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This study aims to explore the optimal comorbidity index for predicting adverse outcomes in elderly peritoneal dialysis (PD) patients and to construct, evaluate, and validate the best risk prediction model for assessing mortality and technical failure rates in this population. Through precise risk assessment, this research aims to assist clinicians in the timely and efficient identification of the risks of mortality and technical failure faced by patients.
This study is a retrospective cohort study that includes elderly peritoneal dialysis (PD) patients aged ≥65 years (N = 411) who were registered and regularly followed up at the Peritoneal Dialysis Center of the Second Affiliated Hospital of Soochow University between January 1, 2009, and December 31, 2023, with follow-up extending until June 30, 2024. Initially, univariate and multivariate Cox regression analysis were performed to screen variables significantly associated with survival and technical survival. The final optimal prediction model was established, with calibration curves plotted to evaluate its goodness of fit and a nomogram constructed. Internal and external validation of the predictive model were subsequently performed.
This study included 411 elderly peritoneal dialysis (PD) patients who met the inclusion criteria. Fifty patients were excluded due to a peritoneal dialysis duration of less than 3 months, renal function recovery, kidney transplantation, or loss to follow-up, leaving 328 patients in the final analysis. Among these, 190 patients (57.9%) died, 52 patients (15.9%) transitioned from peritoneal dialysis to hemodialysis, and 86 patients (26.2%) remained on peritoneal dialysis at the end of the follow-up. Univariate analysis of the training cohort identified nine potential risk factors for mortality and technical failure in elderly PD patients (P < 0.05). Lasso regression analysis further narrowed down the risk factors to seven, indicating that age, hemoglobin, serum phosphate, serum albumin, CDMF-CCI, EVCI, and the Taiwan Index were all significant risk factors for mortality and technical failure in elderly PD patients. The results showed that age, serum albumin, and the three comorbidity indices (CDMF-CCI, EVCI, Taiwan Index) were independent risk factors for mortality and technical failure (P < 0.05). The study constructed a base model using age and serum albumin as variables, and single-factor comorbidity models using CDMF-CCI, EVCI, and the Taiwan Index separately. We then built a multivariate Cox prediction model by combining all three comorbidity indices with the base model. Time-dependent ROC curves were plotted for 1-year, 3-year, 5-year, 8-year, and 10-year survival, and the AUC, NRI, and IDI were compared for all seven prediction models. The results showed that the single-factor comorbidity models were less accurate than the base model in predicting both mortality and technical failure rates in elderly PD patients. However, after adding the comorbidity indices to the base model, we found that the prediction accuracy of all multivariate Cox prediction models improved to varying extents. The multivariate Cox model combining CDMF-CCI with age and serum albumin demonstrated the best performance, especially in predicting mid-term survival and technical survival rates, showing a significant improvement in prediction accuracy. Based on comparisons of different combinations, we selected the model with the best predictive performance for mortality and technical failure in elderly PD patients, which was the multivariate Cox model comprising CDMF-CCI, age, and serum albumin. A Nomogram and calibration curve were generated for this model, and the calibration curve showed good consistency between the observed and predicted probabilities.
Table 1. Comparison of baseline characteristics in elderly PD patients in the survival and death groups
Survival group（N=138）
death group（N=190）
P
Age(years)
69（66~74）
74（70~78）
＜0.001
Dialysis vintage(months)
28.5（17.0~53.0）
28.0（16.0~52.0）
0.545
Gender(n,%)
Male
Female
83（60.1%）
55（39.9%）
99（52.1%）
91（47.9%）
0.148
BMI(kg/m²)
21.97（20.39~23.80）
21.50（19.60~23.80）
0.214
HGB(g/L)
112.5±22.6
114.4±67.2
0.466
PLT(×109/L)
179.5（136.0~223.0）
169.0（135.0~218.0）
0.226
Ca(mmol/L)
2.12（1.98~2.22）
2.11（1.95~2.23）
0.471
P(mmol/L)
1.37（1.17~1.61）
1.28（1.07~1.52）
0.011
Cr(μmol/L)
577.0（479.0~655.0）
506.5（405.0~677.0）
0.027
BUN(mmol/L)
17.5±5.2
16.5±5.2
0.082
ALB(g/L)
32.4±5.9
30.7±5.8
0.012
Kt/v
1.78（1.55~2.05）
1.79（1.54~2.08）
0.773
Episodes of peritonitis(n,%)
50（36.2%）
83（43.7%）
0.175
CDMF-CCI
4.0（3.0~5.0）
5.0（4.0~6.0）
EVCI
9.0（8.0~19.0）
18.0（8.0~21.0）
0.001
Taiwan index
3.0（0.0~6.0）
5.0（3.0~7.0）
Table 2. Time-dependent AUC and Comparative Model Results for Mortality in Elderly Peritoneal Dialysis Patients
Models
T=1年
T=3年
T=5年
T=8年
M1
AUC
(95%CI)
0.67
（0.58~0.77）
-
0.77
（0.71~0.83）
0.79
（0.72~0.86）
0.81
（0.72~0.90）
M2
0.74
（0.66~0.82）
0.060
（0.76~0.86）
0.038
0.84
（0.78~0.90）
0.89
（0.82~0.95）
0.014
M3
0.70
（0.61~0.79）
0.219
0.76
（0.70~0.82）
0.365
0.82
（0.76~0.88）
0.065
（0.76~0.92）
0.282
M4
0.75
（0.67~0.83）
0.013
0.883
（0.75~0.88）
0.212
0.85
（0.78~0.93）
0.172
M1：age+ALB；M2： M1+CDMF-CCI；M3：M1+EVCI；M4：M1+Taiwan index；
1. Age, serum albumin, as well as CDMF-CCI, EVCI, and the Taiwan Index, are independent risk factors for mortality and technical failure in elderly peritoneal dialysis (PD) patients.
2. Among the three comorbidity indices, CDMF-CCI demonstrates the best predictive performance for adverse outcomes in elderly PD patients.
3. The composite model consisting of CDMF-CCI, age, and serum albumin shows the optimal predictive performance and can serve as a prognostic tool to guide clinicians in treatment decision-making.
