Early Initiation of Dialysis Fails to Prolong Survival in Patients with End-Stage Renal Failure

Abstract

Abstract. There is a trend to start dialysis earlier in patients with chronic renal failure. Studies that suggest improved survival from earlier initiation of dialysis are flawed in that they have measured survival from start of dialysis rather than from a time point before dialysis, when patients have the same renal function. This flaw is termed lead-time bias. Using the electronic patient record at the renal unit of Glasgow Royal Infirmary, all patients were identified who had received dialysis for chronic renal failure and who had sufficient data to calculate the time point at which they reached an estimated creatinine clearance (eC Cr ) of 20 ml/min (n ϭ 275). This date was used to time survival. The patients were divided into early and late start groups by the median eC Cr for all patients at initiation of dialysis, which was 8.3 ml/min. There was no significant benefit in patient survival from earlier initiation of dialysis. A Cox proportional hazards model demonstrated a significant inverse relationship between eC Cr at start of dialysis and survival (hazard ratio, 1

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

“…Since the previous survey on this matter in 2000, several debates and cohort studies were published suggesting that starting RRT at higher eGFRs may be harmful. [2][3][4][5][6]8,12,14,18,19,28 Therefore, we needed an update regarding current opinions on this topic.…”

“…In addition, they were unable to assess clinical status or specific reasons to start RRT at a particular moment in time. [2][3][4][5] The IDEAL (Initiating Dialysis Early and Late) trial was the first randomized controlled trial attempting to assess whether starting dialysis therapy at high (10-14 mL/min/1.73 m 2 ) or low (5-7 mL/min/1.73 m 2 ) estimated glomerular filtration rates (eGFRs) is more beneficial with respect to patient survival. 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.…”

Estimated Glomerular Filtration Rate at Re-Initiation of Dialysis and Mortality in Failed Kidney Transplant Recipients

“…Despite the weak evidence, early initiation was accepted and it was common practice until recently. More recent studies, including a randomized controlled trial, did not support early initiation of dialysis in CKD patients [5,8,9,12,[15][16][17][18]. The large multicenter trial from Netherland, the Netherlands Cooperative Study on the Adequacy of Dialysis, was the first observational study which casts doubt on the advantages of early dialysis initiation [7].…”

“…In 2003, Beddhu et al [9] reported that higher eGFR was associated with higher risk of death, but in a subgroup of patients with measured creatinine clearance, there was no association with mortality. Traynor et al [8], on the other hand, reported that higher creatinine clearance at initiation of dialysis was associated with elevated mortality risk. The largest observational study from the USA found a dose-dependent increase in mortality associated with earlier dialysis initiation.…”

“…Data from the US Renal Data System (USRDS) between 1996 and 2008 showed that the proportion of patients initiating hemodialysis (HD) with an estimated GFR (eGFR) >10 mL/min/ 1.73m 2 increased from 20 to 52% and those with a starting eGFR of ≥15 mL/min/1.73m 2 increased from 4 to 17% [5,6]. Interestingly, most of the recent observational trials and a landmark randomized controlled trial failed to show a survival benefit of early initiation of dialysis in CKD patients [5,[7][8][9][10][11][12][13][14][15][16][17][18].…”