Early Initiation of Dialysis Fails to Prolong Survival in Patients with End-Stage Renal Failure

Traynor, Jamie P.; Simpson, Keith; Geddes, Colin C.; Deighan, Christopher J.; Fox, Jonathan G.

doi:10.1097/01.asn.0000025294.40179.e8

Cited by 224 publications

(155 citation statements)

References 18 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

View full text Add to dashboard Cite

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“…Despite the weak evidence, early initiation was accepted and it was common practice until recently. More recent studies, including a randomized controlled trial, did not support early initiation of dialysis in CKD patients [5,8,9,12,[15][16][17][18]. The large multicenter trial from Netherland, the Netherlands Cooperative Study on the Adequacy of Dialysis, was the first observational study which casts doubt on the advantages of early dialysis initiation [7].…”

Section: Discussionmentioning

confidence: 99%

“…In 2003, Beddhu et al [9] reported that higher eGFR was associated with higher risk of death, but in a subgroup of patients with measured creatinine clearance, there was no association with mortality. Traynor et al [8], on the other hand, reported that higher creatinine clearance at initiation of dialysis was associated with elevated mortality risk. The largest observational study from the USA found a dose-dependent increase in mortality associated with earlier dialysis initiation.…”

Section: Discussionmentioning

confidence: 99%

“…Data from the US Renal Data System (USRDS) between 1996 and 2008 showed that the proportion of patients initiating hemodialysis (HD) with an estimated GFR (eGFR) >10 mL/min/ 1.73m 2 increased from 20 to 52% and those with a starting eGFR of ≥15 mL/min/1.73m 2 increased from 4 to 17% [5,6]. Interestingly, most of the recent observational trials and a landmark randomized controlled trial failed to show a survival benefit of early initiation of dialysis in CKD patients [5,[7][8][9][10][11][12][13][14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

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Estimated Glomerular Filtration Rate at Re-Initiation of Dialysis and Mortality in Failed Kidney Transplant Recipients

2012

American Journal of Kidney Diseases

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Background. Recent observational studies and a controlled trial suggest more favorable outcomes upon later dialysis initiation in chronic kidney disease. The role of estimated glomerular filtration rate (eGFR) in predicting outcome at reinitiation of dialysis in failed kidney transplant recipients is unclear. Methods. Five-year data in a large dialysis organization was linked to the 'Scientific Registry of Transplant Recipients' to identify 747 failed kidney transplant patients with CKD Stage 5, who had restarted dialysis therapy. A propensity score for early (eGFR >10.5 mL/min/1.73m 2 ) versus late reinitiation of dialysis was fit by logistic regression. The mortality hazard ratio (HR) was estimated across tertiles of the fitted score. Results. Patients were 44 ± 14 years old and included 42% women. Male gender {odds ratio (OR), [95% confidence interval (CI)]: 1.82 (1.22-2.73)}, diabetes mellitus [OR: 1.75 (1.14-2.68)] and peripheral vascular disease [OR: 3.55 (1.17-10.77)] were associated with higher odds of early dialysis reinitiation. Each mL/min/1.73m 2 higher eGFR was associated with 6% higher death risk in unadjusted model [HR: 1.06 (1.01-1.11)], and although not significant in fully adjusted models [HR: 1.02 (0.96-1.07)], it was significant in some subgroups including women and younger patients. The death HR of higher eGFR across lowest to highest tertiles of propensity score of early dialysis initiation (corresponding healthiest to sickest patients) were 1.10 (0.98-1.24), 1.00 (0.91-1.10) and 0.99 (0.92-1.07), respectively (P for trend <0.05), indicating a trend toward higher mortality risk with earlier dialysis initiation in the healthiest patients. Conclusions. Earlier return to dialysis therapy in failed kidney transplant patients tends to correlate with worse dialysis survival especially among healthiest and younger patients and women. Additional studies need to verify these findings.

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Early Start of Hemodialysis May Be Harmful

Rosansky

Eggers²,

Jackson³

et al. 2011

Arch Intern Med

152

131

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Early Initiation of Dialysis Fails to Prolong Survival in Patients with End-Stage Renal Failure

Cited by 224 publications

References 18 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

Estimated Glomerular Filtration Rate at Re-Initiation of Dialysis and Mortality in Failed Kidney Transplant Recipients

Early Start of Hemodialysis May Be Harmful

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