When to start dialysis

[MooseMom]

From Medscape Nephrology > Berns on Nephrology
When Is the Best Time to Start Dialysis?
Jeffrey S. Berns, MD


Posted: 03/29/2011

 
Hello. This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I am Editor-in-Chief of Medscape Nephrology.

A new paper in the Archives of Internal Medicine by Rosansky and colleagues[1] addresses the issue of when is the appropriate time to start dialysis. A number of observational studies in this area have questioned the increasingly common practice of starting dialysis with higher levels of glomerular filtration rate (GFR) in recent years compared with a decade or so ago, and I have video blogged in the past about the IDEAL [Initiating Dialysis Early and Late] study.

This particular study looked at United States RDS [Renal Data System] data from 1996 to 2006, in a large cohort of healthy dialysis patients. They had no substantial comorbidities other than hypertension, and the top age was 64 years.

As has been seen in other studies,[2] the higher the GFR at the time dialysis was started, the higher the subsequent mortality and, in this study, first year mortality. Patients who started dialysis with GFRs in the 5-10 mL/min range had substantially lower mortality than those who started dialysis at each successively higher level of GFR, including 10-15 mL/min and over 15 mL/min.

This was a relatively healthy group. When the investigators looked at patients who were the most healthy -- that is, those who had normal albumin levels and hemoglobin levels and so forth -- the data were equally striking.

So this study is very important, very well done, observational, and retrospective. It was not a prospective randomized controlled trial, and we need more of those, but this study raises questions about the increasingly common practice of an early start to dialysis. The title of the paper appropriately is "Early Start of Hemodialysis May Be Harmful."

What would be useful here is a comparative effectiveness study because we really do need to balance not only this mortality difference that we are seeing but quality of life at the start of dialysis vs remaining off dialysis, and an examination of those tradeoffs is sorely needed. We start dialysis sometimes at the earlier sign of symptoms, but maybe that is not appropriate either, and maybe the tradeoff is increasing mortality for dialytic management of relatively minor symptoms, something that probably needs to be more individualized.

This is a very interesting article, well worth reading, as is the accompanying editorial in the current issue of Archives in Internal Medicine, emphasizing the need to reexamine the practice of early start of dialysis. We need to be thinking more about later start for those who are going on to dialysis, but, of course, with increasing emphasis on transplantation, appropriateness of dialytic therapy at all, and consideration of hemodialysis options other than traditional 3 times weekly in-center dialysis. This is interesting reading; I would appreciate any comments that you have about this article and this topic, which can be submitted at the end of this transcript.

This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia

[boswife]

This kind of freeks me out because........... hubby definatly needed to get cleaned up due to over medication for a couple things...(within a few days had fistula put in, and 2 other procedures all putting him somewhat 'under' and he wasnt getting rid of the stuff) but!!!!!! i've always felt that he would bounce back to his 20+ gfr but for the life of me i have not been able to get them to do something to prove to me that he hasnt.  Anyway, all i can say is he is feeling really good now being home D'ed and......... they just lessend his tx. (same length, six days per week, just less dialystate) I know everyone sais more is beter, but beings his kidney function is still somewhat happening, this 'less' seems 'best' so i guess blood tests next week will tell.  Sometimes, i really would like to burry my head and let them just tell me what to do, but Well, you know me better than that and i'll keep on digging, and reading, and appreciate all the learning everyone has to offer   

[KarenInWA]

MooseMom, thank you so much for posting this!!! This makes me feel even better for saying "no" when my neph wanted to put me on D 3 weeks ago.  Someone else also posted somewhere on here about how if you're still peeing, to let the clinic staff know so they don't take off any/too much fluid, since by default, that is what they do.  Well, I've been peeing normally, so I know I would experience a crash/cramp and be really "pissed"! My epo nurse told me today that I have good instincts, and I'll know when I'm ready.  Yes, I get tired, but I'm still plugging along and living life!

KarenInWA

[MooseMom]

boswife,, there is no WAY you'd ever be happy with just letting dialysis staff take over!  I know that sometimes it must be very tempting to just let everyone else tell you what to do, but you'd go nuts after a while, not satisfied at all with what they're doing!

Sure, "more is better", but if your hubby is feelin' fine and his numbers are good, then what you're doing is enough.  "More is better" doesn't mean every flippin' minute of the damn day!!

You just keep on keepin' on!  You're going great!

PS, did you ever post a photo of that "arm" that you made?  If you did, could you send me a link to it because I don't think I ever saw it, and I bet it is AWESOME!

