Early start of dialysis: a critical review

Planning vascular access creation: The promising role of the kidney failure risk equation

BACKGROUND

Planning for vascular access (VA) creation is essential in pre-dialysis patients although optimal timing for VA referral and placement is debatable. Guidelines suggest referral when eGFR is 15-20 mL/min/1.73 m2. This study aimed to validate the use of kidney failure risk equation (KFRE) in VA planning.

METHODS

Retrospective analysis of all adult patients with CKD who were referred for first VA placement, namely AVF or AVG, at a tertiary center, between January 2018 and December 2019. The four-variable KFRE was calculated. Start of KRT, mortality, and VA placement were assessed in a 2-year follow-up. We used Cox regression to predict KRT start and calculated the ROC curve.

RESULTS

256 patients were included and 64.5% were male, mean age was 70.4 ± 12.9 years and mean eGFR was 16.09 ± 10.43 mL/min/1.73 m2. One hundred fifty-nine patients required KRT (62.1%) and 72 (28.1%) died in the 2-year follow-up. The KFRE accurately predicted KRT start within 2-years (38.3 ± 23.8% vs 17.6 ± 20.9%, p < 0.001; HR 1.05 95% CI (1.06-1.12), p < 0.001), with an auROC of 0.788 (p < 0.001, 95% CI (0.733-0.837)). The optimal KFRE cut-off was >20%, with a HR of 9.2 (95% CI (5.06-16.60), p < 0.001). Patients with KFRE ⩾ 20% had a significant lower mean time from VA consult to KRT initiation (10.8 ± 9.4 vs 15.6 ± 10.3 months, p < 0.001). On a sub-analysis of patients with an eGFR < 20 mL/min/1.73 m2, a KFRE ⩾ 20% was also a significant predictor of 2-year start of KRT, with an HR of 6.61 (95% CI (3.49-12.52), p < 0.001).

CONCLUSION

KFRE accurately predicted 2-year KRT start in this cohort of patients. A KFRE ⩾ 20% can help to establish higher priority patients for VA placement. The authors suggest referral for VA creation when eGFR < 20 mL/min/1.73 m2 and KFRE ⩾ 20%.

Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania

Objectives

Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease.

Methods

This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis.

Results

The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths.

Conclusion

This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.

The error of estimated GFR in predialysis care

The error of estimated glomerular filtration rate (eGFR) and its consequences in predialysis are unknown. In this prospective multicentre study, 315 predialysis patients underwent measured GFR (mGFR) by the clearance of iohexol and eGFR by 52 formulas. Agreement between eGFR and mGFR was evaluated by concordance correlation coefficient (CCC), total deviation index (TDI) and coverage probability (CP). In a sub-analysis we assessed the impact of eGFR error on decision-making as (i) initiating dialysis, (ii) preparation for renal replacement therapy (RRT) and (iii) continuing clinical follow-up. For this sub-analysis, patients who started RRT due to clinical indications (uremia, fluid overload, etc.) were excluded. eGFR had scarce precision and accuracy in reflecting mGFR (average CCC 0.6, TDI 70% and cp 22%) both in creatinine- and cystatin-based formulas. Variations -larger than 10 ml/min- between mGFR and eGFR were frequent. The error of formulas would have suggested (a) premature preparation for RTT in 14% of stable patients evaluated by mGFR; (b) to continue clinical follow-up in 59% of subjects with indication for RTT preparation due to low GFRm and (c) to delay dialysis in all asymptomatic patients (n = 6) in whom RRT was indicated based on very low mGFR. The error of formulas in predialysis was frequent and large and may have consequences in clinical care.

Prognosis Factors of Patients Undergoing Renal Replacement Therapy

BACKGROUND

Survival in patients with end-stage kidney disease (ESKD) on renal replacement therapy (RRT) is less than that of the general population of the same age, and depends on patient factors, the medical care received, and the type of RRT used. The objective of this study is to analyze the factors associated with survival in patients undergoing RRT.

METHODS

We conducted a retrospective observational study of adult patients with an incident of ESKD on RRT in Andalusia from 1 January 2008 to 31 December 2018. Patient characteristics, nephrological care received, and survival from the beginning of RRT were evaluated. A survival model for the patient was developed according to the variables studied.

RESULTS

A total of 11,551 patients were included. Median survival was 6.8 years (95% CI (6.6; 7.0)). After starting RRT, survival at one year and five years was 88.7% (95% CI (88.1; 89.3)) and 59.4% (95% CI (58.4; 60.4)), respectively. Age, initial comorbidity, diabetic nephropathy, and a venous catheter were independent risk factors. However, non-urgent initiation of RRT and follow-up in consultations for more than six months had a protective effect. It was identified that renal transplantation (RT) was the most influential independent factor in patient survival, with a risk ratio of 0.13 (95% CI (0.11; 0.14)).

CONCLUSIONS

The receiving of a kidney transplant was the most beneficial modifiable factor in the survival of incident patients on RRT. We consider that the mortality of the renal replacement treatment should be adjusted, taking into account both modifiable and nonmodifiable factors to achieve a more precise and comparable interpretation.

Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients

INTRODUCTION

The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization.

METHODS

A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m² ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis.

FINDINGS

A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p = 0.007) when compared to non-diabetic patients.

DISCUSSION

Early initiation of HD at eGFR >5 ml/min/1.73 m² had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

OBJECTIVE

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

DESIGN

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

SETTING

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

PATIENTS

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.

MEASUREMENTS

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

METHODS

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

RESULTS

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

LIMITATIONS

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

CONCLUSIONS

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

TRIAL REGISTRATION

Not applicable.

Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience

Background

The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis.

Methods

We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis.

Results

Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets.

Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets.

Conclusion

This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.

Incremental peritoneal dialysis in incident end-stage kidney disease patients

BACKGROUND

This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre.

