Suboptimal initiation of dialysis with and without early referral to a nephrologist

Mendelssohn, David C.; Curtis, Bryan; Yeates, Karen; Langlois, Simon; MacRae, Jennifer M.; Semeniuk, Lisa M.; Camacho, Fernando; McFarlane, Philip A.

doi:10.1093/ndt/gfq843

Cited by 137 publications

(163 citation statements)

References 29 publications

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“…These factors are especially important for older adults, because they suffer a greater burden of comorbid illness compared with their younger counterparts, 30 often progress to ESRD after episodes of AKI, 31 and may be more likely than younger persons to initiate dialysis under suboptimal circumstances (e.g., emergent inpatient settings). 32 In our study, we identified previously unreported independent risk factors for early dialysis initiation (CHF hospital admissions and all-cause hospitalization days in the 6 months preceding initiation) and found that the consideration of these factors and other predialysis factors served to attenuate, at least somewhat, the risk of poor outcomes associated with early initiation.…”

Section: Discussionmentioning

confidence: 62%

Predialysis Health, Dialysis Timing, and Outcomes among Older United States Adults

Crews

Scialla

Liu

et al. 2014

Journal of the American Society of Nephrology

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Studies of dialysis initiation timing have not accounted for predialysis clinical factors that could impact postdialysis outcomes. We examined the association of predialysis health with timing of dialysis initiation in older adult patients in the United States and contrasted morbidity and mortality outcomes among patients with early [estimated GFR (eGFR)$10 ml/min per 1.73 m 2 ] versus later (eGFR,10 ml/min per 1.73 m 2 ) initiation. We included all patients from the US Renal Data System who initiated dialysis between 2006 and 2008, were $67 years old, and had $2 years of prior Medicare coverage (n=84,654). We calculated patients' propensity to initiate dialysis early and matched patients by propensity scores. Cox models were used to compare risks of mortality and hospitalization among initiation groups. The majority (58%) of patients initiated dialysis early. Early initiators were more likely to have had AKI, multiple congestive heart failure admissions, and other hospitalizations preceding initiation. Among propensity-matched patients (n=61,930), early initiation associated with greater allcause (hazard ratio [HR], 1.11; 95% confidence interval [95% CI], 1.08 to 1.14), cardiovascular (CV; HR, 1.13; 95% CI, 1.09 to 1.17), and infectious (HR, 1.13; 95% CI, 1.06 to 1.22) mortality and greater all-cause (HR, 1.03; 95% CI, 1.01 to 1.05) and infectious (HR, 1.10; 95% CI, 1.07 to 1.13) hospitalizations. There was no difference in CV hospitalizations. Among these older adults, early dialysis initiation associates with greater mortality and hospitalizations, even after accounting for predialysis clinical factors. These findings do not support the common practice of early dialysis initiation in the United States. 25: 370-379, 201425: 370-379, . doi: 10.1681 There has been a global trend toward initiation of dialysis at higher levels of kidney function, particularly among older adults. 1 This trend may have been driven, in part, by clinicians' beliefs that earlier initiation could better preserve patients' nutritional status, thereby decreasing their risks of morbidity and mortality. [2][3][4] However, recent studies have questioned the ability of dialysis to prevent J Am Soc Nephrol

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Section: Discussionmentioning

confidence: 62%

Predialysis Health, Dialysis Timing, and Outcomes among Older United States Adults

Crews

Scialla

Liu

et al. 2014

Journal of the American Society of Nephrology

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“…Patients treated with HHD tend to be younger, have less comorbidity, and have different etiologies of primary kidney disease (8,18,27,39). They are also less likely to have late nephrology referral, another factor associated with poor clinical outcomes (50)(51)(52). Although the previous factors can be addressed by statistical adjustment, other components, such as commitment to dialysis treatment, education level, psychologic skills, social support, and economic status, are much harder to account for, especially in a registry analysis.…”

