Association Between the Publication of the Initiating Dialysis Early and Late Trial and the Timing of Dialysis Initiation in Canada

Variability in Reporting eGFR at Dialysis Initiation in Canada: A Research Letter

Background

Estimated glomerular filtration rate (eGFR) at dialysis initiation is increasingly recognized as a key quality indicator (QI) for patients with end-stage kidney disease (ESKD). Specifically, guidelines recommend assessing deferral of dialysis initiation until symptoms arise or if the eGFR is ≤6 mL/min/1.73 m2. Despite the recognition of the importance of this QI, how eGFR at the time of dialysis initiation is defined, collected, and tracked at dialysis centers across Canada remains unknown.

Objectives

To identify how provincial renal programs define eGFR at dialysis initiation, to compare practice across Canadian provinces, and to determine if there is a consistent benchmark for deferred dialysis start.

Design

Cross-sectional survey distributed to the medical leads of each provincial renal program, administered from July 2021 to November 2021. Quebec was not included given it did not yet participate in Canadian Organ Replacement Register (CORR) data submission.

Setting

The survey was designed and distributed by the Canadian Society of Nephrology Quality Improvement & Implementation Science Committee (CSN-QUIS) Indicator Working Group.

Methods

The survey asked respondents on how eGFR is defined, collected, reported, and perceived barriers to QI data collection. The National Senior Renal Leaders Forum helped identify the key provincial medical leads to disseminate the survey for completion.

Results

Surveys were distributed to the medical leads of the 9 provincial renal programs that participate in CORR. In total, there were 8 responses. Five provinces submit eGFR for all new dialysis starts and 3 provinces only submit this information for chronic patients. There is variation in determining when a patient with acute kidney injury requiring dialysis is classified as a chronic patient. Four provinces use a 30-day trigger, 3 provinces use a 90-day trigger, and the patient's nephrologist makes this determination in 1 province. The creatinine used for the eGFR at dialysis initiation was the value measured on the first dialysis session (ie, day 0) for 5 provinces; the last outpatient clinic creatinine value in 2 provinces, and 1 province did not have a standard definition. Three provinces did not have a benchmark target for eGFR at dialysis initiation, 1 province had a target of <9.5 mL/min/1.73 m2, 3 provinces had a target of <10 mL/min/1.73 m2, 1 province had a target of <15 mL/min/1.73 m2. All 8 responding provincial medical leads support the establishment of a national benchmark for this measure.

Limitations

This survey was restricted to provincial medical leads and therefore is unable to determine practice at individual dialysis sites. The survey was not anonymous, so it may be subject to conformity bias.

Conclusions

There is wide variability in how eGFR at dialysis initiation is measured and reported across Canada. Additionally, there is no consensus on a benchmark target for an intent-to-defer dialysis strategy. Standardization of target eGFR at dialysis initiation may facilitate national reporting and quality improvement initiatives.

Chinese Clinical Practice Guideline for the Management of "CKD-PeriDialysis"-the Periods Prior to and in the Early-Stage of Initial Dialysis

The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.

The IDEAL trial in Australia and New Zealand: Clinical and Economic impact

BACKGROUND

The impact of research findings on clinical practice usually remains uncertain and unmeasured. To address this problem, we examined the long term clinical and economic impact of the Initiating Dialysis Early and Late (IDEAL) study, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry.

METHODS

We performed a registry-based study including all incident adult dialysis patients in Australia and New Zealand from July 2000-June 2018. A piecewise-linear regression model was used to examine differences in mean estimated Glomerular Filtration Rate (eGFR) at dialysis commencement for the years prior (2000-2010) and following (2010-2018) publication of the IDEAL results. The Return on Investment (ROI) was calculated using the total cost of performing the IDEAL study and the cost or savings accruing in Australia and New Zealand from change in dialysis initiation practice.

RESULTS

From July 2000-June 2010, mean eGFR at dialysis commencement increased at a rate of 0.21 mL/min/1.73m2 per year (95% CI 0.19 to 0.23). After IDEAL results were published, mean eGFR at dialysis commencement did not show any temporal change (-0.01 mL/min/1.73m2 per year, 95% CI -0.03 to 0.01). The ROI of the IDEAL study was AUD $35.70 per AUD $1 spent, an estimated saving to Australian and New Zealand health systems of up to AUD $84M per year.