[MooseMom]

MooseMom, thank you so much for posting this!!! This makes me feel even better for saying "no" when my neph wanted to put me on D 3 weeks ago.  Someone else also posted somewhere on here about how if you're still peeing, to let the clinic staff know so they don't take off any/too much fluid, since by default, that is what they do.  Well, I've been peeing normally, so I know I would experience a crash/cramp and be really "pissed"! My epo nurse told me today that I have good instincts, and I'll know when I'm ready.  Yes, I get tired, but I'm still plugging along and living life!

KarenInWA

Your kidneys are failing, not your brain.  I know that making that decision to start D is fraught with 1000 sorts of anxiety, but you are neither stupid nor reckless.  I am sure you have confidence in your own judgment.  But studies do show that there is such a thing as starting D "too early", and they do suggest that a "too early" start can in fact be harmful.  I guess the best course of action is get educated, trust your instincts but at the same time be open-minded and receptive to good advice from your healthcare people.

[MooseMom]

News and Views
Nature Reviews Nephrology 6, 693-694 (December 2010) | doi:10.1038/nrneph.2010.131

Dialysis: 'Early' dialysis start based on eGFR is no longer appropriate
Steven Rosansky & Richard J. Glassock  About the authors

Abstract;  The randomized, controlled IDEAL study reports no survival advantage of 'early' dialysis initiation and data from this study support an estimated glomerular filtration rate of around 7 ml/min/1.73 m2 as a guideline for dialysis initiation. The results of the IDEAL study supplement data from eight observational studies involving over 1.2 million patients which showed a comorbidity-adjusted incremental survival disadvantage of 'early' dialysis initiation.

The long-awaited Initiating Dialysis Early and Late (IDEAL) study, a randomized, controlled trial (RCT) conducted in Australia and New Zealand comparing the 'early' and 'late' initiation of dialysis (as assessed by renal function at the time of starting therapy) did not find 'early' initiation of dialysis to be associated with a survival advantage.1 These results supplement evidence from eight of nine published observational studies that utilized data from over 1.2 million patients and showed a comorbidity-adjusted incremental survival disadvantage of 'early' dialysis initiation.1, 2, 3 The main advantage of the IDEAL study is that the survivor bias, or 'healthy cohort effect', which uniformly confounds comorbidity-adjusted observational studies, is eliminated by RCT methodology. The results of the IDEAL study should finally curtail the disturbing trend towards 'early' dialysis start (Figure 1). In the USA, the fraction of patients initiating dialysis at an estimated glomerular filtration rate (eGFR) >10 ml/min/1.73 m2 (estimated using the Modification of Diet in Renal Disease [MDRD] equation) increased from 20% of new dialysis starters in 1996 to 52% of new dialysis starters in 2008; an even more dramatic rise occurred during this period in the percentage of patients starting dialysis with an eGFR ≥15 ml/min/1.73 m2 (Figure 1).4 The IDEAL study used creatinine clearance estimated using the Cockroft–Gault equation as the measure of renal function; mean eGFR was also estimated using the MDRD equation with mean values being 7.2 ml/min/1.73 m2 in the 'late' start group and 9.0 ml/min/1.73 m2 in the 'early' start group.

Over a median follow-up of 3.59 years, death occurred in 155 of 424 patients (36.6%) in the 'late' start group and 152 of 404 patients (37.6%) in the 'early' start group (P = 0.75). The IDEAL researchers found that none of the deaths occurring during the study period were related to uremia. As there was no significant survival difference between the two groups, this study would support waiting for an MDRD-estimated eGFR of around 7 ml/min/1.73 m2 to initiate dialysis (rather than initiating dialysis at an eGFR >10 ml/min/1.73 m2). The approach to initiating dialysis should evolve from what appears to be a trend toward pre-emptive dialytic therapy based on calculated eGFR levels to a 'wait and see' approach utilizing signs or symptoms of uremia rather than an arbitrary level of eGFR. An important byproduct of such an approach is that it would enable physicians to wait for the maturation of a permanent dialysis access placement, thereby avoiding the troublesome trend towards early mortality that seems to be associated with the use of indwelling catheters for vascular access and the disastrous consequences of attendant infection.4

The design of the IDEAL study allowed patients to be started on dialysis before they reached the assigned eGFR level (which was 10–15 ml/min/1.73 m2 in the early start group and 5–7 ml/min/1.73 m2 in the late start group). This study design resulted in 322 of the 424 randomized patients allocated to a 'late' start initiating dialysis at MDRD eGFR levels >7 ml/min/1.73 m2. Uremia—in 234 patients—was the major reason given for these protocol deviations. It would be useful to know the character of the uremic symptoms and signs that led nephrologists to deviate from the protocol design in these patients.