METHODS

ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed.

RESULTS

One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m². The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year.

CONCLUSIONS

Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Estimating the Fraction of First-Year Hemodialysis Deaths Attributable to Potentially Modifiable Risk Factors: Results from the DOPPS

PURPOSE

Mortality among first-year hemodialysis (HD) patients remains unacceptably high. To address this problem, we estimate the proportions of early HD deaths that are potentially preventable by modifying known risk factors.

METHODS

We included 15,891 HD patients (within 60 days of starting HD) from 21 countries in the Dialysis Outcomes and Practice Patterns Study (1996-2015), a prospective cohort study. Using Cox regression adjusted for potential confounders, we estimated the fraction of first-year deaths attributable to one or more of twelve modifiable risk factors (the population attributable fraction, AF) identified from the published literature by comparing predicted survival based on risk factors observed vs counterfactually set to reference levels.

RESULTS

The highest AFs were for catheter use (22%), albumin <3.5 g/dL (19%), and creatinine <6 mg/dL (12%). AFs were 5%-9% for no pre-HD nephrology care, no residual urine volume, systolic blood pressure <130 or ≥160 mm Hg, phosphorus <3.5 or ≥5.5 mg/dL, hemoglobin <10 or ≥12 g/dL, and white blood cell count >10,000/μL. AFs for ferritin, calcium, and PTH were <3%. Overall, 65% (95% CI: 59%-71%) of deaths were attributable to these 12 risk factors. Additionally, the AF for C-reactive protein >10 mg/L was 21% in facilities where it was routinely measured.

CONCLUSION

A substantial proportion of first-year HD deaths could be prevented by successfully modifying a few risk factors. Highest priorities should be decreasing catheter use and limiting malnutrition/inflammation whenever possible.

Protocol for a prospective, cluster randomized trial to evaluate routine and deferred dialysis initiation (RADDI) in Chinese population

BACKGROUND

The timing of when to initiate dialysis for progressive chronic kidney disease (CKD) patients has not been well established. There has been a strong trend for early dialysis initiation for these patients over the past decades. However, the perceived survival advantage of early dialysis has been questioned by a series of recent observational studies. The only randomized controlled trial (RCT) research on this issue found the all-cause mortality, comorbidities, and quality of life showed no difference between early and late dialysis starters. To better understand optimal timing for dialysis initiation, our research will evaluate the efficacy and safety of deferred dialysis initiation in a large Chinese population.

METHODS

The trial adopts a multicenter, cluster randomized, single-blind (outcomes assessor), and endpoint-driven design. Eligible participants are 18-80 years old, in stable CKD stages 4-5 (eGFR > 7 ml/min /1.73 m2), and with good heart function (NYHA grade I or II). Participants will be randomized into a routine or deferred dialysis group. The reference eGFR at initiating dialysis for asymptomatic patients is 7 ml/min /1.73 m2 (routine dialysis group) and 5 ml/min/1.73 m2 or less (deferred dialysis group) in each group. The primary endpoint will be the difference of all-cause mortality and acute nonfatal cerebro-cardiovascular events between the two groups. The secondary outcomes include hospitalization rate and other safety indices. The primary and secondary outcomes will be analyzed by appropriate statistical methods.

DISCUSSION

This study protocol represents a large, cluster randomized study evaluating deferred and routine dialysis intervention for an advanced CKD population. The reference eGFR to initiate dialysis for both treatment groups is targeted at less than 7 ml/min/1.73m2. With this design, we aim to eliminate lead-time and survivor bias and avoid selection bias and confounding factors. We acknowledge that the study has limitations. Even so, given the low-targeted eGFR values of both arms, this study still has potential economic, health, and scientific implications. This research is unique in that such a low targeted eGFR value has never been studied in a clinical trial.

TRIAL REGISTRATION

The trial has been approved by ClinicalTrials.gov (Trial registration ID NCT02423655). The date of registration was April 22, 2015.

When to initiate dialysis for end-stage kidney disease: evidence and challenges

The decision about when to start dialysis for end-stage kidney disease (ESKD) is complex and is influenced by many factors. ESKD-related symptoms and signs are the most common indications for dialysis initiation. Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD and, thus, the decision to start dialysis should not be based solely on estimated GFR (eGFR). Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m²) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study. This observation has been incorporated into the latest guidelines, which place greater emphasis on the assessment of patients' symptoms and signs rather than eGFR. It is suggested that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m² if there is careful clinical follow-up and adequate patient education. The decision on when to start dialysis is even more challenging in older patients. Due to their comorbidities and frailty, dialysis initiation may be associated with worse outcomes and quality of life. Therefore, the decision to start dialysis in these patients should be carefully weighed against its risks, and conservative care should be considered in appropriate cases. To optimise the decision-making process for dialysis initiation, patients need to be referred to a nephrologist in a timely fashion to allow adequate pre-dialysis care and planning. Dialysis initiation and its timing should be a shared decision between physician, patients and family members, and should be tailored to the individual patient's needs.

Prognostic factors in patients undergoing early-start peritoneal dialysis within 24 h after catheter insertion

This study aimed to investigate the clinical characteristics, prognosis, and factors for survival of patients who underwent early-start peritoneal dialysis (PD) within 24 h after catheter insertion three years after PD. This study was conducted from January 1, 2013 to December 31, 2017. All adult patients who were diagnosed with end-stage renal disease (ESRD) and underwent PD for the first time within 24 h after catheter insertion in our hospital were included. All patients with PD were followed-up until they withdrew from PD, switching to hemodialysis, were transferred to other medical centers, underwent renal transplantation, died or were lost to follow-up, or continued to undergo dialysis until the end of the study period. The follow-up observation lasted three years. The number of eligible patients was 110, and switching to hemodialysis and death were the main reasons for patients to withdraw from PD. The 1-, 2-, and 3-year technical survival rates of patients were 89.1, 79.1, and 79.1% respectively, while the 1-, 2- and 3-year survival rates were 90, 81.8, and 81.8%, respectively. The Charlson comorbidity index, age, hemoglobin, serum albumin, diabetic nephropathy, chronic glomerulonephritis, and hypertensive renal damage were independent risk factors that affected the prognosis of PD patients. Under the condition of ensuring the quality of the PD catheter insertion, early-start PD within 24 h after catheter insertion is a safe treatment approach for ESRD patients.

