Has the Yearly Increase in the Renal Replacement Therapy Population Ended?

Abstract

The recent decline in the number of new patients undergoing dialysis and transplantation in the United States may be linked to a reduction in the incidence of earlystart dialysis, defined as the initiation of renal replacement therapy (RRT) at an estimated GFR $10 ml/min per 1.73 m 2 . We examined the most recent data from the U.S. Renal Data System to determine how this trend will affect the future incidence of ESRD in the United States. The percentage of early dialysis starts grew from 19% to 54% of all new starts between 1996 and 2009 but remained stable between 2009 and 2011. Similarly, the incident RRT population increased substantially in all age groups between 1996 and 2005, with the largest increase occurring in patients aged $75 years. Early dialysis starts accounted for most of the increase in the incident RRT population in all age groups during this time period, and between 2005 and 2010, the increase slowed dramatically. Although the future incident RRT population will be determined in part by population growth, these results suggest that later dialysis starts and greater use of conservative and palliative care, which may improve quality of life for elderly patients with advanced renal failure, will continue to attenuate the increase observed in previous years.

What Drives Early Dialysis Initiation and How Do We Optimize Timing of RRT?

“…There is some evidence that the trend for initiation of dialysis at higher GFRs started to reverse in 2009 (13). This is also evident in Figure 2 in the article by Sood et al (8), in which there is a steady upward trend in early dialysis initiation until 2010.…”

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

“…Despite recent evidence to the contrary (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17), initial observational studies suggested that starting dialysis at higher levels of kidney function might be beneficial, and opinion-based clinical practice guidelines have generally supported a progressively more liberal approach to dialysis initiation (18). Until recently (19), there has been a pervasive temporal trend toward dialysis initiation at increasingly higher levels of eGFR (10,12,(20)(21)(22)(23). The drivers of this trend are poorly understood (6)(7)(8)(10)(11)(12)(13)(14)(15)(16).…”

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

“…In conclusion, the trend toward a progressively earlier start of dialysis is not supported by clinical evidence (4,8). The early-start trend is related not just to patient comorbidity issues and renal function levels but also to provider biases and practice patterns.…”