Classic uremic complications, including pericarditis, uremic encephalopathy, and oligoanuric chronic renal failure, occur only at very low levels of renal function. Australian guidelines for dialysis initiation were published in 2005 and recommended use of malnutrition as a uremic complication that justified dialysis initiation.1 The guidelines also recommended dialysis initiation at an average urea and creatinine clearance of 6 ml/min/1.73 m2, regardless of symptomatology. The 2006 US National Kidney Foundation guidelines recommended dialysis initiation at eGFR <15 ml/min/1.73 m2.1 The guidelines also endorsed initiating dialysis at eGFR >15 ml/min/1.73 m2 in patients with symptoms believed to be related to both their comorbidities and their level of residual renal function.1 Between 2000 and 2006, when IDEAL study patients were recruited, US, Australian and other similar international guidelines may have influenced the IDEAL study physicians in their decision to initiate dialysis early in some patients. The resultant small 1.8 ml/min/1.73 m2 difference in eGFR between the two study groups decreased the ability to demonstrate whether 'early' dialysis initiation has a harmful impact, as had been suggested by many large observational studies.2, 3

Since there is no evidence that early initiation of dialysis provides any survival benefit, and because there are multiple adverse comorbidity and quality-of-life issues related to dialysis treatment, further exploration of the issue of optimal timing of dialysis initiation is needed. Data on the reasons used by nephrologists to guide initiation of dialysis therapy would be particularly valuable. Symptoms related to renal failure are often subjective and do not necessarily correlate with indices of renal function. In one study, most patients commenced dialysis with at least three nonspecific symptoms, most commonly fatigue, nausea and anorexia.5 Symptoms of 'uremia' might be more likely associated with comorbidities than with the level of renal function.5 Serum albumin level is a comorbidity factor that predicts dialysis mortality and may be misused as evidence of 'malnutrition' and justification for dialysis initiation.6 Although malnutrition is included and promoted as an indicator of uremia that is treatable by dialysis, the randomized, controlled HEMO study found this not to be the case.7 In patients with a residual GFR <2 ml/min/1.73 m2, hemodialysis failed to influence the decline in measures of nutrition over the 3-year duration of the study.7

One issue that could not be adequately examined by the IDEAL study was the relationship between the rate of decline in residual renal function prior to the start of dialysis (the 'renal function trajectory'), and the decision to initiate dialysis. The median time from randomization to dialysis initiation was 1.8 months in the 'early' start group and 7.4 months in the 'late' start group. The crossovers meant that no evaluation could be made of the potential benefit of delaying dialysis in patients who maintain stable renal function and thus whose symptoms are less likely to be related to uremia and more likely to be related to comorbidities.

A second issue not addressed by the IDEAL study was the management of the only segment of the US dialysis incident population that is still growing—patients over 75 years of age.4 Compared with younger patients, elderly patients may have a slower decline in residual renal function8 ('renal function trajectory'), a shorter life expectancy independent of dialytic therapy, and more comorbidity-related symptoms that could possibly be interpreted as uremic in nature and result in dialysis initiation. An adequately powered RCT would be useful to determine if there is any clinically significant survival, morbidity, or quality-of-life benefit or hazard associated with 'early' dialysis initiation in the elderly population.

A third issue that the IDEAL study could not address was any differences between peritoneal dialysis and hemodialysis with respect to renal function at dialysis initiation and survival. Several studies have demonstrated that preservation of endogenous residual renal function is a strong positive predictor of survival and that residual renal function might be better preserved with peritoneal dialysis than with hemodialysis.9

Finally, the IDEAL study utilized rigorous multidisciplinary predialysis follow-up which can itself potentially decrease the risk of subsequent mortality and hospitalizations,10 and emergency dialysis was largely avoided for the study participants. Since such close follow-up likely influences patient survival in a positive manner, in order to assign benefit to dialysis treatments, a third arm of an RCT such as IDEAL should include patients assigned to weekly or thrice-weekly programmed care but without dialysis treatment. However, the crossovers and immense difficulty of performing a study such as the IDEAL study make it unlikely that an RCT with such a third arm will be successfully executed.

It is hoped that the IDEAL study results, together with the results from the many observational studies on 'early' dialysis initiation, will help to reverse the epidemic of 'early' start of dialysis. Individuals involved in formulating US and international guidelines may want to consider an eGFR of 5–7 ml/min/1.73 m2 along with definitive uremia-related symptoms as the optimal point at which to initiate dialysis. Such a shift in recommendations might lead to considerable economic savings without adverse impact on patient survival, morbidity or quality of life.