Impact of timing of initiation of dialysis on long-term prognosis of patients undergoing hemodialysis

There are a lot of controversies pertaining to correctness of timing for the initiation of dialysis in chronic kidney disease (CKD) patients. The present study was conducted to examine the potential association of initiation timing of dialyses with long-term prognosis in CKD patients. In total, 294 patients confirmed as end-stage renal disease (ESRD) were included as study subjects. According to the estimated glomerular filtration rate (eGFR) at initiation time, the patients were classified into four groups based on eGFR: ≥10.5, 8–10.4, 6–8 and <6 ml/min × (1.73 m²)⁻¹. The primary outcomes were defined by all-cause mortality. The median eGFR of the 294 patients at initiation time was 5.43 (2.27–13.92) ml/min × (1.73 m²)⁻¹. The patients with lower eGFR at the start of hemodialysis had a higher proportion of Charlson comorbidity index (CCI) scores of 0–2 and had lower hematocrit. The multivariate Cox regression analysis indicated that CCI, cerebrovascular diseases and chronic obstructive pulmonary disease were significantly associated with all-cause mortality, but not eGFR at the dialysis initiation. Furthermore, stratified analyses confirmed elevated eGFR that had no advantage on long-term prognosis. The present findings have shown that the prevalence of anemia, hyperuricemia and calcium and phosphorus metabolism disorders of patients with low eGFRs at the initiation of hemodialysis was higher in comparison to the patients with high eGFRs. Therefore, the long-term prognosis of patients with high eGFRs prior to hemodialysis was not improved.

Early mortality in patients with chronic kidney disease who started emergency haemodialysis in a Peruvian population: Incidence and risk factors

OBJECTIVES

To estimate early mortality in patients with chronic kidney disease who started emergency haemodialysis between 2012 and 2014 in a national referral hospital in Lima, Peru, and to identify risk factors.

DESIGN, CHARACTERISTICS, PARTICIPANTS AND MEASUREMENTS

A retrospective cohort study was conducted by reviewing the medical records of all patients admitted to the hospital's Haemodialysis Unit from 2012 to 2014. Early mortality, defined as death within the first 90 days of starting haemodialysis, as well as age, gender, chronic kidney disease aetiology, comorbidities, cause of death, estimated glomerular filtration rate, vascular access and other variables were evaluated in patients who initiated emergency haemodialysis. Early mortality was estimated using frequencies and risk factors were determined by Poisson regression with robust variance.

RESULTS

43.4% of patients were female, 51.5% were aged≥65 years and the early mortality rate was 9.3%. The main risk factors were estimated glomerular filtration rate>10 ml/min/1.73m² (RR: 2.72 [95% CI: 1.60-4.61]); age≥65 years (RR: 2.51 [95% CI: 1.41-4.48]); central venous catheter infection, RR: 2.25 (95% CI: 1.08-4.67); female gender, RR: 2.15 (95% CI: 1.29-3.58); and albumin<3.5g/dl (RR: 1.97 [95% CI: 1.01-3.82]).

CONCLUSIONS

Early mortality was 9.3%. The main risk factor was starting haemodialysis with an estimated glomerular filtration rate>10ml/min/1.73m².

Nutritional treatment of advanced CKD: twenty consensus statements

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Why do physicians prescribe dialysis? A prospective questionnaire study

INTRODUCTION

The 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.

METHODS

In 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.

RESULTS

In 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).

CONCLUSIONS

DI 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.

The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions

Background

Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions.

Case presentation

Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy).

In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”.

Conclusions

An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.

Treatment decisions for older adults with advanced chronic kidney disease

Dialysis initiation rates among older adults, aged 75 years or greater, are increasing at a faster rate than for younger age groups. Older adults with advanced CKD (eGFR < 30 ml/min/1.73 m2) typically lose renal function slowly, often suffer from significant comorbidity and thus may die from associated comorbidities before they require dialysis.A patient's pattern of renal function loss over time in relation to their underlying comorbidities can serve as a guide to the probability of a future dialysis requirement. Most who start dialysis, initiate treatment "early", at an estimated glomerulofiltration rate (eGFR) >10 ml/min/1.73 m2 and many initiate dialysis in hospital, often in association with an episode of acute renal failure. In the US older adults start dialysis at a mean e GFR of 12.6 ml/min/1.73 m2 and 20.6% die within six months of dialysis initiation. In both the acute in hospital and outpatient settings, many older adults appear to be initiating dialysis for non-specific, non-life threatening symptoms and clinical contexts. Observational data suggests that dialysis does not provide a survival benefit for older adults with poor mobility and high levels of comorbidity. To optimize the care of this population, early and repeat shared decision making conversations by health care providers, patients, and their families should consider the risks, burdens, and benefits of dialysis versus conservative management, as well as the patient specific symptoms and clinical situations that could justify dialysis initiation. The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient's unique goals and priorities.In conclusion, when considering the morbidity and quality of life impact associated with dialysis, many older adults may prefer to delay dialysis until there is a definitive indication or may opt for conservative management without dialysis. This approach can incorporate all CKD treatments other than dialysis, provide psychosocial and spiritual support and active symptom management and may also incorporate a palliative care approach with less medical monitoring of lab parameters and more focus on the use of drug therapies directed to relief of a patient's symptoms.

