Initiation of Dialysis at Higher Levels of Estimated GFR and Subsequent Withdrawal

O’Hare, Ann M.; Vig, Elizabeth K.; Hebert, Paul L.

doi:10.2215/cjn.12841212

Cited by 7 publications

(5 citation statements)

References 28 publications

(27 reference statements)

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“…The growth in the prevalent dialysis population has been driven mainly by increases in longevity. 1,2 Consequently, appropriate use of conservative care for end-stage renal disease (ESRD), [3][4][5][6] palliative care in nephrology, [7][8][9][10][11][12] and elective withdrawal from dialysis [13][14][15][16][17][18][19] are issues currently engaging the nephrology community.…”

Section: Introductionmentioning

confidence: 99%

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Wetmore

Roetker

Gilbertson

et al. 2019

Hemodialysis International

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Introduction: Whether and how factors associated with elective hemodialysis withdrawal differ from those associated with non‐withdrawal death soon after maintenance hemodialysis initiation have not been well studied. Methods: A retrospective cohort analysis was performed using USRDS data from 2011 to 2014. Patients were randomly categorized 2:1 into training and validation samples. Elective withdrawal deaths were identified using the Death Notification form. Multinomial logistic regression was used to fit a prediction model for three outcome categories (withdrawal, non‐withdrawal death, survival at 6 months) as a function of demographic, comorbidity, and functional status. Findings: The training sample comprised 80,284 hemodialysis patients. Mean age was 71.7 ± 11.4 years, 44.9% were female, 72.9% were white, and 22.8% were black. Within 6 months, 19.1% died, of whom 2099 (2.6%) withdrew and 13,223 (16.5%) died of a non‐withdrawal cause; 13.7% of all deaths were withdrawals. Baseline characteristics and event rates were similar among the 40,142 patients in the validation sample. The model was calibrated adequately and could discriminate moderately well between withdrawal and survival (area under ROC curve [AUC]: 0.77) and between non‐withdrawal death and survival (AUC: 0.73). However, discrimination between withdrawal and non‐withdrawal death was relatively low (AUC: 0.62). Older age and white, compared with non‐white, race were each associated with greater odds of death, and these associations were stronger for withdrawal than for non‐withdrawal death. Discussion: Advanced age and white, as opposed to black, race were most strongly associated with early elective hemodialysis withdrawal compared with non‐withdrawal death. However, it is difficult to differentiate between patients who will experience early withdrawal vs. non‐withdrawal death, as many factors are similarly associated with both outcomes.

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Section: Introductionmentioning

confidence: 99%

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Wetmore

Roetker

Gilbertson

et al. 2019

Hemodialysis International

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“…1,3,6,7 Arguing against this possibility, a recent Canadian study found no evidence that widespread eGFR reporting has led to earlier dialysis initiation. 7 A second hypothesis is that there may have been changes over time in indications for dialysis not captured in available data sources, [8][9][10] although stable levels of health care intensity around the time of dialysis initiation among Medicare beneficiaries do not seem to support this possibility. 11 A third hypothesis is that trends in eGFR at initiation may reflect a progressive liberalization of guideline criteria for dialysis initiation from the late 1990s onward to promote initiation at higher levels of eGFR, especially among patients with relatively soft uremic signs and symptoms.…”

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confidence: 99%

Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation

O’Hare

Wong²,

Yu³

et al. 2015

Journal of the American Society of Nephrology

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Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.

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“…Whether the continuous upward trend of eGFR at dialysis initiation seen in the 1990s and early 2000s in the U.S. truly represented a liberalization of dialysis practices as some have suggested 55 , or whether more likely a combination of myriad contributors was responsible, what is clear is that 2010 marked a key inflection point (Figure 1). From 2009 to 2010, the mean eGFR at dialysis initiation in the U.S. did not rise, and instead stayed steady at 11.2 ml/min/1.73m 2 .…”

Section: Trends In the Timing Of Dialysis Initiation Since Idealmentioning

confidence: 99%

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

Rivara

Mehrotra

2017

Seminars in Nephrology

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The optimal timing of initiation of maintenance dialysis in patients with end stage renal disease (ESRD) is currently unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease (CKD) through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, the only randomized trial to have tested the impact of dialysis initiation at two different levels of kidney function on outcomes, demonstrated no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high risk transition period from CKD to ESRD. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 year since publication of the results from IDEAL. Complementary strategies to the use of eGFR to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes are also considered.

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Initiation of Dialysis at Higher Levels of Estimated GFR and Subsequent Withdrawal

Cited by 7 publications

References 28 publications

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Early withdrawal and non‐withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis

Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

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