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
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
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
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
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
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
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
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
National Kidney Foundation (1997) DOQI Clinical Practice Guidelines for hemodialysis and peritoneal dialysis adequacy. Am J Kidney Dis 30:S67–S136
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
US Renal Data System (USRDS) (2009) Annual Data Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases
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
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
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
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
Rosansky SJ, Eggers P, Jackson K et al (2011) Early start of hemodialysis may be harmful. Arch Intern Med 171:396–403
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. (2013) Kidney Int Suppl 3(1):112–119
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
Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16:31–41
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
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
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
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
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
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
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
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
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
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
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
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
Bonomini V, Feletti C, Stefoni S et al (1986) Early dialysis and renal transplantation. Nephron 44:267–271
Bonomini V, Vangelista A, Stefoni S (1978) Early dialysis in renal substitutive programs. Kidney Int 13(Suppl 8):S112–S116
Tattersall J, Greenwood R, Farrington K (1995) Urea kinetics and when to commence dialysis. Am J Nephrol 15:283–289
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
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
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
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
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
Tattersall J (2009) Is it really better to start dialysis as late as possible? Nephrol Dial Transplant 24:2972–2974
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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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DOI: https://doi.org/10.1007/s11255-014-0794-y