) Body mass index and mortality in kidney transplant recipients: a systematic review and meta-analysis. Am J Nephrol 40:315-24
Molnar, Miklos Z; Naser, Mohamed S; Rhee, Connie M et al. (2014) Bone and mineral disorders after kidney transplantation: therapeutic strategies. Transplant Rev (Orlando) 28:56-62
Molnar, Miklos Z; Foster 3rd, Clarence E; Sim, John J et al. (2014) Association of pre-transplant blood pressure with post-transplant outcomes. Clin Transplant 28:166-76
Streja, Elani; Wang, Hsin-Yi; Lau, Wei Ling et al. (2014) Mortality of combined serum phosphorus and parathyroid hormone concentrations and their changes over time in hemodialysis patients. Bone 61:201-7

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