Section: Discussionmentioning

confidence: 99%

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

Nadeau‐Fredette

Hawley

Pascoe

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Home dialysis is often recognized as a first-choice therapy for patients initiating dialysis. However, studies comparing clinical outcomes between peritoneal dialysis and home hemodialysis have been very limited. Design, setting, participants, & measurements This Australia and New Zealand Dialysis and TransplantationRegistry study assessed all Australian and New Zealand adult patients receiving home dialysis on day 90 after initiation of RRT between 2000 and 2012. The primary outcome was overall survival. The secondary outcomes were on-treatment survival, patient and technique survival, and death-censored technique survival. All results were adjusted with three prespecified models: multivariable Cox proportional hazards model (main model), propensity score quintile-stratified model, and propensity score-matched model. ResultsThe study included 10,710 patients on incident peritoneal dialysis and 706 patients on incident home hemodialysis. Treatment with home hemodialysis was associated with better patient survival than treatment with peritoneal dialysis (5-year survival: 85% versus 44%, respectively; log-rank P,0.001). Using multivariable Cox proportional hazards analysis, home hemodialysis was associated with superior patient survival (hazard ratio for overall death, 0.47; 95% confidence interval, 0.38 to 0.59) as well as better on-treatment survival (hazard ratio for on-treatment death, 0.34; 95% confidence interval, 0.26 to 0.45), composite patient and technique survival (hazard ratio for death or technique failure, 0.34; 95% confidence interval, 0.29 to 0.40), and death-censored technique survival (hazard ratio for technique failure, 0.34; 95% confidence interval, 0.28 to 0.41). Similar results were obtained with the propensity score models as well as sensitivity analyses using competing risks models and different definitions for technique failure and lag period after modality switch, during which events were attributed to the initial modality.Conclusions Home hemodialysis was associated with superior patient and technique survival compared with peritoneal dialysis.

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“…The sub-optimal initiation, as defined by Mendelssohn et al [1], is not a covariate recorded in the French Language Peritoneal Dialysis Registry. A period of <30 days on HD before PD initiation was considered as a proxy of the sub-optimal dialysis start.…”

Section: Definition Of the Variablesmentioning

confidence: 99%

“…The term sub-optimal dialysis initiation was recently proposed to describe the treatment of end-stage renal disease patients who started dialysis while hospitalized and/or through a dialysis catheter and/or not on their dialysis modality of choice [1]. The sub-optimal dialysis initiation is a common situation in patients starting renal replacement therapy even for those patients followed regularly in the pre-dialysis clinic [2].…”

Section: Introductionmentioning

confidence: 99%

“…The sub-optimal dialysis initiation is a common situation in patients starting renal replacement therapy even for those patients followed regularly in the pre-dialysis clinic [2]. Late referral to a nephrologist is associated with sub-optimal dialysis initiation [1]. Nevertheless, urgent dialysis start can occur in a well-prepared patient hospitalized for an acute illness [3].…”

Section: Introductionmentioning

confidence: 99%

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Outcome of the sub-optimal dialysis starter on peritoneal dialysis. Report from the French Language Peritoneal Dialysis Registry (RDPLF)

Lobbedez

Verger

Ryckelynck

et al. 2013

Nephrology Dialysis Transplantation

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A B S T R AC TBackground. This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks. Methods. This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of <30 days on HD before PD initiation. Results. Among 8527 patients, there were 568 patients who started PD after <30 days on HD. There were 6562 events: 3078 deaths, 2136 transfers to HD, 1348 renal transplantations. When using a Fine and Gray model, sub-optimal dialysis start, early peritonitis and transplant failure were associated with a higher sub-distribution relative hazard of technique failure. There was no association between the suboptimal dialysis start and the sub-distribution hazard of death or transplantation. In the multivariate analysis using a Fine and Gray regression model, the sub-optimal dialysis start was not associated with a higher sub distribution relative hazard of peritonitis. Conclusions. Sub-optimal dialysis initiation is neither associated with a higher risk of death nor with a lower risk of renal transplantation. Sub-optimal PD patients had a higher risk of transfer to HD.

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Suboptimal initiation of dialysis with and without early referral to a nephrologist

Abstract: Suboptimal initiation of dialysis is common in patients referred early or late. The benefits of early referral are lost if dialysis is initiated suboptimally. There is a need to identify factors that lead to suboptimal initiation despite early referral.

Cited by 137 publications

References 29 publications

Predialysis Health, Dialysis Timing, and Outcomes among Older United States Adults

Predialysis Health, Dialysis Timing, and Outcomes among Older United States Adults

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

Outcome of the sub-optimal dialysis starter on peritoneal dialysis. Report from the French Language Peritoneal Dialysis Registry (RDPLF)

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