Association between estimated glomerular filtration rate at initiation of dialysis and mortality

Clark, William F.; Na, Yingbo; Rosansky, Steven J.; Sontrop, Jessica M.; Macnab, Jennifer; Glassock, Richard J.; Eggers, Paul W.; Jackson, Ken; Moist, Louise

doi:10.1503/cmaj.100349

Cited by 105 publications

(107 citation statements)

References 30 publications

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

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

confidence: 99%

“…In addition, they were unable to assess clinical status or specific reasons to start RRT at a particular moment in time. [2][3][4][5] The IDEAL (Initiating Dialysis Early and Late) trial was the first randomized controlled trial attempting to assess whether starting dialysis therapy at high (10-14 mL/min/1.73 m 2 ) or low (5-7 mL/min/1.73 m 2 ) estimated glomerular filtration rates (eGFRs) is more beneficial with respect to patient survival. However, 76% of patients randomly assigned to start at low eGFRs actually started at higher levels because of uremic signs and symptoms, resulting in a relatively small difference in eGFRs between the groups.…”

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confidence: 99%

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

Luijtgaarden

Noordzij

Tomson

et al. 2012

American Journal of Kidney Diseases

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

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

confidence: 99%

mentioning

confidence: 99%

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

Luijtgaarden

Noordzij

Tomson

et al. 2012

American Journal of Kidney Diseases

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“…These studies led to promulgation of the so-called healthy start dialysis concept, where dialysis was instigated before the development of uremic signs and symptoms (10). Conversely, a number of more recently published observational studies, including a meta-analysis (11), has shown that dialysis initiation at higher estimated GFR (eGFR) levels is paradoxically associated with an increased risk of mortality compared with initiation at lower levels (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). These results may have been limited by selection, indication, survivor, and misclassification biases.…”

Section: Introductionmentioning

confidence: 99%

Association between GFR Estimated by Multiple Methods at Dialysis Commencement and Patient Survival

Pollock

Cooper

Branley

et al. 2014

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives The Initiating Dialysis Early and Late study showed that planned early or late initiation of dialysis, based on the Cockcroft and Gault estimation of GFR, was associated with identical clinical outcomes. This study examined the association of all-cause mortality with estimated GFR at dialysis commencement, which was determined using multiple formulas.Design, setting, participants, & measurements Initiating Dialysis Early and Late trial participants were stratified into tertiles according to the estimated GFR measured by Cockcroft and Gault, Modification of Diet in Renal Disease, or Chronic Kidney Disease-Epidemiology Collaboration formula at dialysis commencement. Patient survival was determined using multivariable Cox proportional hazards model regression.Results Only Initiating Dialysis Early and Late trial participants who commenced on dialysis were included in this study (n=768). A total of 275 patients died during the study. After adjustment for age, sex, racial origin, body mass index, diabetes, and cardiovascular disease, no significant differences in survival were observed between estimated GFR tertiles determined by Cockcroft and Gault (lowest tertile adjusted hazard ratio, 1.11; 95% confidence interval, 0.82 to 1.49; middle tertile hazard ratio, 1.29; 95% confidence interval, 0.96 to 1.74; highest tertile reference), Modification of Diet in Renal Disease (lowest tertile hazard ratio, 0.88; 95% confidence interval, 0.63 to 1.24; middle tertile hazard ratio, 1.20; 95% confidence interval, 0.90 to 1.61; highest tertile reference), and Chronic Kidney Disease-Epidemiology Collaboration equations (lowest tertile hazard ratio, 0.93; 95% confidence interval, 0.67 to 1.27; middle tertile hazard ratio, 1.15; 95% confidence interval, 0.86 to 1.54; highest tertile reference).Conclusion Estimated GFR at dialysis commencement was not significantly associated with patient survival, regardless of the formula used. However, a clinically important association cannot be excluded, because observed confidence intervals were wide.

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“…1,8,9 In parallel with the introduction of automated eGFR reporting, a steady rise in the eGFR at dialysis initiation has been observed over the same decade. [10][11][12] This trend is concerning, because the initiation of dialysis at higher levels of eGFR is associated with early mortality and excess costs. 11,[13][14][15] Reasons for why these trends are occurring seem multifactorial.…”

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confidence: 99%

“…[10][11][12] This trend is concerning, because the initiation of dialysis at higher levels of eGFR is associated with early mortality and excess costs. 11,[13][14][15] Reasons for why these trends are occurring seem multifactorial. [16][17][18] Dialysis patients are, on average, older with substantial comorbid illnesses; therefore, determining whether nonspecific symptoms, such as fatigue, are attributed to uremia or underlying illness is difficult.…”

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confidence: 99%

The Association of eGFR Reporting with the Timing of Dialysis Initiation

Sood

Komenda

Rigatto

et al. 2014

Journal of the American Society of Nephrology

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Automated reporting of eGFR by laboratories has been widely implemented during the last decade. Over this same period, a steady increase in eGFR at dialysis initiation has been reported. This study examined trends in eGFR at dialysis initiation over time among incident dialysis patient populations before and after eGFR reporting. All patients who initiated dialysis between January of 2001 and December of 2010 in four Canadian provinces that implemented province-wide automated eGFR reporting and had an eGFR measure at dialysis initiation were included in the study (n=22,208). The primary outcome was change over time in eGFR among patients at dialysis initiation. An interrupted time series and adjusted multilevel regression models were used to determine the differences in eGFR at dialysis initiation before and after reporting. We observed a linear increase in the mean eGFR at dialysis initiation from 9.1 to 10.8 ml/min per m 2 during the study period. There was no change in the trajectory of the eGFR at dialysis initiation before or after eGFR reporting in crude or adjusted models accounting for case mix and facility characteristics. These findings were consistent among age and sex strata and when the proportions of patients with an eGFR$10.5 or $12 ml/min per m 2 were examined. In conclusion, automated laboratory-based eGFR reporting did not influence eGFR at dialysis initiation among incident dialysis patient populations. Concerns that widespread eGFR reporting leads to earlier dialysis initiation are not supported by this study.

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Association between estimated glomerular filtration rate at initiation of dialysis and mortality

Cited by 105 publications

References 30 publications

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

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

Association between GFR Estimated by Multiple Methods at Dialysis Commencement and Patient Survival

The Association of eGFR Reporting with the Timing of Dialysis Initiation

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