Explaining trends and variation in timing of dialysis initiation in the United States

The United States Renal Data System (USRDS) registry of end-stage renal disease has often been used to study the timing of dialysis initiation, measured by estimated glomerular filtration rate (eGFR) at dialysis initiation. We conducted an observational study and examined how well variables in the USRDS database explain the trends and variation in eGFR at dialysis initiation.We identified 971,481 patients who initiated dialysis between 1995 and 2012 in the USRDS registry.The mean eGFR at dialysis initiation monotonically rose from 7.7 in 1995 to 11.1 in 2009, and then leveled off to 10.9 mL/min/1.73 m in 2012. The trend of rising, then leveling off was similar across all subgroups studied. Substantial variation in eGFR at dialysis initiation was observed, with standard deviation of 4.38 (95% CI: 2.0-18.4). A total of 11.4% of the total variation occurred across physicians and 88.6% within physicians. Adjustment for measured factors only modestly decreased the total variation. Of the total variance, 10.7% was explained by measured patient-level variables and 1.2% by measured physician and other factors, while 9.2% of physician-level variation and 78.9% of patient-level variation remained unexplained. The extent of variation explained by measured variables was similar over the entire study period.The finding that the majority of variation in eGFR at dialysis initiation is unexplained by measured variables casts doubt on how well eGFR serves as a measure for "timing" of dialysis initiation, and it indicates the need to collect more focused data to gain understanding of factors that affect timing of dialysis initiation in the US.

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.

The Glomerular Filtration Rate (GFR) at Dialysis Initiation and Mortality in Chronic Kidney Disease (CKD) in East Asian Populations: A Meta-analysis

Objective The impact of dialysis initiation on survival is still somewhat controversial. Given that race or ethnicity has been observed to be a predictor of mortality and the rate of progression of chronic kidney disease, we conducted a meta-analysis to investigate the effect of early vs. late dialysis initiation on mortality in East Asian populations. Methods All eligible cohort studies of target were selected from the MEDLINE (PubMed), EMBASE, The Cochrane Library and the Clinical Trials Registry databases from inception to October 2014. The data were extracted with all-cause mortality rates as the primary outcome, and pooled adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Results Ten studies examined the association between early vs. late dialysis initiation and mortality. Compared to late dialysis initiation, patients who received early dialysis initiation had a higher overall mortality risk (adjusted HR, 1.36; 95% CI, 1.0-1.85; p<0.05) in East Asian populations. In a subgroup analysis, baseline characteristic differences (adjusted HR, 2.0; 95%CI, 1.56-2.57; p<0.001), initial dialysis modalities (adjusted HR, 2.12; 95% CI, 1.72-2.62; p<0.001) and follow up duration (adjusted HR, 1.59; 95% CI, 1.19-2.12; p=0.002), demonstrated that the association between early dialysis initiation and mortality were significant. Conclusion A higher glomerular filtration rate (early) at the initiation of dialysis is associated with a higher all-cause mortality risk in East Asian populations.

Baseline Residual Kidney Function and Its Ensuing Rate of Decline Interact to Predict Mortality of Peritoneal Dialysis Patients

Background

Baseline residual kidney function (RKF) and its rate of decline during follow-up are purported to be reliable outcome predictors of patients undergoing Peritoneal Dialysis (PD). The independent contribution of each of these factors has not been elucidated.

Method

We report a multicenter, longitudinal study of 493 patients incident on PD and satisfying two conditions: a glomerular filtration rate (GFR) ≥1 mL/minute and a daily diuresis ≥300 mL. The main variables were the GFR (mean of urea and creatinine clearances) at PD inception and the GFR rate of decline during follow-up. The main outcome variable was patient mortality. The secondary outcome variables were: PD technique failure and risk of peritoneal infection. The statistical analysis was based on a multivariate approach, placing an emphasis on the interactions between the two main study variables.

Main Results

Baseline GFR and its rate of decline performed well as independent predictors of both patient mortality and risk of peritoneal infection. These two main study variables maintained a moderate correlation with each other (r² = 0.12, p<0.0005), and interacted clearly, as predictors of patient mortality. A low baseline GFR followed by a fast decline portended the worst survival outcome (adjusted HR 3.84, 95%CI 1.81–8.14, p<0.0005)(Ref. baseline GFR above median plus rate of decline below median). In general, the rate of decline of RKF had a greater effect on mortality than baseline GFR, which had no detectable effect on survival when the decline of RKF was slow (HR 1.17, 95% CI 0.81–2.22, p = 0.22). Conversely, a relatively high GFR at the start of PD still carried a significant risk of mortality, when RKF declined rapidly (HR 1.89, 95% CI 1.05–3.72, p = 0.028).

Conclusion

The risk-benefit balance of an early versus late start of PD cannot be evaluated without taking into consideration the rate of decline of RKF. This circumstance may contribute to explain the controversial results observed at the time of evaluating the potential benefits of an early initiation of PD.

Timing of start of dialysis in diabetes mellitus patients: a systematic literature review

BACKGROUND

Diabetes mellitus is a frequent cause of the need for renal replacement therapy (RRT). Historically, RRT was started earlier in patients with diabetes, in an attempt to prevent complications of uraemia and diabetes. We did a systematic review to find support for this earlier start of dialysis in patients with versus without diabetes.

METHODS

The MEDLINE, EMBASE and CENTRAL databases were searched for articles about the timing of dialysis initiation in (subgroups of) patients with diabetes and CKD Stage 5.