CONCLUSIONS

The previous trend to higher eGFR at dialysis commencement changed following publication of IDEAL results to a steady eGFR which has continued for a decade, avoiding unnecessary dialysis treatments and accruing savings to Australian and New Zealand health systems.

Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial

BACKGROUND

The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise.

METHODS

To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m²). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting.

RESULTS

The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient.

CONCLUSIONS

A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.

Recovery of kidney function after dialysis initiation in children and adults in the US: A retrospective study of United States Renal Data System data

BACKGROUND

Little is known about factors associated with recovery of kidney function-and return to dialysis independence-or temporal trends in recovery after starting outpatient dialysis in the United States. Understanding the characteristics of individuals who may have the potential to recover kidney function may promote better recognition of such events. The goal of this study was to determine factors associated with recovery of kidney function in children compared with adults starting dialysis in the US.

METHODS AND FINDINGS

We determined factors associated with recovery of kidney function-defined as survival and discontinuation of dialysis for ≥90-day period-in children versus adults who started maintenance dialysis between 1996 and 2015 according to the United States Renal Data System (USRDS) followed through 2016 in a retrospective cohort study. We also examined temporal trends in recovery rates over the last 2 decades in this cohort. Among 1,968,253 individuals included for study, the mean age was 62.6 ± 15.8 years, and 44% were female. Overall, 4% of adults (83,302/1,953,881) and 4% of children (547/14,372) starting dialysis in the outpatient setting recovered kidney function within 1 year. Among those who recovered, the median time to recovery was 73 days (interquartile range [IQR] 43-131) in adults and 100 days (IQR 56-189) in children. Accounting for the competing risk of death, children were less likely to recover kidney function compared with adults (sub-hazard ratio [sub-HR] 0.81; 95% CI 0.74-0.89, p-value <0.001; point estimates <1 indicating increased risk for a negative outcome). Non-Hispanic black (NHB) adults were less likely to recover compared with non-Hispanic white (NHW) adults, but these racial differences were not observed in children. Of note, a steady increase in the incidence of recovery of kidney function was noted initially in adults and children between 1996 and 2010, but this trend declined thereafter. The diagnoses associated with the highest recovery rates of recovery were acute tubular necrosis (ATN) and acute interstitial nephritis (AIN) in both adults and children, where 25%-40% of patients recovered kidney function depending on the calendar year of dialysis initiation. Limitations to our study include the potential for residual confounding to be present given the observational nature of our data.

CONCLUSIONS

In this study, we observed that discontinuation of outpatient dialysis due to recovery occurred in 4% of patients with end-stage kidney disease (ESKD) and was more common among those with ATN or AIN as the cause of their kidney disease. While recovery rates rose initially, they declined starting in 2010. Additional studies are needed to understand how to best recognize and promote recovery in patients whose potential to discontinue dialysis is high in the outpatient setting.

Early initiation of PD therapy in elderly patients is associated with increased risk of death

Background

The effect of early initiation of dialysis on outcomes of patients with end-stage renal disease (ESRD) remains controversial. We conducted this study to investigate the association between the timing of peritoneal dialysis (PD) initiation and mortality in different age groups.

Methods

In this single-centre cohort study, incident patients receiving PD from 1 January 2006 to 31 December 2016 were enrolled. Patients were categorized into three groups according to the estimated glomerular filtration rate (eGFR) at the initiation of PD, with early, mid and late initiation of PD defined as eGFR ≥7.5, 5–7.5 and <5 mL/min/1.73 m², respectively.

Results

A total of 2133 incident patients receiving PD were enrolled with a mean age of 47.1 years, 59.6% male and 25.3% with diabetes, of whom 1803 were young (age <65 years) and 330 were elderly (age ≥65 years). After multivariable adjustment, the overall and cardiovascular (CV) mortality risks for young patients receiving PD were not significantly different between these three groups. However, for elderly patients, early initiation of PD therapy was associated with increased risks of all-cause {hazard ratio [HR} 1.54 [95% confidence interval (CI) 1.06–2.25]} and CV [HR 2.07 (95% CI 1.24–3.48)] mortality compared with late initiation of PD, while no significant difference was observed in overall or CV mortality between the mid- and late-start groups.

