Predialysis predictors for identifying patients requiring dialysis at a higher glomerular filtration rate

Background

Current evidence suggests that the initiation of maintenance hemodialysis should not be based on a specific glomerular filtration rate (GFR) but on symptoms or signs attributable to kidney disease. However, it is difficult to predict the time point at which overt uremic syndrome develops in individuals. The estimated GFR is poorly correlated with occurrence of uremic symptoms, and some patients require dialysis at a higher eGFR than others. In this case, patients are more likely to be improperly prepared for dialysis. We investigated the predialysis characteristics of patients who require dialysis at a higher eGFR.

Methods

A total of 453 incident dialysis patients being monitored by a nephrologist from January 2013 to December 2018 were included. The predialysis characteristics when eGFR decreased to 20 mL/min/1.73 m² were obtained.

Results

The mean age was 61 years, and 65.7% were men. Overall, the median eGFR at the first dialysis was 5.8 (interquartile range 4.6–7.3) mL/min/1.73 m² and initiation of dialysis at the first quintile (≥7.8 mL/min/1.73 m²) was defined as ‘early initiation of dialysis’ Among the predialysis characteristics, heart failure (adjusted odds ratio 3.68; 95% confidence interval, 1.59–8.03), serum albumin <4.0 mg/dL (2.22; 1.30–3.77), blood urea nitrogen (BUN)/creatinine (Cr) ratio >15 mg/mg (1.92, 1.16–3.18), and hyperuricemia (1.84; 1.05–3.23) were independent predictors of early initiation. Diabetes mellitus and the causes of kidney disease were not independent predictors of early initiation. The early initiation group was less likely to initiate dialysis with a permanent vascular access than the late initiation group.

Conclusions

For patients with heart failure, low serum albumin level, high BUN/Cr ratio, or hyperuricemia, clinicians can provide predialysis counseling in advance and consider early creation of vascular access.

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate

Background

Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care.

Methods

In the ‘Peridialysis’ study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI.

Results

SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI.

Conclusions

SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Predictors of late presentation to renal dialysis: a cohort study of linked primary and secondary care records in East London

OBJECTIVES

The outcomes and experience of care for patients who start renal replacement therapy (RRT) in an unplanned manner are worse than for those who have planned care. The objective of this study was to examine the primary care predictors of unplanned starts to RRT.

DESIGN

Retrospective cohort study with linked primary care and hospital data.

SETTING

128 general practices in East London with a combined population of 1 043 346 people.

PARTICIPANTS

999 consecutive patients starting dialysis at Barts Health National Health Service Trust between September 2014 and August 2017.

PRIMARY OUTCOME MEASURES

Unplanned versus a planned start to dialysis among the cohort of 389 patients with a linked primary care record. An unplanned start to dialysis is defined as receiving nephrology care in the low clearance clinic (or equivalent) for less than 90 days. A planned start is defined as access to pre-dialysis counselling and care for at least 90 days prior to commencing dialysis.

RESULTS

The adjusted logistic regression analysis showed that the most important modifiable risk factors for unplanned dialysis were the absence of a chronic kidney disease (CKD) code in the general practice (GP) record (OR 8.02, 95% CI 3.65 to 17.63) and the absence of prescribed lipid lowering medication (OR 2.37, 95% CI 1.05 to 5.34). Other contributing factors included male gender and a greater number of long-term conditions.

CONCLUSIONS

Improving CKD coding in primary care and the additional review and clinical scrutiny associated with this may contribute to a further reduction in unplanned RRT rates.

Outcome of the sub-optimal dialysis starter on peritoneal dialysis. Report from the French Language Peritoneal Dialysis Registry (RDPLF)

BACKGROUND

This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks.

METHODS

This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of <30 days on HD before PD initiation.

RESULTS

Among 8527 patients, there were 568 patients who started PD after <30 days on HD. There were 6562 events: 3078 deaths, 2136 transfers to HD, 1348 renal transplantations. When using a Fine and Gray model, sub-optimal dialysis start, early peritonitis and transplant failure were associated with a higher sub-distribution relative hazard of technique failure. There was no association between the sub-optimal dialysis start and the sub-distribution hazard of death or transplantation. In the multivariate analysis using a Fine and Gray regression model, the sub-optimal dialysis start was not associated with a higher sub distribution relative hazard of peritonitis.

CONCLUSIONS

Sub-optimal dialysis initiation is neither associated with a higher risk of death nor with a lower risk of renal transplantation. Sub-optimal PD patients had a higher risk of transfer to HD.