RESULTS

A total of 340 papers were screened and 11 papers were selected to be reviewed. Only three studies showed data of at least one subgroup of patients with diabetes. Two observational studies concluded that start of dialysis with a higher estimated glomerular filtration rate (eGFR) is beneficial with regard to survival, one did not find a difference and six observational studies concluded that start of dialysis with a lower eGFR is associated with better survival in patients with diabetes. The effect of timing of initiation of dialysis did not differ between patients with versus without diabetes. Lastly, one randomized controlled trial (two papers) reported that there was no difference in survival between start at higher versus lower eGFR overall and a P-value for the interaction with diabetes of P = 0.63, indicating no difference between patients with versus without diabetes with regard to the timing of start of dialysis and subsequent mortality on dialysis.

CONCLUSIONS

There is no difference between early (eGFR) and late (lower eGFR) start of RRT with regard to mortality in patients with versus without diabetes. RRT should thus be initiated based on the same criteria in all patients, irrespective of the presence or absence of diabetes.

When to initiate renal replacement therapy: The trend of dialysis initiation

The timing of renal replacement therapy for patients with end-stage renal disease has been subject to considerable variation. The United States Renal Data System shows an ascending trend of early dialysis initiation until 2010, at which point it decreased slightly for the following 2 years. In the 1990s, nephrologists believed that early initiation of dialysis could improve patient survival. Based on the Canadian-United States Peritoneal Dialysis study, the National Kidney Foundation Dialysis Outcomes Quality Initiative recommended that dialysis should be initiated early. Since 2001, several observational studies and 1 randomized controlled trial have found no beneficial effect when patients were placed on dialysis early. In contrast, they found that an increase in mortality was associated with early dialysis initiation. The most recent dialysis initiation guidelines recommend that dialysis should be initiated at an estimated glomerular filtration rate (eGFR) of greater than or equal to 6 mL/min per 1.73 m(2). Nevertheless, the decision to start dialysis is mainly based on a predefined eGFR value, and no convincing evidence has demonstrated that patients would benefit from early dialysis initiation as indicated by the eGFR. Even today, the optimal dialysis initiation time remains unknown. The decision of when to start dialysis should be based on careful clinical evaluation.

The changing trends and outcomes in renal replacement therapy: data from the ERA-EDTA Registry

BACKGROUND

This study examines the time trends in incidence, prevalence, patient and kidney allograft survival and causes of death (COD) in patients receiving renal replacement therapy (RRT) in Europe.

METHODS

Eighteen national or regional renal registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry between 1998 and 2011 were included. Incidence and prevalence time trends between 2001 and 2011 were studied with Joinpoint and Poisson regression. Patient and kidney allograft survival and COD between 1998 and 2011 were analysed using Kaplan-Meier and competing risk methods and Cox regression.

RESULTS

From 2001 to 2008, the adjusted incidence of RRT rose by 1.1% (95% CI: 0.6, 1.7) annually to 131 per million population (pmp). During 2008-2011, the adjusted incidence fell by 2.2% (95% CI: -4.2, -0.2) annually to 125 pmp. This decline occurred predominantly in patients aged 45-64 years, 65-74 years and in the primary renal diseases diabetes mellitus type 1 and 2, renovascular disease and glomerulonephritis. Between 2001 and 2011, the overall adjusted prevalence increased from 724 to 1032 pmp (+3.3% annually, 95% CI: 2.8, 3.8). The adjusted 5-year patient survival on RRT improved between 1998-2002 and 2003-2007 [adjusted hazard ratio (HRa) 0.85, 95% CI: 0.84, 0.86]. Comparing these time periods, the risk of cardiovascular deaths fell by 25% (HRa 0.75, 95% CI: 0.74, 0.77). However the risk of malignant death rose by 9% (HRa 1.09, 95% CI: 1.03, 1.16) in patients ≥65 years.

CONCLUSION

This European study shows a declining RRT incidence, particularly in patients aged 45-64 years, 65-74 years and secondary to diabetic nephropathy. Encouragingly, the adjusted RRT patient survival continues to improve. The risk of cardiovascular death has decreased, though the risk of death from malignancy has increased in the older population.

The first year on haemodialysis: a critical transition

The first year following the start of haemodialysis (HD) is associated with increased mortality, especially during the first 90–120 days after the start of dialysis. Whereas the start of dialysis has important effects on the internal environment of the patient, there are relatively few studies assessing changes in phenotype and underlying mechanisms during the transition period following pre-dialysis to dialysis care, although more insight into these parameters is of importance in unravelling the causes of this increased early mortality. In this review, changes in cardiovascular, nutritional and inflammatory parameters during the first year of HD, as well as changes in physical and functional performance are discussed. Treatment-related factors that might contribute to these changes include vascular access and pre-dialysis care, dialysate prescription and the insufficient correction of the internal environment by current dialysis techniques. Patient-related factors include the ongoing loss of residual renal function and the progression of comorbid disease. Identifying phenotypic changes and targeting risk patterns might improve outcome during the transition period. Given the scarcity of data on this subject, more research is needed.

Kidney Failure and ESRD in the Atherosclerosis Risk in Communities (ARIC) Study: Comparing Ascertainment of Treated and Untreated Kidney Failure in a Cohort Study

BACKGROUND

Linkage to the US Renal Data System (USRDS) registry commonly is used to identify end-stage renal disease (ESRD) cases, or kidney failure treated with dialysis or transplantation, but it underestimates the total burden of kidney failure. This study validates a kidney failure definition that includes both kidney failure treated and not treated by dialysis or transplantation. It compares kidney failure risk factors and outcomes using this broader definition with USRDS-identified ESRD risk factors and outcomes.

STUDY DESIGN

Diagnostic test study with stratified random sampling of hospitalizations for chart review.

SETTING & PARTICIPANTS

Atherosclerosis Risk in Communities Study (n=11,530; chart review, n=546).

INDEX TEST

USRDS-identified ESRD; treated or untreated kidney failure defined by USRDS-identified ESRD or International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification (ICD-9-CM/ICD-10-CM) code for hospitalization or death.

