Timing of Initiation of Uremia Therapy and Survival in Patients with Progressive Renal Disease

Abstract

We conducted a prospective cohort study to detect any relationships between specific clinical features and laboratory indices at initiation of hemodialysis and long-term survival. One hundred and thirty-nine consecutive patients with chronic renal failure hospitalized to start maintenance hemodialysis between January 1990 and December 1994 were enrolled, and follow-up was completed through December 1995. At baseline, subjects were assigned to one of five groups based on their major indication for initiation of hemodialysis. The indications were: (a) nausea and vomiting; (b) severe weakness; (c) no major symptom (dialysis started because of ‘high’ serum creatinine and blood urea nitrogen concentrations); (d) volume overload, and (e) miscellaneous (angina, pericarditis, seizure, pruritus, and hyperkalemia). Blood urea nitrogen, serum creatinine and serum albumin concentrations were measured once before the first dialysis. The main outcome measure was death. The 139 study subjects included 77 women and 62 men comprising 116 Blacks (83%), 15 Hispanics (11%), and 8 Whites (6%) of mean age 54 ± 15 years. Mean length of follow-up was 39 months. At baseline, mean blood urea nitrogen concentration was 121 ± 38 mg/dl, mean serum creatinine concentration was 12.6 ± 5.2 mg/dl, and mean serum albumin concentration was 3.5 ± 0.62 g/dl. Forty-two subjects (30%) died during follow-up. Cox regression analysis showed that there was no significant association between mortality and any of the indicators evaluated (indication for initiation of dialysis (p = 0.2), serum creatinine concentration (<10 vs. ≥10 mg/dl) (p = 0.8), blood ure nitrogen concentration (<100 vs. ≥100 mg/dl) (p = 0.68) and serum albumin concentration (<4 vs. ≥4 g/dl) (p = 0.62). All analyses included adjustment for age and diabetes.We conclude that in patients with chronic renal failure, the clinical features and laboratory indices used as guidelines for initiation of renal replacement therapy do not correlate with survival. Objective parameters that will permit initiation of dialysis at a time that will maximize survival in patients with chronic renal failure are needed.

Management of the Hemodialysis Patient: A European Perspective

“…Nephrologists initiate dialysis treatment in most cases on the basis of the observed evolution of uremic symptoms and laboratory investigations, such as plasma creatinine concentration and creatinine clearance [32]. However, the evolution of uremic symptoms varies from patient to patient [33], so there is substantial variation in timing of dialysis initiation [34][35][36]. The study by Obrador et al [36] revealed that there is wide variation in renal function at the initiation of dialysis in the US ESRD population, and a substantial fraction of patients (23%) start dialysis at levels of predicted glomerular filtration rate (GFR) !5 ml/ min.…”

Is There a Role for Protein Restriction in the Treatment of Chronic Renal Failure?

“…Thus patients started earlier are liable to be those with more comorbid conditions, for example. One such analysis was reported by Ifudu et al [27] (fig. 9).…”

“…No difference is seen (note that this was not a randomized study). Reprinted by permission from Ifudu et al [27].…”

Another Call for Timely Initiation of Dialysis

“…Others and we have argued that the current practice of initiation of dialysis is flawed [1][2][3][4][5] and the study by Ifudu published last year supports this belief [51]. Based upon the similarity in the relationship of DPI to small solute clearances in predialysis patients and patients on continuous ambulatory peritoneal dialysis (CAPD) [33], the PD subcommittee of the NKF-DOQI suggested that adequacy targets for CAPD be used as the renal function at which dialysis should be instituted i.e., when the renal function declines to below a weekly renal Kt/V urea of 2.0 [9].…”