Effect of Comorbidity on the Increased Mortality Associated With Early Initiation of Dialysis

Kazmi, Waqar; Gilbertson, David T.; Obrador, Gregorio T.; Guo, Haifeng; Pereira, Brian J.G.; Collins, Allan J.; Kausz, Annamaria T.

doi:10.1053/j.ajkd.2005.08.005

Cited by 148 publications

(127 citation statements)

References 17 publications

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“…4,[17][18][19] Consistent with our finding that only 7% indicated that the planned start was never delayed, a possible explanation for these differences may be that the actual start usually is later than the planned start.…”

Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofsupporting

confidence: 85%

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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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Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofsupporting

confidence: 85%

“…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.…”

Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofmentioning

confidence: 99%

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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“…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].…”

Section: Introductionmentioning

confidence: 99%

“…The impact of psychosocial factors, including depressive symptoms, on the outcomes of dialysis patients has been emphasized in several studies [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. In the Dialysis Outcomes and Practice Patterns Study (DOPPS), the presence of depressive symptoms, as assessed by the Center for Epidemiologic Studies Depression Scale (CES-D) or by the two depression questions on the Medical Outcomes Study Short Form-36 (SF-36), was strongly associated with mortality and hospitalizations in a large cohort of prevalent hemodialysis (HD) patients maintained on dialysis for a median time of >2.4 years [4].…”

Section: Introductionmentioning

confidence: 99%

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

2012

American Journal of Kidney Diseases

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Background. Recent observational studies and a controlled trial suggest more favorable outcomes upon later dialysis initiation in chronic kidney disease. The role of estimated glomerular filtration rate (eGFR) in predicting outcome at reinitiation of dialysis in failed kidney transplant recipients is unclear. Methods. Five-year data in a large dialysis organization was linked to the 'Scientific Registry of Transplant Recipients' to identify 747 failed kidney transplant patients with CKD Stage 5, who had restarted dialysis therapy. A propensity score for early (eGFR >10.5 mL/min/1.73m 2 ) versus late reinitiation of dialysis was fit by logistic regression. The mortality hazard ratio (HR) was estimated across tertiles of the fitted score. Results. Patients were 44 ± 14 years old and included 42% women. Male gender {odds ratio (OR), [95% confidence interval (CI)]: 1.82 (1.22-2.73)}, diabetes mellitus [OR: 1.75 (1.14-2.68)] and peripheral vascular disease [OR: 3.55 (1.17-10.77)] were associated with higher odds of early dialysis reinitiation. Each mL/min/1.73m 2 higher eGFR was associated with 6% higher death risk in unadjusted model [HR: 1.06 (1.01-1.11)], and although not significant in fully adjusted models [HR: 1.02 (0.96-1.07)], it was significant in some subgroups including women and younger patients. The death HR of higher eGFR across lowest to highest tertiles of propensity score of early dialysis initiation (corresponding healthiest to sickest patients) were 1.10 (0.98-1.24), 1.00 (0.91-1.10) and 0.99 (0.92-1.07), respectively (P for trend <0.05), indicating a trend toward higher mortality risk with earlier dialysis initiation in the healthiest patients. Conclusions. Earlier return to dialysis therapy in failed kidney transplant patients tends to correlate with worse dialysis survival especially among healthiest and younger patients and women. Additional studies need to verify these findings.

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“…These studies led to promulgation of the so-called healthy start dialysis concept, where dialysis was instigated before the development of uremic signs and symptoms (10). Conversely, a number of more recently published observational studies, including a meta-analysis (11), has shown that dialysis initiation at higher estimated GFR (eGFR) levels is paradoxically associated with an increased risk of mortality compared with initiation at lower levels (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). These results may have been limited by selection, indication, survivor, and misclassification biases.…”

Section: Introductionmentioning

confidence: 99%

Association between GFR Estimated by Multiple Methods at Dialysis Commencement and Patient Survival

Pollock

Cooper

Branley

et al. 2014

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives The Initiating Dialysis Early and Late study showed that planned early or late initiation of dialysis, based on the Cockcroft and Gault estimation of GFR, was associated with identical clinical outcomes. This study examined the association of all-cause mortality with estimated GFR at dialysis commencement, which was determined using multiple formulas.Design, setting, participants, & measurements Initiating Dialysis Early and Late trial participants were stratified into tertiles according to the estimated GFR measured by Cockcroft and Gault, Modification of Diet in Renal Disease, or Chronic Kidney Disease-Epidemiology Collaboration formula at dialysis commencement. Patient survival was determined using multivariable Cox proportional hazards model regression.Results Only Initiating Dialysis Early and Late trial participants who commenced on dialysis were included in this study (n=768). A total of 275 patients died during the study. After adjustment for age, sex, racial origin, body mass index, diabetes, and cardiovascular disease, no significant differences in survival were observed between estimated GFR tertiles determined by Cockcroft and Gault (lowest tertile adjusted hazard ratio, 1.11; 95% confidence interval, 0.82 to 1.49; middle tertile hazard ratio, 1.29; 95% confidence interval, 0.96 to 1.74; highest tertile reference), Modification of Diet in Renal Disease (lowest tertile hazard ratio, 0.88; 95% confidence interval, 0.63 to 1.24; middle tertile hazard ratio, 1.20; 95% confidence interval, 0.90 to 1.61; highest tertile reference), and Chronic Kidney Disease-Epidemiology Collaboration equations (lowest tertile hazard ratio, 0.93; 95% confidence interval, 0.67 to 1.27; middle tertile hazard ratio, 1.15; 95% confidence interval, 0.86 to 1.54; highest tertile reference).Conclusion Estimated GFR at dialysis commencement was not significantly associated with patient survival, regardless of the formula used. However, a clinically important association cannot be excluded, because observed confidence intervals were wide.

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Effect of Comorbidity on the Increased Mortality Associated With Early Initiation of Dialysis

Cited by 148 publications

References 17 publications

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

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

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

Association between GFR Estimated by Multiple Methods at Dialysis Commencement and Patient Survival

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