Why do physicians prescribe dialysis? A prospective questionnaire study

Abstract

IntroductionThe incidence of unplanned dialysis initiation (DI) with consequent increased comorbidity, mortality and reduced modality choice remains high, but the optimal timing of dialysis initiation (DI) remains controversial, and there is a lack of studies of specific reasons for DI. We investigated why and when physicians prescribe dialysis and hypothesized that physician motivation for DI is an independent factor which may have clinical consequences.MethodsIn the Peridialysis study, an ongoing multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis, physicians in 11 hospitals were asked to describe their primary, secondary and further reasons for prescribing DI. The stated reasons for DI were analyzed in relation to clinical and biochemical data at DI, and characteristics of physicians.ResultsIn 446 patients (median age 67 years; 38% females; diabetes 25.6%), DI was prescribed by 84 doctors who stated 23 different primary reasons for DI. The primary indication was clinical in 63% and biochemical in 37%; 23% started for life-threatening conditions. Reduced renal function accounted for only 19% of primary reasons for DI but was a primary or contributing reason in 69%. The eGFR at DI was 7.2 ±3.4 ml/min/1.73 m2, but varied according to comorbidity and cause of DI. Patients with cachexia, anorexia and pulmonary stasis (34% with heart failure) had the highest eGFR (8.2–9.8 ml/min/1.73 m2), and those with edema, “low GFR”, and acidosis, the lowest (4.6–6.1 ml/min/1.73 m2). Patients with multiple comorbidity including diabetes started at a high eGFR (8.7 ml/min/1.73 m2). Physician experience played a role in dialysis prescription. Non-specialists were more likely to prescribe dialysis for life-threatening conditions, while older and more experienced physicians were more likely to start dialysis for clinical reasons, and at a lower eGFR. Female doctors started dialysis at a higher eGFR than males (8.0 vs. 7.1 ml/min/1.73 m2).ConclusionsDI was prescribed mainly based on clinical reasons in accordance with current recommendations while low renal function accounted for only 19% of primary reasons for DI. There are considerable differences in physicians´ stated motivations for DI, related to their age, clinical experience and interpretation of biochemical variables. These differences may be an independent factor in the clinical treatment of patients, with consequences for the risk of unplanned DI.

Prognostic implications of predialysis patients’ symptoms in peritoneal dialysis patients

“…Anorexia (58%) was the most common symptom in the present cohort, followed by insomnia (32.7%), fatigue (27.6%), syndromes of heart failure (27.6%), and nausea (20.5%). These results are different from the previous study that the most common symptoms were fatigue (44%), nausea (24%), and anorexia (22%) at the dialysis initiation [ 6 ]. Nausea and anorexia are major uremic symptoms and a frequent indication for starting dialysis [ 14 ].…”

“…To identify the most meaningful symptoms and accordingly, to decide the right timing of dialysis initiation is still a challenge for the nephrologists. However, there are very few studies reporting spectrum of predialysis patients’ symptoms in peritoneal dialysis (PD) patients and little is known about the burden of symptoms of predialysis patients especially PD patients [ 6 ]. In addition, unlike many predialysis indictors linking to the patients outcomes, such as GFR, serum albumin [ 7 , 8 ], calcium [ 9 , 10 ], body mass index [ 11 ], and comorbidities [ 8 , 12 ], the potential predictive value of patients’ predialysis symptoms have not been fully elucidated.…”

Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…[32][33][34][35] Generally, current guidelines do not support preemptive dialysis initiation, [36][37][38] although an exception is the 2011 European guideline. 39 While the optimal timing for starting dialysis is unclear, and in clinical practice the reasons for initiating dialysis are varied, 40 risk equations can be helpful in predicting a time frame for when kidney replacement therapy may be necessary ( Table 2).…”

“…There is considerable variation in physician reliance on biochemical and hematologic variables such as creatinine, eGFR, urea, bicarbonate, potassium and phosphate levels, and hemoglobin levels among patients at the start of dialysis. 40 Indices that measure frailty in CKD may be useful for informing patient decision-making, 49 research is needed regarding the effectiveness of this approach ( Table 3). The timing of predialysis assessments depends on the absolute level and rate of decline in kidney function, symptom load, and associated metabolic, hematologic, and clinical comorbidities but will generally fall within the range of monthly to every 3 months.…”

Incidence of Fractures Before and After Dialysis Initiation

“…In this period, worsening of uremic symptoms including fatigue, anorexia, nausea, fluid overload with dyspnea, anemia, and other laboratory changes due to uremia including electrolyte and mineral disturbances such as hyperkalemia and acidosis, are factors that necessitate start of dialysis. ( 23–25 )…”