When to start dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study

Tattersall, James; Dekker, Friedo W.; Heimbürger, O.; Jager, Kitty J.; Lameire, Norbert; Lindley, Elizabeth; Biesen, Wim Van; Vanholder, Raymond; Zoccali, Carmine

doi:10.1093/ndt/gfr168

Cited by 146 publications

(126 citation statements)

References 23 publications

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“…12,13 A recently updated position statement argues that eGFR equations are not appropriate to determine the need for starting RRT because they are not validated in lower ranges of GFR (Ͻ30 mL/min/1.73 m 2 ), in other words, just before initiating dialysis therapy. [14][15][16] Possibly, nephrologists do not use the recommended method because in their decision making, they consider the exact level of excretory kidney function less important than symptoms and social conditions and therefore may attribute less importance to knowing its exact value.…”

Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofmentioning

confidence: 99%

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Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Luijtgaarden

Noordzij

Tomson

et al. 2012

American Journal of Kidney Diseases

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Background:Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT.Study Design: European web-based survey. Predictors: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors.Setting & Participants: Nephrologists from 11 European countries. Outcomes & Measurements:We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT.Results: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m 2 . Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from highversus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m 2 ) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m 2 ).Limitations: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists.Conclusions: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making. Am J Kidney Dis. 60 (6) P atients with end-stage renal disease (ESRD) receive renal replacement therapy (RRT) to improve their survival and quality of life. The decision of when to start RRT is likely to be guided by the level and rate of decrease in residual kidney function and the clinical condition of the patient. Whereas RRT might be life-saving in certain conditions, dialysis also is unphysiologic and may have life-threatening complications. It carries a significant burden for patients and consumes substantial health care resources. 1 Many studies evaluating associations between the timing of the start of RRT and survival were limited in that they considered only serum creatinine level, which is decreased in pa...

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Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofmentioning

confidence: 99%

“…Since the previous survey on this matter in 2000, several debates and cohort studies were published suggesting that starting RRT at higher eGFRs may be harmful. [2][3][4][5][6]8,12,14,18,19,28 Therefore, we needed an update regarding current opinions on this topic.…”

Section: Most Frequently Mentioned Reasons As Basis For Opinion (% Ofmentioning

confidence: 99%

Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Luijtgaarden

Noordzij

Tomson

et al. 2012

American Journal of Kidney Diseases

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“…As reviewed recently (27), the association does not prove that starting dialysis with a higher eGFR causes the increased mortality, although this is one possible explanation. In that case, it could be seen as competing risks between the dialysis process itself in the patients with early starts versus the risks of uremic toxicity over the same period of time in the later-start cohort.…”

Section: Optimal Timing Of the Start Of Rrt: Was It Left Too Late?mentioning

confidence: 93%

Timing of Initiation of RRT and Modality Selection

Bargman¹

2015

Clinical Journal of the American Society of Nephrology

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There is no shortage of studies and registry data examining outcomes of patients on dialysis and those with a renal transplant. However, recently, there has been a greater focus on the events leading up to the institution of kidney replacement therapy. Associative data suggest that early and consistent predialysis care leads to better outcomes, including greater take-on to home-based therapy, diminished use of tunneled venous hemodialysis catheters, and improved early and even late survival. What transpires during predialysis visits is also important. Simple dissemination of facts to the unprepared patient is unlikely to be effective in moving the patient and family along in the process of the series of choices that have to be made around therapy. A more flexible and circumspect approach is needed, including recognizing when the patient is or is not ready for change. There seems to be no optimal timing of dialysis start that can be applied to the ESRD population as a whole, although the pendulum seems to be swinging back toward symptom-based rather than eGFR-based starts.

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“…In Europe, guidelines from 2002 recommend that dialysis should be started when the GFR is between 8 and 10 mL/min/ 1.73m 2 [3]. However, the latter guideline has recently been revised and suggests that 'the majority of patients will be symptomatic and need to start dialysis with GFR in the range of 9-6 mL/min/1.73m 2 ' [4]. Data from the US Renal Data System (USRDS) between 1996 and 2008 showed that the proportion of patients initiating hemodialysis (HD) with an estimated GFR (eGFR) >10 mL/min/ 1.73m 2 increased from 20 to 52% and those with a starting eGFR of ≥15 mL/min/1.73m 2 increased from 4 to 17% [5,6].…”

Section: Introductionmentioning

confidence: 99%

“…The impact of psychosocial factors, including depressive symptoms, on the outcomes of dialysis patients has been emphasized in several studies [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. In the Dialysis Outcomes and Practice Patterns Study (DOPPS), the presence of depressive symptoms, as assessed by the Center for Epidemiologic Studies Depression Scale (CES-D) or by the two depression questions on the Medical Outcomes Study Short Form-36 (SF-36), was strongly associated with mortality and hospitalizations in a large cohort of prevalent hemodialysis (HD) patients maintained on dialysis for a median time of >2.4 years [4].…”

Section: Introductionmentioning

confidence: 99%

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 start dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study

Cited by 146 publications

References 23 publications

Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Factors Influencing the Decision to Start Renal Replacement Therapy: Results of a Survey Among European Nephrologists

Timing of Initiation of RRT and Modality Selection

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

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