REFERENCE TEST

For ESRD, determination of permanent dialysis therapy or transplantation; for kidney failure, determination of permanent dialysis therapy, transplantation, or estimated glomerular filtration rate < 15 mL/min/1.73 m(2).

RESULTS

During 13 years' median follow-up, 508 kidney failure cases were identified, including 173 (34.1%) from the USRDS registry. ESRD and kidney failure incidence were 1.23 and 3.66 cases per 1,000 person-years in the overall population and 1.35 and 6.59 cases per 1,000 person-years among participants older than 70 years, respectively. Other risk-factor associations were similar between ESRD and kidney failure, except diabetes and albuminuria, which were stronger for ESRD. Survivals at 1 and 5 years were 74.0% and 24.0% for ESRD and 59.8% and 31.6% for kidney failure, respectively. Sensitivity and specificity were 88.0% and 97.3% comparing the kidney failure ICD-9-CM/ICD-10-CM code algorithm to chart review; for USRDS-identified ESRD, sensitivity and specificity were 94.9% and 100.0%.

LIMITATIONS

Some medical charts were incomplete.

CONCLUSIONS

A kidney failure definition including treated and untreated disease identifies more cases than linkage to the USRDS registry alone, particularly among older adults. Future studies might consider reporting both USRDS-identified ESRD and a more inclusive kidney failure definition.

Clinical characteristics of very elderly patients at hemodialysis initiation

OBJECTIVE

The patient's clinical features at hemodialysis initiation can affect their prognosis in the subsequent dialysis period; however, these features have not been fully elucidated in very elderly subjects. The purpose of this study was to clarify the clinical characteristics associated with cardiovascular and chronic kidney disease at hemodialysis initiation.

METHODS

Twenty consecutive very elderly patients with end-stage renal disease (ESRD) (≥80 years; VE group) and 35 consecutive control patients with ESRD (<60 years; control group) were included in this study. All patients had started maintenance hemodialysis therapy at our institution. We evaluated the clinical characteristics, laboratory data, thoracic aortic calcification (TAC) and echocardiographic parameters, including aortic valve calcification (AVC), mitral valve calcification and mitral annular calcification (MAC).

RESULTS

The diastolic blood pressure was significantly lower and pulse pressure values were significantly higher in the VE group than in the control group, whereas the estimated glomerular filtration rate and cardiac function were comparable between the two groups. Despite having lower serum phosphate and calcium-phosphate product levels, the VE group exhibited more severe TAC, AVC and MAC than the control group. Furthermore, the duration of hospitalization was significantly shorter in the very elderly patients followed by nephrologists than in those who were not.

CONCLUSION

Our findings suggest that atherosclerotic lesions are more severe in very elderly patients at hemodialysis initiation.

The growth of acute kidney injury: a rising tide or just closer attention to detail?

Acute kidney injury (AKI), previously termed acute renal failure, is associated with increased mortality, prolonged hospital stay, and accelerated chronic kidney disease (CKD). Over the past 2 decades, dramatic rises in the incidences of AKI have been reported, particularly within the United States. The question arises as to whether these changes reflect actual increases in disease incidence, or are potentially explained by the introduction of consensus definitions that rely on small standardized changes in serum creatinine, changes in coding and reimbursement, or increasingly available and more liberal use of dialysis. In this review, we explore the secular trends in AKI incidence in North America and Western Europe and its potential contributors.

Effect of dialysis initiation timing on clinical outcomes: a propensity-matched analysis of a prospective cohort study in Korea

BACKGROUND

Controversy persists regarding the appropriate initiation timing of renal replacement therapy for patients with end-stage renal disease. We evaluated the effect of dialysis initiation timing on clinical outcomes. Initiation times were classified according to glomerular filtration rate (GFR).

METHODS

We enrolled a total of 1691 adult patients who started dialysis between August 2008 and March 2013 in a multi-center, prospective cohort study at the Clinical Research Center for End Stage Renal Disease in the Republic of Korea. The patients were classified into the early-start group or the late-start group according to the mean estimated GFR value, which was 7.37 ml/min/1.73 m2. The primary outcome was patient survival, and the secondary outcomes were hospitalization, cardiovascular events, vascular access complications, change of dialysis modality, and peritonitis. The two groups were compared before and after matching with propensity scores.

RESULTS

Before propensity score matching, the early-start group had a poor survival rate (P<0.001). Hospitalization, cardiovascular events, vascular access complications, changes in dialysis modality, and peritonitis were not different between the groups. A total of 854 patients (427 in each group) were selected by propensity score matching. After matching, neither patient survival nor any of the other outcomes differed between groups.

CONCLUSIONS

There was no clinical benefit after adjustment by propensity scores comparing early versus late initiation of dialysis.

The right patient, the right treatment, the right access and the right time

As the incidence of CKD increases, so will the ESRD population. Pre-ESRD care, including early referral to nephrology and patient education, enables patients and providers working together to determine which therapy modality is best suited for their individualized needs: conservative therapy, kidney transplant, hemodialysis, or peritoneal dialysis. Differentiating the therapy modality should be based on many factors and not solely based on outcome data. Acknowledging that there is no "one-size-fits-all" therapy modality allows the patient and the interdisciplinary team to ensure that the appropriate access is chosen at the appropriate time. Lastly, the timing of initiation is paramount for improving patient outcomes, including less central venous catheter placement in incident hemodialysis and more planned arteriovenous accesses, improved quality of life, less hospitalization time, and reduced costs.

Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry

BACKGROUND

Several observational studies of hemodialysis patients show an association between early dialysis therapy initiation and increased mortality. Few studies have examined this association among peritoneal dialysis patients.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

A cohort of 8,047 incident peritoneal dialysis patients who started dialysis therapy in 2001-2009 and were treated in Canada.

