No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease

Abstract

Abstract. Evans M., Tettamanti G., Nyrén O., Bellocco R., Fored C.M., Elinder C.-G. (Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden; University of Milano-Bicocca, Milan, Italy; Karolinska Institutet, Stockholm, Sweden) No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. J Intern Med 2011; 269: 289-298.Objective. To investigate how the timing of dialysis initiation is associated with mortality.Design. Population-based, prospective, observational cohort study.Setting. Clinical laboratories (n = 69) provided information on all patients in Sweden whose serum creatinine level for the first time and exceeded 3.4 mg dL )1 (men) or 2.8 mg dL )1 (women) between 20 May 1996 and 31 May 1998.Subjects. All patients (n = 901), aged 18-74 years, in whom the cause of serum creatinine elevation was chronic kidney disease, were included in the study; participants were interviewed and followed for 5-7 years. Conclusion. We found no survival benefit from early initiation of dialysis.

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

“…The main concern of observational studies including ours is the difference between the clinical characteristics and dialysis indications of the early and late initiation groups. Patients with early dialysis initiation were more likely to be men and diabetic, have severe heart failure or coronary heart disease, are less likely to have glomerulonephritis or polycystic kidney disease and have lower serum albumin level and more comorbidity and in summary, they are sicker patients [5,9,14,17]. In our DAGL patients, we found similar results.…”

“…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].…”

“…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].…”

“…While 25-30% of prevalent ESRD patients have clinical depression [8], Watnick et al [17] observed that among 123 incident dialysis patients screened within 10 days of starting dialysis, 44% had Beck Depression Inventory (BDI) scores above the validated cutoff for clinical depression. Two recent studies have begun to focus their attention on the association of depressive symptoms and mortality in chronic kidney disease and incident ESRD patients [13,14].…”

Clinical Decision Making in a Patient with Stage 5 CKD—Is eGFR Good Enough?

“…Several retrospective studies suggest that dialysis initiation with eGFR,5 ml/min per 1.73 m 2 is associated with lower mortality than higher eGFR dialysis starts (69)(70)(71)(72), although such studies are limited by survival bias, confounding by indication, and other issues. At least one prospective cohort study, however, found a significantly higher mortality (hazard ratio, 4.65; 95% confidence interval, 2.28-9.49) among patients not yet on dialysis with eGFR,7.5 ml/ min per 1.73 m 2 (73). A recent Canadian clinical practice guideline recommends deferring dialysis until the eGFR is 6 ml/min per 1.73 m 2 (74), whereas another indicates that clinical indications for starting dialysis "often but not invariably" occur when eGFR is 5-10 ml/min per 1.73 m 2 (2).…”