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Study finds no clinical reason why patients are initiating dialysis earlier

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Patients with advanced kidney disease have been starting dialysis progressively earlier in the course of their disease, likely because doctors are embracing higher levels of kidney function as being appropriate for dialysis initiation, according to a new study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN).

Researchers Ann O’Hare, MD, MA, Paul Hebert Ph, and their colleagues from the University of Washington reviewed the medical records of a random sample of 1,691 patients who initiated maintenance dialysis in the Department of Veterans Affairs from 2000–2009 to characterize trends in clinical presentation in relation to eGFR at initiation.

Between fiscal years 2000–2004 and 2005–2009, mean eGFR at initiation increased from 9.865.8 to 11.065.5 ml/min per 1.73 m2. The percentage of patients with an eGFR of 10–15 ml/min per 1.73 m2 increased from 23.4% to 29.9%, and the percentage of patients with an eGFR15 ml/min per 1.73 m2 increased from 12.1% to 16.3% .

"An upward trend in eGFR at dialysis initiation within the VA health care system from 2000 to 2009 seems to reflect changes in the timing of dialysis initiation among patients with similar indications rather than changing indications over time," the authors wrote.

Neither the percentage of patients who were acutely ill nor the distribution of different types of clinical signs or symptoms present around the time of dialysis initiation changed appreciably over time. Cardiopulmonary and gastrointestinal signs and symptoms and weakness and/or fatigue were the most commonly documented. Also, while treatment decisions were occasionally driven by level of kidney function in the absence of other clinical signs or symptoms, this practice was no more common in recent compared with earlier years.

The results suggest that doctors’ practices have changed over the years to embrace higher levels of kidney function as being appropriate for dialysis initiation among symptomatic patients with advanced kidney disease.

“Our findings seem to highlight the influential role of opinion-based clinical practice guidelines in promoting earlier initiation of dialysis across a wide range of different clinical contexts over this time period,” said Dr. O’Hare.

The authors noted that studies on the benefits and harms of dialysis compared with other approaches to managing cardiopulmonary, gastrointestinal, and other symptoms of patients with advanced kidney disease are needed.

"Our findings seem to indicate that dialysis initiation practices have changed over time to embrace higher threshold levels of eGFR as being appropriate for dialysis initiation across a wide range of different clinical contexts," the authors wrote.