Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate

Abstract

Background Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. Methods In the ‘Peridialysis’ study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. Results SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. Conclusions SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

First-year mortality in incident dialysis patients: results of the Peridialysis study

“…In a previous study of factors associated with suboptimal DI in the same population, we found that late referral and rapid eGFR loss were independent predictors of suboptimal DI and that patients with suboptimal DI were more uremic at DI as judged by eGFR, had more electrolyte disturbances over and above what would be expected from the level of eGFR, and had a higher CRP [43] (ref. CKJ suboptimal DI article 2020).…”

“…In our study, factors associated with one-year mortality after DI among 1580 incident dialysis patients participating in the Peridialysis study [42][43][44] were investigated in three models that -in addition to age, sex, comorbidity, plasma albumin and renal diagnoses -included data on predialysis course ("predialysis" model), biochemical parameters ("biochemical" model), and primary clinical cause of DI ("clinical" model). A fourth "combined model" that included all statistically signi cant factors in the three separate models (Table 2), showed that only high CRP, physical contraindications to PD, and suboptimal DI, were associated with increased risk of death within one year after DI, independent of high age, low serum albumin and comorbidity, whereas eGFR at DI was not related to mortality.…”

“…This observational multinational multi-centre prospective study comprised 1619 ESRD patients who started dialysis over a 3-year period at 15 nephrology departments from seven Nordic and Baltic countries. The methodology of the "Peridialysis" project has been previously described [42][43][44]. All centers delivered both PD and in-centre HD; some also home-HD; all had a developed and working multidisciplinary pre-dialysis care team structure with nephrologists and experienced nurses; 13/15 centers also had access to a dietician, and 5/15 had access to social worker.…”

“…Details of these have already been published. [42][43][44]. For the purposes of the present study, clinical symptoms were registered if they were the primary cause of DI.…”

“…The "Peridialysis" study is a prospective, multi-center, international prospective observational study of the relevance of pre-dialysis renal care on causes and timing of dialysis initiation, modality choice and clinical outcomes [42][43][44] . The present study focuses on the relationships of the predialysis course, circumstances of DI, and choice of modality on short-term (1-year) mortality after DI.…”