When to initiate dialysis --is early start always better?

Liberek, Tomasz; Warzocha, Alicja; Gałgowska, Joanna; Taszner, Katarzyna; Clark, William F.; Rutkowski, Bolesław

doi:10.1093/ndt/gfr181

Cited by 17 publications

(18 citation statements)

References 29 publications

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“…These guidelines suggest that the majority of patients will be symptomatic and need to start dialysis with an eGFR in the 6–9 ml/min/1.73 m 2 range. 4, 67 Similar recommendations for late dialysis start have been suggested in an increasing number of publications. 42, 44 …”

Section: Discussionmentioning

confidence: 74%

“…eGFR is an inaccurate measure of true GFR in patients with stage 5 CKD as it more accurately reflects muscle mass, [ not detectable by BMI. 67 Therefore, a high eGFR in patients with stage 5 CKD largely reflects sarcopenia (leading to low creatinine levels), not higher renal function. 68–70 Sarcopenia is in turn a predictor of poor outcomes in hemodialysis.…”

Section: Biological Contributors To Outcomesmentioning

confidence: 99%

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Timing of dialysis initiation in transplant-naive and failed transplant patients

et al. 2012

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Over the past two decades, most guidelines have advocated early dialysis initiation on the basis of studies showing improved survival in patients starting dialysis early. These recommendations led to an increase in the proportion of patients initiating dialysis with an estimated glomerular filtration rate (eGFR) >10 ml/min/1.73 m2, from 20% in 1996 to 52% in 2008. During this period, patients starting dialysis with an eGFR ≥15 ml/min/1.73 m2 increased from 4% to 17%. However, recent studies have failed to substantiate a benefit of early dialysis initiation and some data have suggested worse outcomes in patients starting dialysis with a higher eGFR. Several reasons for this seemingly paradoxical observation have been suggested, including the fact that patients requiring early dialysis are likely to have more severe symptoms and comorbidities, leading to confounding by indication, as well as biological mechanisms that causally relate early dialysis therapy to adverse outcomes. Dialysis reinitiation in patients with a failing renal allograft encounters similar problems. However, unique factors associated with a failed allograft means that the optimal timing of dialysis initiation in failed transplant patients might differ from that in transplant-naive patients. In this Review, we will discuss studies of dialysis initiation and compare risks and benefits of early versus late dialysis therapy.

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Section: Discussionmentioning

confidence: 74%

Section: Biological Contributors To Outcomesmentioning

confidence: 99%

Timing of dialysis initiation in transplant-naive and failed transplant patients

et al. 2012

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“…The patients who initiated HD at eGFR > 10 mL/min/1.73 m 2 has increased from 12.5% in 1996 to 40.5% in 2012 [21]. But recently, more and more trials and clinical observational studies had questioned this trend [22][23][24][25]. According to the RCT trial IDEAL (Initiating Dialysis Early and Late) studied by Cooper et al [26], the results showed that no significant differences were noted between early (eGFR was 5.0-7.0 mL/min) and late (eGFR was 10.0-15.0 mL/min) starting HD therapy for cardiovascular death or nonfatal cardiovascular, all-cause mortality outcomes, quality of life, and so on.…”

Section: Discussionmentioning

confidence: 99%

Initiation Condition of Hemodialysis Is Independently Associated with All-Cause Mortality in Maintenance Hemodialysis Patients: A Retrospective Study

Wang

Yang²,

Yuan³

et al. 2019

Blood Purif

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Background: Despite the progression of dialysis techniques, the mortality of hemodialysis (HD) patients is still high in China. Here, a retrospective study was performed to investigate the neglected risk factors of all-cause mortality during maintenance HD (MHD). Methods: We investigated 117 MHD patients who died between 2011 and 2016 in the Second Xiangya Hospital of Central South University HD center. In order to analyze the risk factors of 48 months all-cause death, the methods of Kaplan-Meier and Cox regression were used. Results: Multivariate analyses of adjusted age and gender showed that MHD patients with estimated glomerular filtration rate <7 or >10 mL/min/1.73 m² and anemia (hemoglobin <100 g/L) at the initiation of dialysis are independently associated with the higher death risk. Using central venous catheter vascular access, cerebrovascular comorbidities, diabetes, low-flux dialyzer, and dialysis frequency ≤2 times weekly were also the independent risk factors of death within 48 months. Conclusions: This study indicated that the status of HD initiation is a risk factor of long-term survival in MHD patients, which were usually ignored for lacking of nephrology care prior and could potentially be identified and modified to improve the survival prognosis. Video Journal Club “Cappuccino with Claudio Ronco” at https://www.karger.com/Journal/ArticleNews/223997?sponsor=52

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“…Similar data from CKD patients showed controversial results [33]. From the mid-1970s, some observational studies supported the early initiation of dialysis in CKD patients.…”

Section: Discussionmentioning

confidence: 98%

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

2012

American Journal of Kidney Diseases

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Background. Recent observational studies and a controlled trial suggest more favorable outcomes upon later dialysis initiation in chronic kidney disease. The role of estimated glomerular filtration rate (eGFR) in predicting outcome at reinitiation of dialysis in failed kidney transplant recipients is unclear. Methods. Five-year data in a large dialysis organization was linked to the 'Scientific Registry of Transplant Recipients' to identify 747 failed kidney transplant patients with CKD Stage 5, who had restarted dialysis therapy. A propensity score for early (eGFR >10.5 mL/min/1.73m 2 ) versus late reinitiation of dialysis was fit by logistic regression. The mortality hazard ratio (HR) was estimated across tertiles of the fitted score. Results. Patients were 44 ± 14 years old and included 42% women. Male gender {odds ratio (OR), [95% confidence interval (CI)]: 1.82 (1.22-2.73)}, diabetes mellitus [OR: 1.75 (1.14-2.68)] and peripheral vascular disease [OR: 3.55 (1.17-10.77)] were associated with higher odds of early dialysis reinitiation. Each mL/min/1.73m 2 higher eGFR was associated with 6% higher death risk in unadjusted model [HR: 1.06 (1.01-1.11)], and although not significant in fully adjusted models [HR: 1.02 (0.96-1.07)], it was significant in some subgroups including women and younger patients. The death HR of higher eGFR across lowest to highest tertiles of propensity score of early dialysis initiation (corresponding healthiest to sickest patients) were 1.10 (0.98-1.24), 1.00 (0.91-1.10) and 0.99 (0.92-1.07), respectively (P for trend <0.05), indicating a trend toward higher mortality risk with earlier dialysis initiation in the healthiest patients. Conclusions. Earlier return to dialysis therapy in failed kidney transplant patients tends to correlate with worse dialysis survival especially among healthiest and younger patients and women. Additional studies need to verify these findings.

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When to initiate dialysis --is early start always better?

Cited by 17 publications

References 29 publications

Timing of dialysis initiation in transplant-naive and failed transplant patients

Timing of dialysis initiation in transplant-naive and failed transplant patients

Initiation Condition of Hemodialysis Is Independently Associated with All-Cause Mortality in Maintenance Hemodialysis Patients: A Retrospective Study

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

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