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Discrepancies cited as reason for early dialysis commencement

Physicians may be initiating dialysis earlier for symptomatic patients with advanced kidney disease who have high estimated glomerular filtration rates, according to recently published data.

“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 ,” Ann M. O’Hare, MA, MD, of the department of Veterans Affairs Puget Sound Healthcare System, Seattle, said in a press release.

To analyze the trends of dialysis initiation in conjunction with estimated glomerular filtration rates (eGFR), O’Hare and colleagues reviewed medical records from between 2000 and 2009 from the Department of Veterans Affairs (VA). Researchers evaluated a random sampling of patients (n = 1,691) who had begun dialysis at the VA.

Cohorts who began dialysis later in the study period had a greater frequency of diabetes, a higher median risk score and a similar prevalence for comorbid conditions in comparison with patients who began treatment in the study period.

Results demonstrated that the mean eGFR at the start of dialysis increased from 9.8 mL/min to 11.0 mL/min per 1.73 m² (P < .001) from the fiscal period of 2000 to 2004 and 2005 to 2009. Among patients with an eGFR of 10 to 15 mL/min per 1.73 m², initiation increased from 23.4% to 29.9% (P = .002), and patients with eGFR > 15mL/min per 1.73 m² increased from 12.1% to 16.3% (P = .01), according to researchers.

The researchers found the adjusted odds for initiating dialysis with an eGFR between 10 to 15 mL/min or > 15 mL/min per 1.73 m² was 1.43 between 2005 and 2009 (95% CI, 1.13 -1.81) and 1.46 (95% CI, 1.09 – 1.97) between 2000 and 2004.

Data did not show why there was an upward trend in eGFR at dialysis initiation between 2000 and 2009 since changes in the percentage of patients who were acutely ill or showed other clinical signs or symptoms did not change during this time period.

“We suspect that a selective increase in the frequency of dialysis initiation at very high levels of eGFR among patients with softer indications for dialysis probably reflects the effect of changes in opinion-based clinical practice guidelines for dialysis initiation from the late 1990s onward,” O’Hare and colleagues wrote. – by Casey Hower

Disclosure: O’Hare reports receiving royalties from UpToDate. Please see the full study for a list of all other authors’ relevant financial disclosures.