Conclusions

No significant difference in mortality risk was found among the three levels of eGFR at PD therapy initiation in young patients, while early initiation of PD was associated with a higher risk of overall and CV mortality among elderly patients.

Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease

IMPORTANCE

In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined.

OBJECTIVE

To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year.

MAIN OUTCOMES AND MEASURES

One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort.

RESULTS

In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study.

CONCLUSIONS AND RELEVANCE

The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD.

A Cost-Minimization Analysis of Nurse-Led Virtual Case Management in Late-Stage CKD

Introduction

Interventions are needed to improve early detection of indications for dialysis before development of severe symptoms or complications. This may reduce suboptimal dialysis starts, prevent hospitalizations, and decrease costs. Our objectives were to explore assumptions around a nurse-led virtual case management intervention for patients with late-stage chronic kidney disease (CKD) with a 2-year Kidney Failure Risk Equation (KFRE) estimated risk of kidney failure ≥80% and to estimate how these assumptions affect potential cost savings.

Methods

We performed a cost-minimization analysis by developing a decision analytic microsimulation model constructed from the perspective of the health payer. Our primary outcome was the break-even point, defined as the maximum amount a health payer could spend on the intervention without incurring any net financial loss or gain. The intervention group received remote telemonitoring, including daily measurement of several health metrics (blood pressure, oxygen saturation, and weight), and a validated symptom questionnaire accompanied by nurse-led case management, whereas the comparator group received usual care. We assumed patients received the intervention for a maximum of 2 years.

Results

The break-even point was $7339 per late-stage CKD patient enrolled in the intervention. Based on the distribution of time receiving the intervention, we determined a maximum monthly intervention cost of $703.37. In probabilistic sensitivity analyses, we found that 75% of simulations produced break-even points between $3929 and $9460.

Conclusion

Nurse-led virtual home monitoring interventions in patients with CKD at high risk of kidney failure have the potential for significant cost savings from the perspective of the health payer.

Novel trial strategies to enhance the relevance, efficiency, effectiveness, and impact of nephrology research

Randomized controlled trials (RCTs) are considered the gold standard for evaluating the effectiveness of interventions. However, criticisms of traditional designs are that they can be inefficient, inflexible, expensive, and conducted in a manner disconnected from real-life clinical practice. Novel strategies and approaches are being utilized to overcome these limitations, including comprehensive consumer engagement, core outcome sets, novel trial designs, streamlined data collection, cost-effectiveness and return on investment evaluations, knowledge dissemination plans, and impact evaluation. These strategies can be implemented at the design, conduct, implementation, and dissemination stages of the trial process. This review aims to provide an overview of these strategies and approaches to improve the relevance, efficiency, effectiveness, and impact of nephrology research.

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

Dialysis and nutrition are two sides of the same coin—dialysis depurates metabolic waste that is typically produced by food intake. Hence, dietetic restrictions are commonly imposed in order to limit potassium and phosphate and avoid fluid overload. Conversely, malnutrition is a major challenge and, albeit to differing degrees, all nutritional markers are associated with survival. Dialysis-related malnutrition has a multifactorial origin related to uremic syndrome and comorbidities but also to dialysis treatment. Both an insufficient dialysis dose and excessive removal are contributing factors. It is thus not surprising that dialysis alone, without proper nutritional management, often fails to be effective in combatting malnutrition. While composite indexes can be used to identify patients with poor prognosis, none is fully satisfactory, and the definitions of malnutrition and protein energy wasting are still controversial. Furthermore, most nutritional markers and interventions were assessed in hemodialysis patients, while hemodiafiltration and peritoneal dialysis have been less extensively studied. The significant loss of albumin in these two dialysis modalities makes it extremely difficult to interpret common markers and scores. Despite these problems, hemodialysis sessions represent a valuable opportunity to monitor nutritional status and prescribe nutritional interventions, and several approaches have been tried. In this concept paper, we review the current evidence on intradialytic nutrition and propose an algorithm for adapting nutritional interventions to individual patients.