Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation

Abstract

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.

Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway?

“…A disease-specific approach to ACP may hold particular promise for patients with advanced kidney disease. Dialysis is often initiated in the acute setting and is among the intensive procedures that may be listed in an advance directive (60,61). Indeed, many of the providers interviewed for this study tended to default to discussing dialysis initiation and/or discontinuation when asked about ACP.…”

Treatment frequency and mortality among incident hemodialysis patients in the United States comparing incremental with standard and more frequent dialysis

“…Nearly half , and 90% are HD patients. 1,22 In observational studies, the presence of RKF in dialysis patients has been associated with improved quality of life, lower concentration of middle molecules, such as b 2 -microglobulin, 23 decreased inflammation, and lower risk of death. 17,18,24 These benefits are thought to be mediated by continuous and efficient clearance of middle molecules and protein-bound solutes, better fluid management, more endogenous vitamin D and erythropoietin production, and less inflammation.…”

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

“…First, data were collected from the ESRD Medical Evidence report (CMS-2728), which may contain inaccurate information regarding medical history (48) and predialysis care (49). Second, there may be residual confounding by unmeasured factors that influence clinical decision making, especially because there are often systematic reasons that veterans initiate dialysis outside the VA, such as the urgency of their presentation (36). Future studies might address this limitation by collecting detailed information regarding the clinical context of dialysis initiation, including the trajectory of renal function before initiation (50).…”