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Timing of nephrology referral and initiation of dialysis as predictors for survival in hemodialysis patients: 5-year follow-up analysis

  • Nephrology - Original Paper
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Abstract

Background

A consensus about the optimal timing of dialysis initiation is still controversial. Thus, the goal of this analysis was to compare outcomes in patients with early and late referral with early and late initiation of hemodialysis (HD).

Methods

We studied 190 patients (mean age 52.03 ± 14.22) who were initiated on HD between 1994 and 2004. Patients who received regular nephrology care during 12 months before HD initiation were categorized as early referrals (ER) and those without nephrology care were late referrals (LR). The early start (E-start) was defined by the estimated GFR (eGFR) at start of HD ≥7.5 mL/min/1.73 m2, and the late start (L-start) by eGFR of <7.5 mL/min/1.73 m2. The four groups of patients (ER with E-start and L-start; LR with E-start and L-start) were prospectively followed in the next 60 months after HD initiation.

Results

During the follow-up, 43.3 % of E-start and 43.2 % of L-start patients died, without significant difference in survival between the groups [HR for L-start vs. E-start = 1.06 (95 % CI 0.69–1.62); p = 0.797]. When survival between ER and LR groups was compared (28.1 % patients in the ER and 53.2 % in the LR died), there was significant difference in survival [HR for LR vs. ER = 2.16 (95 % CI 1.28–3.65); p = 0.004]. Compared with patients with ER and L-start, higher mortality was observed among those with LR and L-start [HR 3.51 (95 % CI 1.48–8.35); p = 0.004] and LR with E-start [HR 2.79 (95 % CI 1.16–6.7); p = 0.022]. There was no significant difference between patients in ER with L-start and ER with E-start.

Conclusions

Our study showed that ER above 12 months before HD initiation and L-start of dialysis was associated with a reduced mortality risk in HD patients.

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References

  1. Obrador GT, Pereira BJ (1998) Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis 31:398–417

    Article  CAS  PubMed  Google Scholar 

  2. Baer G, Lameire N, Van Biesen W (2010) Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions. NDT Plus 3:17–27

    Google Scholar 

  3. National Kidney Foundation (2002) K-DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 39(Suppl 1):S65–S71

    Google Scholar 

  4. Joint Specialty Committee on Renal Medicine of Royal College of Physicians and the Renal Association and the Renal College of General Practitioners (2006) Chronic kidney disease in adults: UK guidelines for identification, management and referral. Royal College of Physicians, London

    Google Scholar 

  5. Levin A, Mendelssohn DC (2006) Care and referral of adult patients with reduced kidney function: position paper from the Canadian Society of Nephrology. Canadian Society of Nephrology, Vancouver

    Google Scholar 

  6. Thomas MC (2007) The CARI guidelines: prevention of progression of kidney disease: early referral of patients with pre-end-stage kidney disease. Nephrology (Carlton) 12(Supp l1):S41–S43

    Article  Google Scholar 

  7. European Best Practice Guidelines: Measurement of renal function, when to refer and when to start dialysis. (2002) Nephrol Dial Transplant 17(Suppl 7):7–11

  8. National Kidney Foundation (1997) DOQI Clinical Practice Guidelines for hemodialysis and peritoneal dialysis adequacy. Am J Kidney Dis 30:S67–S136

    Article  Google Scholar 

  9. Obrador GT, Aurora P, Kausz AT et al (1999) Level of renal function at the initiation of dialysis in the US end stage renal disease population. Kidney Int 5:2227–2235

    Article  Google Scholar 

  10. US Renal Data System (USRDS) (2009) Annual Data Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases

  11. Stel VS, Tomson C, Ansell D et al (2010) Level of renal function in patients starting dialysis: an ERA-EDTA Registry study. Nephrol Dial Transplant 25(10):3315–3325

    Article  PubMed  Google Scholar 

  12. Clark WF, Na Y, Rosansky SJ et al (2011) Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ 183(1):47–53

    Article  PubMed Central  PubMed  Google Scholar 

  13. Traynor JP, Simpson K, Geddes CC et al (2002) Early initiation of dialysis fails to prolong survival in patients with endstage renal failure. J Am Soc Nephrol 13:2125–2132

    Article  PubMed  Google Scholar 

  14. Kazmi WH, Gilbertson DT, Obrador GT et al (2005) Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis 46:887–896

    Article  PubMed  Google Scholar 

  15. Rosansky SJ, Eggers P, Jackson K et al (2011) Early start of hemodialysis may be harmful. Arch Intern Med 171:396–403

    PubMed  Google Scholar 

  16. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. (2013) Kidney Int Suppl 3(1):112–119

