Dialysis timing may be deferred toward very late initiation: An observational study

Abstract

The optimal timing to initiate dialysis among patients with an estimated glomerular filtration rate (eGFR) of <5 mL/min/1.73 m 2 is unknown. We hypothesized that dialysis initiation time can be deferred in this population even with high uremic burden. A case-crossover study with case (0-30 days before dialysis initiation [DI]) and control (90-120 days before DI) periods was conducted in 1,079 hemodialysis patients aged 18-90 years at China Medical University Hospital between 2006 and 2015. The uremic burden was quantified based on 7 uremic indicators that reached the predefined threshold in case period, namely hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate. Dialysis timing was classified as standard (met 0-2 uremic indicators), late (3-5 indicators), and very late (6-7 indicators). Median eGFR-DI of the 1,079 patients was 3.4 mL/min/1.73 m 2 and was 2.7 mL/min/1.73 m 2 in patients with very late initiation. The median follow-up duration was 2.42 years. Antibiotics, diuretics, antihypertensive medications, and non-steroidal anti-inflammatory drugs (NSAIDs) were more prevalently used during the case period. The fully adjusted hazards ratios of all-cause mortality for the late and very late groups were 0.97 (95% confidence interval 0.76-1.24) and 0.83 (0.61-1.15) compared with the standard group. It is safe to defer dialysis initiation among patients with chronic kidney disease (CKD) having an eGFR of <5 mL/min/1.73 m 2 even when patients having multiple biochemical uremic burdens. Coordinated efforts in acute infection prevention, optimal fluid management, and prevention of accidental exposure to NSAIDs are crucial to prolong the dialysis-free survival.

Optimal initiation of dialysis in end stage kidney disease patients: is it a resolved question? A Systematic Literature Review

“…Hence, a number of other studies paid attention to comprehensive assessment of uremic signs and/or symptoms for optimal dialysis initiation. Chang et al [17] quanti ed uremic burden based on 7 uremic indicators that reached the prede ned threshold (hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate); dialysis timing was classi ed as standard (met 0-2 uremic indicators), late (3-5indicators), and very late (6-7 indicators); and no correlation was found between late or very late group and mortality. Ying et al [26] developed an equation based on fuzzy mathematics to assess the timing of haemodialysis initiation, the results showed that the combination of sex, age, serum creatinine, blood urea nitrogen, serum albumin, haemoglobin, serum phosphorus, diabetes mellitus, and heart failure as equation variables resulted in the best accuracy to prognose 3-year survival.…”

“…Liu et al [14] demonstrated that after adjusting for effectors of age, gender, diabetes, type of vascular access at initiation, clinical signs, and/or symptoms at the initiation of dialysis, and serum albumin, there was no signi cant difference in survival rate between the 3 groups (< 4 mL/min/1.73 m 2 was used as the reference, in comparison with 4-8 mL/min/1.73 m 2 [p = 0.681] and > 8 mL/min/1.73 m 2 [p = 0.403]). Chang et al [17] also found the fully adjusted hazards ratios of mortality for the late (3-5indicators) and very late (6-7 indicators) groups were 0.97 (95% con dence interval 0.76-1.24) and 0.83 (0.61-1.15) compared with the standard (met 0-2 uremic indicators) group. The 7 uremic indicators that reached the prede ned threshold in case period, namely hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate.…”

“…The smallest study included 72 patients [15] and the largest included 10 692 patients [12]. Four studies included only haemodialysis patients [11,14,17,18], three studies only peritoneal dialysis patients [8, 15,16] and the rest included both. All but two studies used Cox proportional hazards regression to calculate hazard ratios (HRs) for mortality.…”

The ratio and difference of urine protein-to-creatinine ratio and albumin-to-creatinine ratio facilitate risk prediction of all-cause mortality

“…All patients enrolled in the CMUH-CRDR were followed up until December 31, 2017, or death—whichever occurred earlier. The description of CMUH-CRDR had been reported in our previous work 31 , 32 .…”

Algoritmo de diagnóstico y tratamiento del hiperparatiroidismo secundario en la enfermedad renal crónica avanzada

“…La progresión de las alteraciones bioquímicas del metabolismo mineral en pacientes con ERC avanzada en prediálisis se acompaña de una pérdida de la función renal residual. Las medidas dietéticas de restricción de fosfato en la dieta en pacientes en prediálisis tienen el riesgo de desnutrición energético-proteica 54 y un inicio tardío de la diálisis 55 , por lo cual los autores consideran que los individuos con síntomas urémicos vinculados con elevación progresiva de la PTHi o hiperfosfatemia deben valorarse para el inicio del tratamiento de sustitución de la función renal 56 .…”