Study finds link between earlier dialysis initiation, ESKD risk in 2 decades
Click Here to Manage Email Alerts
A study of patients receiving care at Kaiser Permanente Northern California showed the likelihood of initiating long-term dialysis at eGFR levels of 10 mL/min/1.73 m2 to 24 mL/min/1.73 m2 increased in the past 2 decades.
According to Chi-yuan Hsu, MD, MSc, of the University of California, San Francisco, and colleagues, the incidence of end-stage kidney disease could have been 16% lower if timing of long-term dialysis initiation had not changed in this way.
“To put the observed relative 16% change between 2001 and 2018 in context, this is approximately two-thirds of the target relative 25% reduction in new ESKD cases by 2030 called for in the 2019 White House Advancing American Kidney Health initiative,” they wrote.
Explaining that no prior studies have examined how patterns in the likelihood of dialysis initiation at varying eGFR levels can impact the number of patients with incident ESKD over time, Hsu and colleagues compared the risk of dialysis initiation by eGFR levels between 2001 to 2018, dividing time into 3-year intervals (an initial cohort consisted of patients who started dialysis between 2001 and 2003; a final cohort consisted of patients who started dialysis between 2016 and 2018). Adjustments were made for age, sex, race and diabetes status.
Results showed the likelihood of initiating dialysis at eGFR levels of 10 mL/min/1.73 m2 to 24 mL/min/1.73 m2 increased over time. More specifically, researchers observed the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% among patients with an index eGFR of 20 mL/min/1.73 m2 to 24 mL/min/1.73 m2, by 6.6% for those with an eGFR of 16 mL/min/1.73 m2 to 17 mL/min/1.73 m2 and by 5.3% for those with an eGFR of 10 mL/min/1.73 m2 to 13 mL/min/m2.
Estimations showed the incidence of ESKD could have been 16% lower if, according to the researchers, there were no changes in system-level practice patterns or other factors besides the timing of dialysis initiation.
Hsu and colleagues stressed the importance of potentially decreasing ESKD incidence by 16%, contending that it could lead to $2.2 billion in cost savings because Medicare spending for out-patient dialysis services was $13.7 billion in 2016 to 2017.
“Given the lack of strong evidence that earlier initiation of long-term dialysis has net clinical benefit, careful evaluation of contemporary dialysis initiation practices is needed, along with ongoing improved shared decision-making efforts to personalize the approach with patients,” the researchers concluded.
Perspective
Back to Top
It has been more than 10 years since nephrologists in the United States and other countries were made aware, by overwhelming clinical evidence, that an early start of dialysis (at a eGFR above 10 mL/min/1.73 m2) is not beneficial for many patients and may well be harmful.1 This study by Hsu and colleagues is another reminder of how many patients start dialysis early (eGFR of more than 15 mL/min/1.73 m2).
The costs of this early start go beyond the financial burden to the Medicare program. More importantly, this practice can lead to unnecessary surgeries, pain, suffering and death as a complication of dialysis. For older adults in the United States with high comorbidities, death in the first 3 months of dialysis was 39% and 55% in the first 6 months of a recent study.
At a minimum, if dialysis is nonemergent and to avoid line sepsis, a delay in creating an AV fistula or graft should be required by Medicare. With the slow loss of renal function for older adults and with the lack of clear benefit to start dialysis, these patients should be managed conservatively unless there is a pressing issue that justifies an early start. Most patients with advanced CKD who do not receive dialysis die of a cardiovascular event and not a renal failure-related event. On the other hand, patients with an eGFR below 5 mL/min/1.73 m2 may be at risk of a renal failure death.
The latest Canadian guideline for dialysis initiation recommends an “intent to defer strategy.” The guideline suggests that patients with an eGFR below 15 mL/min/1.73 m2 be closely monitored with dialysis initiated when clinical indications emerge or eGFR is 6 mL/min/1.73 m2 or less whichever of these comes first. If this guideline was followed, many older adults would die of a non-renal failure issue before ever truly needing dialysis.
Hsu and colleagues refer to the history (unknown to most nephrologists) whereby Medicare required justification for patients to start dialysis when their creatinine clearance was above 10 mL/min/1.73 m2. Clearly, U.S. nephrologists have too many incentives to start patients on dialysis early. The only way to reverse this practice is to require justification for an early start of dialysis to receive payment from CMS.
References:
Nesrallah GE, et al. CMAJ. 2014;doi:10.1503/cmaj.130363.
Rosansky SJ, et al. Semin Dial. 2013;doi:10.1111/sdi.12134.
Thamer M, et al. Am J Kidney Dis. 2015;doi:10.1053/j.ajkd.2015.05.014.
Collapse
Read more about
Click Here to Manage Email Alerts