A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis

Cooper, Bruce A.; Branley, Pauline; Bulfone, Liliana; Collins, John; Craig, Jonathan C.; Fraenkel, Margaret; Harris, Anthony; Johnson, David W.; Kesselhut, Joan; Li, Jing Jing; Luxton, Grant; Pilmore, Andrew; Tiller, David J.; Harris, David C.H.; Pollock, Carol

doi:10.1056/nejmoa1000552

Cited by 774 publications

(659 citation statements)

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“…A study in 2009 suggested that among nursing home residents with advanced kidney disease, initiation of dialysis was associated with a substantial and sustained decline in functional status 4. A provocative clinical trial from Australia and New Zealand in 2010 suggested that planned early initiation of dialysis in patients with Stage 5 CKD was not associated with improved survival or other clinical outcomes 3. These data have been supported by an increasing number of observational studies across different dialysis populations 33.…”

Section: Discussionmentioning

confidence: 99%

“…Management strategies have largely focused on slowing down progression to end‐stage renal disease (ESRD), at which time, patients are invariably expected to transition to renal replacement therapy, mostly in the form of maintenance dialysis treatment 2. Nevertheless, recent data suggest that attempts to delay or even prevent transition to dialysis therapy may not be inappropriate,3 including a 2009 study that showed that the initiation of dialysis was associated with a substantial and sustained decline in functional status of the elderly nursing home patients 4. Many patients with kidney disease prefer to opt to exhaust all conservative management options for CKD, including nutritional strategies, prior to considering dialysis therapy 5…”

Section: Introductionmentioning

confidence: 99%

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Low‐protein diet for conservative management of chronic kidney disease: a systematic review and meta‐analysis of controlled trials

Rhee

Ahmadi

Kövesdy

et al. 2017

J cachexia sarcopenia muscle

167

126

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BackgroundRecent data pose the question whether conservative management of chronic kidney disease (CKD) by means of a low‐protein diet can be a safe and effective means to avoid or defer transition to dialysis therapy without causing protein‐energy wasting or cachexia. We aimed to systematically review and meta‐analyse the controlled clinical trials with adequate participants in each trial, providing rigorous contemporary evidence of the impact of a low‐protein diet in the management of uraemia and its complications in patients with CKD.MethodsWe searched MEDLINE (PubMed) and other sources for controlled trials on CKD to compare clinical management of CKD patients under various levels of dietary protein intake or to compare restricted protein intake with other interventions. Studies with similar patients, interventions, and outcomes were included in the meta‐analyses.ResultsWe identified 16 controlled trials of low‐protein diet in CKD that met the stringent qualification criteria including having 30 or more participants. Compared with diets with protein intake of >0.8 g/kg/day, diets with restricted protein intake (<0.8 g/kg/day) were associated with higher serum bicarbonate levels, lower phosphorus levels, lower azotemia, lower rates of progression to end‐stage renal disease, and a trend towards lower rates of all‐cause death. In addition, very‐low‐protein diets (protein intake <0.4 g/kg/day) were associated with greater preservation of kidney function and reduction in the rate of progression to end‐stage renal disease. Safety and adherence to a low‐protein diet was not inferior to a normal protein diet, and there was no difference in the rate of malnutrition or protein‐energy wasting.ConclusionsIn this pooled analysis of moderate‐size controlled trials, a low‐protein diet appears to enhance the conservative management of non‐dialysis‐dependent CKD and may be considered as a potential option for CKD patients who wish to avoid or defer dialysis initiation and to slow down the progression of CKD, while the risk of protein‐energy wasting and cachexia remains minimal.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Low‐protein diet for conservative management of chronic kidney disease: a systematic review and meta‐analysis of controlled trials

Rhee

Ahmadi

Kövesdy

et al. 2017

J cachexia sarcopenia muscle

167

126

View full text Add to dashboard Cite

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“…However, 76% of patients randomly assigned to start at low eGFRs actually started at higher levels because of uremic signs and symptoms, resulting in a relatively small difference in eGFRs between the groups. 6 The study failed to show a survival difference between those randomly assigned to start dialysis therapy with higher and lower eGFRs, possibly because of this relatively small difference, but suggested that clinical status is important in the decision making of nephrologists. [6][7][8] Nevertheless, little is known about exactly which criteria nephrologists use in their decision for when to start dialysis therapy.…”

mentioning

confidence: 98%

Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Luijtgaarden

Noordzij

Tomson

et al. 2012

American Journal of Kidney Diseases

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Background:Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT.Study Design: European web-based survey. Predictors: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors.Setting & Participants: Nephrologists from 11 European countries. Outcomes & Measurements:We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT.Results: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m 2 . Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from highversus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m 2 ) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m 2 ).Limitations: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists.Conclusions: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making. Am J Kidney Dis. 60 (6) P atients with end-stage renal disease (ESRD) receive renal replacement therapy (RRT) to improve their survival and quality of life. The decision of when to start RRT is likely to be guided by the level and rate of decrease in residual kidney function and the clinical condition of the patient. Whereas RRT might be life-saving in certain conditions, dialysis also is unphysiologic and may have life-threatening complications. It carries a significant burden for patients and consumes substantial health care resources. 1 Many studies evaluating associations between the timing of the start of RRT and survival were limited in that they considered only serum creatinine level, which is decreased in pa...

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“…While urgent initiation of HD may seem like the only option, timing is usually flexible. Early HD has failed to improve survival, 26,27 and many patients may die before reaching the point of inevitable HD. 28 Peritoneal dialysis is a viable option for many 29 that is underutilized in the US.…”

Section: Respect For Autonomy: Patients Are Often Provided Neither Inmentioning

confidence: 99%

“…6 A recent push toward earlier initiation of HD has failed to improve survival. 26,27 Best supportive care for elderly ESRD patients has achieved a 1-year overall survival of 65 %, which rivals survival on HD. Of those patients, 71 % died at home 60 -a central goal for many patients.…”

Section: Nonmaleficence: the Harms Of Hemodialysis Often Outweigh Itsmentioning

confidence: 99%

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

2013

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A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis

Cited by 774 publications

References 27 publications

Low‐protein diet for conservative management of chronic kidney disease: a systematic review and meta‐analysis of controlled trials

Low‐protein diet for conservative management of chronic kidney disease: a systematic review and meta‐analysis of controlled trials

Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

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