  17. Devereux RB, Alonso DR, Lutas EM et al (1986) Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 57:450–458

    Article  CAS  PubMed  Google Scholar 

  18. Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16:31–41

    Article  CAS  PubMed  Google Scholar 

  19. Du Bois D, Du Bois EF (1916) A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med 17:863–871

    Article  Google Scholar 

  20. Stojceva-Taneva O, Ivanovski N, Selim G et al (2005) End-stage renal failure and referral for dialysis in the F.Y.R.M. Hippokratia 9(1):45–48

    Google Scholar 

  21. Selim G, Stojceva-Taneva O, Polenakovic M et al (2007) Effect of nephrology referral on the initiation of haemodyalisis and mortality in ESRD patients. Prilozi 28(2):111–126

    CAS  PubMed  Google Scholar 

  22. Kinchen KS, Sadler J, Fink N et al (2002) The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 137(6):479–486

    Article  PubMed  Google Scholar 

  23. Jungers P, Massy ZA, Nguyen-Khoa T et al (2001) Longer duration of predialysis nephrological care is associated with improved longterm survival of dialysis patients. Nephrol Dial Transplant 16:2357–2364

    Article  CAS  PubMed  Google Scholar 

  24. Mendelssohn DC, Curtis B, Yeates K, For the STARRT Study investigators et al (2011) Suboptimal initiation of dialysis with and without early referral to a nephrologist. Nephrol Dial Transplant 26:2959–2965

    Article  PubMed  Google Scholar 

  25. Black C, Sharma P, Scotland G et al (2010) Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis. Health Technol Assess 14(21):1–184

    Article  CAS  PubMed  Google Scholar 

  26. Chan MR, Dall AT, Fletcher KE et al (2007) Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med 120(12):1063–1070

    Article  PubMed  Google Scholar 

  27. Smart NA, Titus TT (2011) Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med 124(11):1073–1080

    Article  PubMed  Google Scholar 

  28. Shemin D, Bostom AG, Laliberty P et al (2001) Residual renal function and mortality risk in hemodialysis patients. Am J Kidney Dis 38:85–90

    Article  CAS  PubMed  Google Scholar 

  29. Shafi T, Jaar BG, Plantinga LC et al (2010) Association of residual urine output with mortality, quality of life, and inflammation in incident hemodialysis patients: the CHOICE (choices for healthy outcomes in caring for end-stage renal disease) study. Am J Kidney Dis 56(2):348–358

    Article  PubMed Central  PubMed  Google Scholar 

  30. Lopez-Vargas PA, Craig JC, Gallagher MP et al (2011) Barriers to timely arteriovenous fistula creation: a study of providers and patients. Am J Kidney Dis 57(6):873–882

    Article  PubMed  Google Scholar 

  31. Bonomini V, Feletti C, Stefoni S et al (1986) Early dialysis and renal transplantation. Nephron 44:267–271

    Article  CAS  PubMed  Google Scholar 

  32. Bonomini V, Vangelista A, Stefoni S (1978) Early dialysis in renal substitutive programs. Kidney Int 13(Suppl 8):S112–S116

  33. Tattersall J, Greenwood R, Farrington K (1995) Urea kinetics and when to commence dialysis. Am J Nephrol 15:283–289

    Article  CAS  PubMed  Google Scholar 

  34. Beddhu S, Samore MH, Roberts MS et al (2003) Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol 14:2305–2312

    Article  PubMed  Google Scholar 

  35. Lassalle M, Labeeuw M, Frimat L et al (2010) Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int 77:700–707

    Article  PubMed  Google Scholar 

  36. Stel VS, Dekker FW, Ansell D et al (2009) Residual renal function at the start of dialysis and clinical outcomes. Nephrol Dial Transplant 24:3175–3182

    Article  PubMed  Google Scholar 

  37. Susantitaphong P, Altamimi S, Ashkar M et al (2012) GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis 59(6):829–840

    Article  PubMed Central  PubMed  Google Scholar 

  38. Cooper BA, Branley P, Bulfone L et al (2010) IDEAL Study: a randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 363(7):609–619

    Article  CAS  PubMed  Google Scholar 

  39. Tattersall J (2009) Is it really better to start dialysis as late as possible? Nephrol Dial Transplant 24:2972–2974

    Article  PubMed  Google Scholar 

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The authors declare that they have no conflict of interest.

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Correspondence to Gjulsen Selim.

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Selim, G., Stojceva-Taneva, O., Spasovski, G. et al. Timing of nephrology referral and initiation of dialysis as predictors for survival in hemodialysis patients: 5-year follow-up analysis. Int Urol Nephrol 47, 153–160 (2015). https://doi.org/10.1007/s11255-014-0794-y

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