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

Abstract

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...

Provider and Care Characteristics Associated with Timing of Dialysis Initiation

“…This finding contrasts with the findings of a European study that found that women nephrologists aimed to start dialysis at higher eGFRs (12). Although 35% of the nephrologists who responded to the questionnaires in the European study were women, only 15% of the patients in our cohort were cared for by women nephrologists.…”

“…Possibly, HSAs differ in their capacity to accommodate patients with ESRD, competition for patients, incentive to initiate patients at lower eGFRs, and health care intensity (29). In a study of factors that influence the decision to start dialysis among European nephrologists, presence of a waiting list in a dialysis facility was cited as a reason to delay dialysis initiation (12). Also, nephrologists from countries with high incidence of treated ESRD and nephrologists who practiced in forprofit dialysis facilities chose higher eGFR for dialysis initiation and were more likely to initiate their patients early in the presence of advanced age and chronic conditions (12).…”

“…In a study of factors that influence the decision to start dialysis among European nephrologists, presence of a waiting list in a dialysis facility was cited as a reason to delay dialysis initiation (12). Also, nephrologists from countries with high incidence of treated ESRD and nephrologists who practiced in forprofit dialysis facilities chose higher eGFR for dialysis initiation and were more likely to initiate their patients early in the presence of advanced age and chronic conditions (12). Similarly, in the United States, incidence of treated ESRD, particularly among elderly patients and patients with multiple comorbid conditions, is highest in regions with the highest intensity of end of life care (29).…”

The Association of eGFR Reporting with the Timing of Dialysis Initiation

“…For example, in a recent European survey of nephrologists, 11% felt that starting dialysis in patients with eGFR$10.5 ml/min per m 2 was always beneficial, even in the absence of symptoms. 20 The clinical uncertainty about when to start dialysis was reported in Canada, where facility-level variation in eGFR at dialysis initiation was found to be 4.5% after accounting for case mix and facility-level factors. 21 A recent international survey study randomized clinical vignettes presented to nephrologists to contain one of eGFR or serum creatinine and assessed opinions regarding the initiation of dialysis.…”

Early Dialysis Initiation, a Look from the Rearview Mirror to What’s Ahead

“…Although symptoms of renal failure may drive dialysis start in the future, a recent European survey of nephrologists found that eGFR is still an important consideration (14). The 2012 Kidney Disease Improving Global Outcomes guidelines on dialysis initiation state that renal failure symptoms are likely to occur at an eGFR of 5-9 ml/min per 1.73 m 2 (15).…”