Early Dialysis Initiation, a Look from the Rearview Mirror to What’s Ahead

Rosansky, Steven J.

doi:10.2215/cjn.12231213

Cited by 7 publications

(3 citation statements)

References 26 publications

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“…Consistent with previous work, our study also suggests that these trends are not explained by changes in patient characteristics (6)(7)(8)(10)(11)(12)(13)(14)(15)(16) or the clinical context of dialysis initiation (36) over time. Other hypotheses to explain trends in eGFR at dialysis initiation include acceptance by the nephrology community of opinion-based clinical practice guidelines supporting earlier dialysis (18), more widespread automated eGFR reporting (37), provider preference for dialysis compared with other strategies for managing patients with advanced kidney disease (38,39), and provider belief in the benefit of preemptive dialysis (10,24). Slinin et al found that earlier dialysis initiation was associated with several provider characteristics, including provider inexperience, foreign (outside the United States) medical training, a high-or low-density of nephrologists, and receipt of predialysis nephrology care (38).…”

Section: Discussionmentioning

confidence: 99%

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

O’Hare

Batten

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States.Design, setting, participants, & measurements The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR$10 ml/min per 1.73 m 2 .Results The adjusted probability of starting dialysis at an eGFR$10 ml/min per 1.73 m 2 increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction ,0.001) and those with a higher risk of 1-year mortality (P for interaction ,0.001).Conclusions Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.

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Section: Discussionmentioning

confidence: 99%

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

O’Hare

Batten

et al. 2015

Clinical Journal of the American Society of Nephrology

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“…The only randomized trial, the Initiating Dialysis Early and Late (IDEAL) study [1], and the following observation studies including 1 meta-analysis have suggested no survival benefit of initiating dialysis early, which was defined as a range of the estimated glomerular filtration rate (eGFR) at dialysis initiation (eGFR-DI) of >10 mL/ min/1.73 m 2 [2][3][4][5][6][7]. In light of emerging evidence, the international practice pattern of dialysis initiation has moved from eGFR-DI of >10 mL/min/1.73 m 2 in the 2000s toward close to 7 mL/min/1.73 m 2 in the 2010s [8][9][10][11]. Furthermore, the recent practice guidelines in Nephrology endorse the "safe intent-to-defer" approach rather than the specific eGFR threshold-based approach [12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

Dialysis timing may be deferred toward very late initiation: An observational study

et al. 2020

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The optimal timing to initiate dialysis among patients with an estimated glomerular filtration rate (eGFR) of <5 mL/min/1.73 m 2 is unknown. We hypothesized that dialysis initiation time can be deferred in this population even with high uremic burden. A case-crossover study with case (0-30 days before dialysis initiation [DI]) and control (90-120 days before DI) periods was conducted in 1,079 hemodialysis patients aged 18-90 years at China Medical University Hospital between 2006 and 2015. The uremic burden was quantified based on 7 uremic indicators that reached the predefined threshold in case period, namely hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate. Dialysis timing was classified as standard (met 0-2 uremic indicators), late (3-5 indicators), and very late (6-7 indicators). Median eGFR-DI of the 1,079 patients was 3.4 mL/min/1.73 m 2 and was 2.7 mL/min/1.73 m 2 in patients with very late initiation. The median follow-up duration was 2.42 years. Antibiotics, diuretics, antihypertensive medications, and non-steroidal anti-inflammatory drugs (NSAIDs) were more prevalently used during the case period. The fully adjusted hazards ratios of all-cause mortality for the late and very late groups were 0.97 (95% confidence interval 0.76-1.24) and 0.83 (0.61-1.15) compared with the standard group. It is safe to defer dialysis initiation among patients with chronic kidney disease (CKD) having an eGFR of <5 mL/min/1.73 m 2 even when patients having multiple biochemical uremic burdens. Coordinated efforts in acute infection prevention, optimal fluid management, and prevention of accidental exposure to NSAIDs are crucial to prolong the dialysis-free survival.

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“…This practice has been driven by the mistaken opinion that there is a benefit to ‘early' dialysis before the patient has the traditional indications for initiation of dialysis [3]. Financial factors are also likely to play a part with more elderly patient initiating, and higher eGFRs at initiation of dialysis, in high health care cost areas where there is a greater density (competition) of nephrologists [4].…”

mentioning

confidence: 99%

Should Dialysis be Offered to All Elderly Patients?

Germain

2015

Blood Purif

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Nephrologist are often faced with the question of the appropriate initiation and withdrawal from dialysis. Many clinicians feel that patient should be offered dialysis when they have ESRD regardless of the potential risks vs. benefits. My position in this debate is that nephrologists have the obligation to order treatments that are indicated and effective for their patients and will provide more benefit that harm. They should not order dialysis in patient that are not likely to benefit from the treatment. Patients have the right to refuse treatments but not the right to demand that a clinician order an ineffective treatment. Shared decision making is the key principle in deciding on the initiation and withdrawal from dialysis. The national guideline; Shared Decision Making: The Appropriate Initiation and Withdrawal from Dialysis supports this approach.

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Early Dialysis Initiation, a Look from the Rearview Mirror to What’s Ahead

Cited by 7 publications

References 26 publications

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Dialysis timing may be deferred toward very late initiation: An observational study

Should Dialysis be Offered to All Elderly Patients?

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