Let's Start Dialysis As Late As Possible

[okarol]

COMMENTARY
Let's Start Dialysis As Late As Possible
Kamyar Kalantar-Zadeh, MD, MPH, PhD
August 15, 2011

Traditional nephrology training makes us believe that it is good practice to start maintenance dialysis therapy sooner rather than later. Nevertheless, recent data indicate that we may encounter yet another “old-practice-was-wrong” paradigm shift.

Indeed for decades, there have been minority camps within the nephrology community advocating late start. Non-randomized studies by late MacKenzie Walser, MD, suggested greater survival if dialysis therapy can be deferred by months to years. Recently, studies have revived the old discussions on late versus early dialysis therapy initiation. Observational studies show an association between higher creatinine clearance at dialysis initiation and worse outcomes, but this may be due to an association of higher serum creatinine level with larger muscle mass and greater survival. However, a recent randomized, controlled trial confirmed trends towards better outcome in the group that started dialysis therapy with lower residual renal function. It is not clear whether the dialysis therapy is inherently harmful or whether the contemporary practice of treatment causes or aggravates harm.

Thrice-weekly hemodialysis (HD) treatment may lead to subtle but cumulative mechanical and oxidative stress upon the cardiovascular system and engender hemodynamic instability. There may be repeated bouts of acute tubular necrosis by lowering blood pressure during each HD session, resulting in faster loss of residual kidney function and frequent ischemic events upon hypotensive episodes. Exposure to foreign tubing and toxic medications may play a role. Patient anxiety that accompanies each HD treatments, along with post-HD fatigue and lightheadedness, may aggravate harm. And then there is the stress of vascular access surgery and frequent infections. Peritoneal dialysis may cause different types of harms including substantial protein loss and frequent peritonitis. As to how to delay the start of dialysis, the old school of maintaining a low protein diet (0.6-0.7 g/kg/day) while providing amino acids and proteins of high biologically value can be attempted. In many countries outside of the United States, keto-analogues are used routinely, as are indoxyl sulfate modulators. Recent discussion about vegetarian diet that is also linked with lower phosphorus burden deserves investigation. Fluid and salt control with or without diuretics may be used more diligently. As to the concerns of the dialysis industry that such calls to late start may interfere with the business, I have one final message. In Taiwan, where the median estimated glomerular filtration rate at dialysis initiation is less than 5 mL/min/1.73 m2, there are even more dialysis patients per general population than the United States.

Kamyar Kalantar-Zadeh, MD, MPH, PhD, is Associate Professor of Medicine and Pediatrics, and Director, Dialysis Expansin & Epidemiology, Harbor-UCLA Division of Nephrology & Hypertension Dr. Kalantar-Zadeh is Medical Director, Nephrology, for Renal & Urology News.

http://www.renalandurologynews.com/lets-start-dialysis-as-late-as-possible/article/209625/

[MooseMom]

It is not clear whether the dialysis therapy is inherently harmful or whether the contemporary practice of treatment causes or aggravates harm.

I'd say, "Both."

[jbeany]

In the end, we're back to the same difficult decision we've all had to make about when to start.  How bad to you have to feel to feel bad enough to start?  And that's still going to vary by patient.

[Dannyboy]

In the end, we're back to the same difficult decision we've all had to make about when to start.  How bad to you have to feel to feel bad enough to start?  And that's still going to vary by patient.

Well said.   

As someone nearing Dialysis this 'hits' very current for me.   In my research I found as you say a wide variance in (for example) GFR numbers when D was started.   My neph has emphasized that "when to start" is very much an individual proposition, and not merely because of a particular GFR or any one or two numbers, but a clinical judgment based on the whole picture.   

I have heard some talk about "earlier is better", but this and other articles give one pause.
---Dan

[MooseMom]

"Earlier is better" if you are suffering from symptoms of uremia, but in the absence of this, the idea of starting early is becoming more and more discredited.  My transplant coordinator was a dialysis nurse for 13 years, and she told me that when it is time to start dialysis, you will KNOW.

[Dannyboy]

Hi MM,
Yeah I've been told the "you will know" thing too.  Perhaps symptoms like a LOT more swelling of ankles, etc; metallic taste; etc. not to mention 'numbers'.

I know you've had this business hanging over your head a lot longer than me.   My numbers unfortunately are sliding a bunch lately, maybe D in September??   But then I know that things can level off/get a bit better too, so you never really know what to plan for, besides the eventual outcome.
--Dan

[MooseMom]

True, you don't know exactly what to plan for, but you can certainly devise a working plan.  My grand plan is to eventually do nocturnal hemo at home.  I've looked at all the options, and I've decided that's the best for my life as I'm living it now.  I know it will take time and training to get to the point where that becomes routine, but that's OK.  At least it is a goal.  And I know that my marvellous plan may not work out and I may have to have a plan B.  But plan A has a reasonable chance of working, so I'm sticking with it.

You can make a plan, too.  You've already done so much to educate yourself, so you are way ahead in this game.  Just being on IHD shows that you are planning and thinking and evaluating and learning.  That's an enormous advantage that is impossible to overestimate.

[Dannyboy]

A plan?  You betcha.  NxStage at home, too [and yes, nocturnal down the road also].     Re-arranging furniture/desk etc. in my study and have planned out the logistics for the Pure Flow section.

And yep, IHD has been a major help in all of this, the best thing overall about IHD is that it helps one 'cut through the crap'.........

And yes, I have come a long way....I used to be an ill-informed, apprehensive, 'why did this have to happen to me',  guy....now at least I'm a somewhat more informed, apprehensive, 'why did this have to happen to me' guy.   

---Dan