Comparative Effectiveness of Home Hemodialysis versus Kidney Transplantation in t

描述（由申请人提供）：在50多万患有终末期肾病（ESRD）的美国人中，老年人（65岁以上）的比例持续增加。在1990年、2000年和2010年，39%、44%和44%的透析患者以及4%、10%和20%的肾移植受者是老年人。随着人口金字塔中老年人的绝对增加，ESRD的患病率和发病率也有所上升。肾移植通常被认为是治疗终末期肾病的首选，与年龄无关。然而，没有关于老年ESRD患者肾脏替代治疗的最佳选择的比较数据，其中诸如夜间和家庭血液透析（HHD）等新型和快速发展的透析方式可能提供与已故供体移植（老年人最常见的肾移植）相同甚至更好的生存优势。以前的数据表明， 与常规透析相比，年龄在65-69岁和70-74岁的患者中，移植患者分别为2.8年和1.1年。最近的一些研究表明，无论年龄大小，夜间HHD和死亡供体移植的校正生存率没有差异。我们假设，在大多数无活体供体的等待移植的老年ESRD患者中，HHD等当代透析治疗与死亡供体移植相比生存率更高相关，并且基于人口统计学和其他受体临床和实验室数据的评分系统可以识别这些透析方式或多或少有利的老年ESRD患者。在这个项目中，我们将从DaVita（美国最大的透析提供商之一）获得，改进和链接数据，并将其与被称为移植接受者科学登记处（SRTR）的国家移植数据库联系起来。然后，我们将研究大约1,000名老年（>65岁）HHD患者，这些患者在2007年1月至2011年12月（5年）期间在DaVita诊所开始透析治疗，并将其数据与SRTR数据库合并，以创建老年尸体肾移植受者的倾向评分匹配（1：4）队列（n=5,000）。我们还将建立一个与活体供肾移植受者的倾向匹配队列。此外，我们将开发和检查一系列预测评分，用于选择65岁以上ESRD受者的活体和尸体肾移植。我们的评分工具将预测1年、3年和5年患者和肾移植物存活率以及老年人群中移植物丢失的死亡率。该比较有效性研究应用将创新性地利用新的方法学方法，包括基于倾向评分的分析，以评估和量化肾移植与某些透析方式（包括HHD）相比的真实有效性。这个为期2年的项目将有效地产生大量的时间敏感的信息的潜在治疗的选择 在老年ESRD患者中，

DESCRIPTION (provided by applicant): 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