PREDICTOR

Estimated glomerular filtration rate (eGFR) at dialysis therapy initiation. Defined early, mid, and late starts as eGFR>10.5, 7.5-10.5, and <7.5mL/min/1.73m(2), respectively.

OUTCOMES

Time to death.

MEASUREMENTS

Proportional piecewise exponential survival models to compare mortality (overall and early) for the 3 predictor groups.

RESULTS

Between 2001 and 2009, the proportion of patients starting peritoneal dialysis therapy as early starts increased from 29% (95% CI, 26%-32%) to 44% (95% CI, 41%-47%). Compared with the late-start group, the overall mortality rate was not higher for the early- (adjusted HR, 1.08; 95% CI, 0.96-1.23) or mid-start (adjusted HR, 0.96; 95% CI, 0.86-1.09) groups. However, when examined yearly, patients in the early-start group were significantly more likely to die within the first year of dialysis therapy compared with those in the late-start group (adjusted HR, 1.38; 95% CI, 1.10-1.73), but not in subsequent years.

LIMITATIONS

Bias and residual confounding may have influenced the observed relationship between predictor and outcome.

CONCLUSIONS

Patients are initiating peritoneal dialysis therapy at increasingly higher eGFRs. Contrary to most observational studies assessing hemodialysis, the early initiation of peritoneal dialysis therapy, at eGFR>10.5mL/min/1.73m(2), is not associated with increased mortality.

Controversies in timing of dialysis initiation and the role of race and demographics

Dialysis remains the predominant form of renal replacement therapy in the United States, but the optimal timing for the initiation of dialysis remains poorly defined. Not only clinical factors such as signs/symptoms of uremia, co-existing cardiovascular disease, and presence of diabetes but also key demographic characteristics including age, gender, race/ethnicity, and socioeconomics have all been considered as potential modifying factors in the decision for the timing of dialysis initiation. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of chronic kidney disease (CKD) suggests that dialysis be initiated when signs/symptoms attributable to kidney failure such as serositis, acid-base or electrolyte abnormalities, pruritus, poorly controlled volume status or blood pressure, deteriorating nutritional status despite dietary intervention, or cognitive impairment are visible or noted. These signs/symptoms typically occur when the glomerular filtration rate (GFR) is in the range of 5-10 ml/minute/1.73 m(2) , although they may occur at higher levels of GFR. We review recent data on the timing of dialysis initiation, their implications for managing patients with late-stage CKD, and the important role of considering key demographics in making patient-centered decisions for the timing of dialysis initiation.

Dialysis initiation: what's the rush?

The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided.

Financial and medico-legal implications of late-start dialysis: understanding the present policies through a window of past performance

In the United States, multiple stakeholders have impacted the timing of dialysis initiation for patients with end-stage renal disease. The optimal policy to start dialysis for this vulnerable population remains unknown. Historically, patients initiated dialysis weeks after the appearance of uremic symptoms. This changed not only due to an evolution in medical providers' practice but also due to changes in the care delivery system, the political imperatives, and the economic driving forces surrounding the care of these patients. One large randomized control trial looked at patient outcomes with strategies of early versus late start. The trial included an economic analysis. Depending on the specific comparison, cost was either lower in the late-start group or was equivalent between groups. This result would tend to favor a late-start strategy, where patients had an additional 6 months of dialysis-free time. However, the generalizability of this analysis has been questioned. Future care models that would include patients before and after dialysis initiation would be ideal to study cost and quality at the time of this transition of care. The recently implemented CMS Quality Incentive Program is one mechanism that could use such findings to implement a high-value strategy for patients starting chronic dialysis therapies.

Timing of return to dialysis in patients with failing kidney transplants

In the last decade, the number of patients starting dialysis after a failed kidney transplant has increased substantially. These patients appear to be different from their transplant-naïve counterparts, and so may be the timing of dialysis therapy initiation. An increasing number of studies suggest that in transplant-naïve patients, later dialysis initiation is associated with better outcomes. Very few data are available on timing of dialysis reinitiation in failed transplant recipients, and they suggest that an earlier return to dialysis therapy tended to be associated with worse survival, especially among healthier and younger patients and women. Failed transplant patients may also have unique issues such as continuation of immunosuppression versus withdrawal or the need for remnant allograft nephrectomy with regard to dialysis reinitiation. These patients may have a different predialysis preparation work-up, worse blood pressure control, higher or lower serum phosphorus levels, lower serum bicarbonate concentration, and worse anemia management. The choice of dialysis modality may also represent an important question for these patients, even though there appears to be no difference in mortality between patients starting peritoneal versus hemodialysis. Finally, failed transplant patients returning to dialysis appear to have a higher mortality rate compared with transplant-naïve incident dialysis patients, especially in the first several months of dialysis therapy. In this review, we will summarize the available data related to the timing of dialysis initiation and outcomes in failed kidney transplant patients after returning to dialysis.

Initiation of dialysis should be timely: neither early nor late

Over the last decade, individuals with end-stage renal disease (ESRD) in the United States are starting maintenance dialysis therapy at progressively higher estimated glomerular filtration rate (eGFR). Moreover, several observational studies have demonstrated an association of a higher risk of death with higher serum creatinine-based estimates of GFR at the time of initiation of dialysis. In contrast, studies in which renal function has been measured by timed urinary collection show either a lower risk of death or no significant association with higher GFR at the time of initiation of dialysis. There are numerous potential sources of bias in such observational studies, particularly in those that use serum creatinine-based eGFR. The only randomized controlled clinical trial to have examined this question did not demonstrate either benefit or harm with initiation of dialysis at higher level of renal function. Thus, the data to date suggest that eGFR should not be the sole consideration when assessing the need for initiating maintenance dialysis in patients with advanced chronic kidney disease. Given the high societal costs of starting renal replacement therapy earlier in the course of the disease, these considerations also suggest that dialysis can be safely be postponed in otherwise asymptomatic individuals with advanced chronic kidney disease. By the same token, dialysis should not be denied to individuals who could clearly benefit from renal replacement therapy simply because the GFR is too high (viz., volume overload, refractory hyperkalemia). Finally, there is a compelling need to reexamine the symptoms that could be attributed to uremia and clearly improve upon initiation of dialysis to better guide clinical decision-making.

