New study: Planned early initiation of dialysis does not improve outcomes

[RightSide]

Early Dialysis Initiation Does Not Improve Outcomes
Jody A. Charnow
June 27 2010

MUNICH, GERMANY—Planned early initiation of dialysis does not improve survival or clinical outcomes among patients with end-stage renal disease, study findings show.

Investigators presented their findings during a symposium at the European Renal Association-European Dialysis and Transplant Association 2010 Congress, where one of the symposium's moderators, Johannes F.E. Mann, MD, said the results “will shake the nephrology world for some time.”

The study, presented by lead investigator Bruce A. Cooper, MB, BS, PhD, of Royal North Shore Hospital in St. Leonards, New South Wales, Australia, was conducted at 32 centers in Australia and New Zealand. The researchers randomized 828 adults (542 men and 286 women) to start dialysis when their estimated glomerular filtration rate (eGFR) was 10-14 mL/min (early start) or when their eGFR decline to 5-7 mL/min (late start). Subjects had a mean age of 60.4 years. The median time to initiation of dialysis was 1.8 months in the early-start group compared with 7.4 months in the late-start group. Nearly 76% of patients in the late-start group started dialysis when their estimated eGFR was the 7 mL/min target because of the development of symptoms. Of the 404 patients assigned to early-start dialysis, 383 started dialysis; of the 424 patients assigned to late-start dialysis, 386 started dialysis.

After a median follow-up of 3.59 years, the two groups showed no significant differences in the primary outcome of all-cause mortality or the secondary outcomes of cardiovascular and infectious events and dialysis complications, said Dr. Cooper, who told listeners that dialysis should not be started on the basis of GFR alone.

His presentation coincided with the study's publication in the New England Journal of Medicine. The researchers noted that, according to U.S. Renal Data System, the proportion of patients who started dialysis when the eGFR was above 10 mL/min rose from 19% in 1996 to 45% in 2005. “Our results indicate that such trends toward early initiation of dialysis, which have enough implications in terms of cost and infrastructure of dialysis services, are unlikely to improve clinical outcomes,” the authors wrote.

At a press conference following Dr. Cooper's presentation, Norbert H. Lamiere, MD, PhD, Professor Emeritus of Medicine at the University of Ghent in Belgium, who co-wrote an accompanying editorial in NEJM, called the study “a landmark paper.”

“This is obviously a fantastic study,” Dr. Lamiere said, adding that the findings suggest that “clinical symptoms should dictate the start of dialysis.”

http://www.renalandurologynews.com/early-dialysis-initiation-does-not-improve-outcomes/article/173402/

[RichardMEL]

hey, I was part of this study!!!!

Nice to see some results - even nicer to know that I was picked for late start (thank you, God!) and that there is apparently no significant difference there.

Good stuff.

[galvo]

Interesting.

[Zach]

I think what's important is seeing a nephrologist early on, rather than early initiation of dialysis.

[Sunny]

Interesting study. I won't be letting a nephrologist push me into an early start, now that I know it doesn't make a difference in the long run anyway.

[RightSide]

“clinical symptoms should dictate the start of dialysis.”

That's what's important.  How the patient is feeling is more important than any blood test numbers. 

My GFR was 16 when I started dialysis.  Theoretically I could have waited.

But I was feeling so rotten that I decided to start dialysis anyway.

My GFR seems to have remained at 16.

[okarol]

Jenna should have started earlier. She had lost a lot of weight, had one episode of swollen ankles, was unable to keep food down, slept alot and was really weak. We saw her nephrologist on Friday and he said "start thinking about getting access done." Two days later she was in emergency getting a chest catheter to begin dialysis right away (this was through our pediatrician who would not let her go home.) It's pretty alarming that the neph at Children's Hospital was not more helpful. I think the symptoms were pretty bad, and looking back, I'd do it differently. I think we almost lost her. So GFR is important, but keeping the patient healthy is the most important thing, in my opinion.

[totosidney]

Just an opinion, but I think fistula placement and healing should be done ahead of time even if the treatment isn't started. No need then for emergencies down the line.

[okarol]

I agree. That would have been good advice from Jenna's neph. He was clueless. I heard he left Children's Hospital in Los Angeles and moved back to Ohio.

[Sunny]

It is important to be ready with an access point so you aren't in an emergency situation needing a neck cathater and hospitalization.

[RichardMEL]

I agree with what a few of you are saying. In my case when I joined the study they did not know which group I would be allocated to, so I had my fistula placed then, but did not end up starting for another 2 years... so when I did start it was nice and mature and I have had next to no problems with it. I also agree that it should be symptom based as much as based on lab numbers like the eGFR. Down here, at least, I think we do have a bit of common sense in that dept - in they won't just stick you on at GFR 10 or something.

The only downside of course is that you don't want to be that ill that you're throwing up and can hardly move by the time you start. I think there's got to be some common sense at work - don't just go on numbers, but try and be proactive.

[billybags]

I agree with Richard, figures do not show up every thing. My husband was 6gf and feeling really well when he was put on to PD. The neph wanted him to go on PD before he got ill, and for us "touch wood" it has worked.I think some times they leave it too late, they wait until some one is really ill.
But as we all say, every one is different.

[RichardMEL]

I think what I was trying to say was that it's a balancing act. I, too, started D when I was a eGFR 6 - and I felt fine. Well OK I felt tired, but I didn't have nausea, throwing up and all the other nasty stuff you hear about. I personally feel it was a good decision to put me on at that point - I don't think much more would be gained by hanging on, apart from me getting physically sicker and sicker - and I personally feel it was much better for me to start when I wasn't feeling anything bad except tiredness, because I wasn't coping with feeling extra crappy on top of getting into the D thing. Having written that I don't think it would be right to start at a set GFR reading of 15 or 10 if the patient is doing OK - and I think this study has underlined that if you do wait longer (within reason, 6 or 5 is clearly getting real low) then the end results probably aren't much different to starting at 10 or 12 - and the patient may get a few more months of relative freedom. Of course if someone's feeling bad at GFR 17 then absolutely start because that WILL improve their quality of life. All patient experiences are different and Idon't think there should be a set limit, but common srense and intuition should come into it... and for goodness' sake - talk to the patient about how THEY are feeling and what THEY want....