Estimated GFR Reporting Influences Recommendations for Dialysis Initiation

Brimble, K. Scott; Mehrotra, Rajnish; Hawley, Carmel M.; Castledine, Clare; McDonald, S.; Levidiotis, Vicki; Gangji, Azim S.; Treleaven, Darin; Margetts, Peter J.; Walsh, Michael

doi:10.1681/asn.2013010035

Cited by 7 publications

(5 citation statements)

References 20 publications

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“…Because Canada does not have for-profit dialysis facilities, our study was unable to examine the question of whether initiation of dialysis varies on the basis of the profit status of the dialysis unit. Finally, many provinces began regional eGFR reporting during the study period, and on the basis of recent survey results, eGFR reporting may influence the timing of dialysis initiation (44).…”

Section: Discussionmentioning

confidence: 99%

Variation in the Level of eGFR at Dialysis Initiation across Dialysis Facilities and Geographic Regions

Sood

Manns

Dart

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives The relative influence of facilities and regions on the timing of dialysis initiation remains unknown. The purpose of the study is to determine the variation in eGFR at dialysis initiation across dialysis facilities and geographic regions in Canada after accounting for patient-level factors (case mix).Design, setting, participants, & measurements In total, 33,263 dialysis patients with an eGFR measure at dialysis initiation between January of 2001 and December of 2010 representing 63 dialysis facilities and 14 geographic regions were included in the study. Multilevel models and intraclass correlation coefficients were used to evaluate the variation in timing of dialysis initiation by eGFR at the patient, facility, and geographic levels.Results The proportion initiating dialysis with an eGFR$10.5 ml/min per 1.73 m 2 was 35.3%, varying from 20.1% to 57.2% across geographic regions and from 10% to 67% across facilities. In an unadjusted, intercept-only linear model, 90.7%, 6.6%, and 2.7% of the explained variability were attributable to patient, facility, and geography, respectively. After adjustment for patient and facility factors, 96.9% of the explained variability was attributable to patient case mix, 3.1% was attributable to the facility, and 0.0% was attributable to the geographic region. These findings were consistent when the eGFR was categorized as a binary variable ($10.5 ml/min per 1.73 m 2 ) or in an analysis limited to patients with .3 months of predialysis care.Conclusions Patient characteristics accounted for the majority of the explained variation regarding the eGFR at the initiation of dialysis. There was a small amount of variation at the facility level and no variation among geographic regions that was independent of patient-and facility-level factors.

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Section: Discussionmentioning

confidence: 99%

Variation in the Level of eGFR at Dialysis Initiation across Dialysis Facilities and Geographic Regions

Sood

Manns

Dart

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…The survey found that participants randomized to scenarios reporting the eGFR modestly increased the likelihood of initiating dialysis. 22 There was no difference in responses from participants among the different countries (Canada included), and therefore, it is plausible that automated eGFR reporting might sway physicians to recommend dialysis earlier and more strongly, irrespective of symptom severity. Reasons for discrepant findings between the two studies may include limited generalizability in the survey study (response rate=19%), a relatively small number of respondents from Canada (n=119), and actual practice patterns differing from theoretical scenarios.…”

Section: Discussionmentioning

confidence: 95%

The Association of eGFR Reporting with the Timing of Dialysis Initiation

Sood

Komenda

Rigatto

et al. 2014

Journal of the American Society of Nephrology

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Automated reporting of eGFR by laboratories has been widely implemented during the last decade. Over this same period, a steady increase in eGFR at dialysis initiation has been reported. This study examined trends in eGFR at dialysis initiation over time among incident dialysis patient populations before and after eGFR reporting. All patients who initiated dialysis between January of 2001 and December of 2010 in four Canadian provinces that implemented province-wide automated eGFR reporting and had an eGFR measure at dialysis initiation were included in the study (n=22,208). The primary outcome was change over time in eGFR among patients at dialysis initiation. An interrupted time series and adjusted multilevel regression models were used to determine the differences in eGFR at dialysis initiation before and after reporting. We observed a linear increase in the mean eGFR at dialysis initiation from 9.1 to 10.8 ml/min per m 2 during the study period. There was no change in the trajectory of the eGFR at dialysis initiation before or after eGFR reporting in crude or adjusted models accounting for case mix and facility characteristics. These findings were consistent among age and sex strata and when the proportions of patients with an eGFR$10.5 or $12 ml/min per m 2 were examined. In conclusion, automated laboratory-based eGFR reporting did not influence eGFR at dialysis initiation among incident dialysis patient populations. Concerns that widespread eGFR reporting leads to earlier dialysis initiation are not supported by this study.

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“…In a recent study, 822 physicians from five countries were randomly presented with case vignettes of patients with advanced chronic kidney disease with results of serum creatinine, but with/without an eGFR value . Physicians presented with an eGFR value were more likely to recommend initiation of dialysis at a higher eGFR than those without . Notwithstanding this study, it is difficult to estimate the overall contribution of automated reporting of eGFR by clinical laboratories to the trend of higher level of renal function at the time of initiation of dialysis.…”

Section: Secular Trends In Renal Function At the Time Of Initiation Omentioning

confidence: 96%

“…In contrast to this, there is at least some evidence that automated reporting of eGFR by clinical laboratories each time serum creatinine is measured may have contributed to recommending dialysis at higher levels of renal function. In a recent study, 822 physicians from five countries were randomly presented with case vignettes of patients with advanced chronic kidney disease with results of serum creatinine, but with/without an eGFR value . Physicians presented with an eGFR value were more likely to recommend initiation of dialysis at a higher eGFR than those without .…”

Section: Secular Trends In Renal Function At the Time Of Initiation Omentioning

confidence: 99%

Initiation of Dialysis Should be Timely: Neither Early Nor Late

Mehrotra

Rivara

Himmelfarb

2013

Seminars in Dialysis

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Over the last decade, individuals with end-stage renal disease (ESRD) in the United States are starting maintenance dialysis therapy at progressively higher estimated glomerular filtration rate (eGFR). Moreover, several observational studies have demonstrated an association of a higher risk of death with higher serum creatinine-based estimates of GFR at the time of initiation of dialysis. In contrast, studies in which renal function has been measured by timed urinary collection show either a lower risk of death or no significant association with higher GFR at the time of initiation of dialysis. There are numerous potential sources of bias in such observational studies, particularly in those that use serum creatinine-based eGFR. The only randomized controlled clinical trial to have examined this question did not demonstrate either benefit or harm with initiation of dialysis at higher level of renal function. Thus, the data to date suggest that eGFR should not be the sole consideration when assessing the need for initiating maintenance dialysis in patients with advanced chronic kidney disease. Given the high societal costs of starting renal replacement therapy earlier in the course of the disease, these considerations also suggest that dialysis can be safely be postponed in otherwise asymptomatic individuals with advanced chronic kidney disease. By the same token, dialysis should not be denied to individuals who could clearly benefit from renal replacement therapy simply because the GFR is too high (viz., volume overload, refractory hyperkalemia). Finally, there is a compelling need to reexamine the symptoms that could be attributed to uremia and clearly improve upon initiation of dialysis to better guide clinical decision-making.

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Estimated GFR Reporting Influences Recommendations for Dialysis Initiation

Cited by 7 publications

References 20 publications

Variation in the Level of eGFR at Dialysis Initiation across Dialysis Facilities and Geographic Regions

Variation in the Level of eGFR at Dialysis Initiation across Dialysis Facilities and Geographic Regions

The Association of eGFR Reporting with the Timing of Dialysis Initiation

Initiation of Dialysis Should be Timely: Neither Early Nor Late

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