Has the yearly increase in the renal replacement therapy population ended?

The recent decline in the number of new patients undergoing dialysis and transplantation in the United States may be linked to a reduction in the incidence of early-start dialysis, defined as the initiation of renal replacement therapy (RRT) at an estimated GFR ≥10 ml/min per 1.73 m(2). We examined the most recent data from the U.S. Renal Data System to determine how this trend will affect the future incidence of ESRD in the United States. The percentage of early dialysis starts grew from 19% to 54% of all new starts between 1996 and 2009 but remained stable between 2009 and 2011. Similarly, the incident RRT population increased substantially in all age groups between 1996 and 2005, with the largest increase occurring in patients aged ≥75 years. Early dialysis starts accounted for most of the increase in the incident RRT population in all age groups during this time period, and between 2005 and 2010, the increase slowed dramatically. Although the future incident RRT population will be determined in part by population growth, these results suggest that later dialysis starts and greater use of conservative and palliative care, which may improve quality of life for elderly patients with advanced renal failure, will continue to attenuate the increase observed in previous years.

Effect of timing of dialysis commencement on clinical outcomes of patients with planned initiation of peritoneal dialysis in the IDEAL trial

BACKGROUND

Since the mid-1990s, early dialysis initiation has dramatically increased in many countries. The Initiating Dialysis Early and Late (IDEAL) study demonstrated that, compared with late initiation, planned early initiation of dialysis was associated with comparable clinical outcomes and increased health care costs. Because residual renal function is a key determinant of outcome and is better preserved with peritoneal dialysis (PD), the present pre-specified subgroup analysis of the IDEAL trial examined the effects of early-compared with late-start dialysis on clinical outcomes in patients whose planned therapy at the time of randomization was PD.

METHODS

Adults with an estimated glomerular filtration rate (eGFR) of 10 - 15 mL/min/1.73 m(2) who planned to be treated with PD were randomly allocated to commence dialysis at an eGFR of 10 - 14 mL/min/1.73 m(2) (early start) or 5 - 7 mL/min/1.73 m(2) (late start). The primary outcome was all-cause mortality.

RESULTS

Of the 828 IDEAL trial participants, 466 (56%) planned to commence PD and were randomized to early start (n = 233) or late start (n = 233). The median times from randomization to dialysis initiation were, respectively, 2.03 months [interquartile range (IQR):1.67 - 2.30 months] and 7.83 months (IQR: 5.83 - 8.83 months). Death occurred in 102 early-start patients and 96 late-start patients [hazard ratio: 1.04; 95% confidence interval (CI): 0.79 - 1.37]. No differences in composite cardiovascular events, composite infectious deaths, or dialysis-associated complications were observed between the groups. Peritonitis rates were 0.73 episodes (95% CI: 0.65 - 0.82 episodes) per patient-year in the early-start group and 0.69 episodes (95% CI: 0.61 - 0.78 episodes) per patient-year in the late-start group (incidence rate ratio: 1.19; 95% CI: 0.86 - 1.65; p = 0.29). The proportion of patients planning to commence PD who actually initiated dialysis with PD was higher in the early-start group (80% vs 70%, p = 0.01).

CONCLUSION

Early initiation of dialysis in patients with stage 5 chronic kidney disease who planned to be treated with PD was associated with clinical outcomes comparable to those seen with late dialysis initiation. Compared with early-start patients, late-start patients who had chosen PD as their planned dialysis modality were less likely to commence on PD.

Regional variation in care at the end of life: discontinuation of dialysis

Background

Regional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care. The interpretation of patterns of regional variation hinges, in part, on appropriate adjustment for regional variation in demographic variables such as age, race, sex, and rural vs. urban residence. This study examined regional variation in discontinuation of dialysis prior to death in the US, after adjustment for key demographic variables.

Methods

In this retrospective cohort study of the 2009 United States Renal Data System (USRDS) database we examined discontinuation of dialysis prior to death among deceased adult patients with end-stage renal disease (ESRD) from the 50 states and the District of Columbia. The discontinuation of dialysis prior to death was ascertained from the Centers for Medicare & Medicaid Services form 2746 (ESRD Death Notification form). We used logistic regression to estimate the log-odds of discontinuation of dialysis with ESRD network as independent variable adjusted for urban–rural status, demographic and treatment variables.

Results

The study cohort included 715,605 deceased ESRD patients; for 176,021 of whom (24.6%) dialysis was discontinued prior to death. Dialysis was discontinued at higher rates for women than for men (26.3% vs. 23.0%, p < 0.001) and for whites than for blacks (29.5% vs. 14.7%, p < 0.001). Significant regional variation in dialysis discontinuation prior to death was noted after adjustment for age, race and rural–urban status: rates of discontinuation in the Upper Midwest and Mountain regions were more than double the rates in Southern and Coastal regions. This pattern parallels the regional pattern of end-of-life health service utilization documented in the Dartmouth Atlas and other studies.

Conclusions

Discontinuation of dialysis prior to death was common in the US between 1995 and 2009. The deaths of nearly one quarter of chronic dialysis patients followed a decision to discontinue dialysis. Significant regional variation in discontinuation rates exists after adjusting for age, race, sex, and rural–urban status. Further research and analysis is needed on the cultural and economic factors that affect regional variation in health services utilization, especially in regard to the use of expensive medical services near the end of life.