Doctors are likely embracing higher levels of kidney function as being appropriate for dialysis initiation
- In VA medical centers, patients started dialysis progressively earlier in the course of their kidney disease in more recent years.
- There were no measurable differences in how sick patients were at the time of initiation or in the reasons for dialysis initiation to explain this trend.
- More than 400,000 patients are undergoing maintenance dialysis in the United States.
Over time, patients with advanced kidney disease have been starting dialysis progressively earlier in the course of their disease, likely because doctors are embracing higher levels of kidney function as being appropriate for dialysis initiation. The findings come from a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN).
Over the years, US patients with advanced kidney disease seem to be starting dialysis earlier in the course of their illness, which could mean that some patients will spend a significantly longer time on dialysis. To understand why patients might be initiating dialysis earlier, Ann O’Hare, MD, MA, Paul Hebert PhD (University of Washington), and their colleagues conducted a study using the electronic medical records of 1691 veterans in whom the decision to start dialysis was made at a VA medical center from 2000 to 2009.
The researchers found that, as for the wider dialysis population, patients in the study were starting dialysis with higher levels of kidney function in more recent years. Over time, there were no measurable differences in how sick patients seemed to be at the time of initiation to explain this trend or in the documented reasons for dialysis initiation. For example, neither the percentage of patients who were acutely ill nor the distribution of different types of clinical signs or symptoms present around the time of dialysis initiation changed appreciably over time. Cardiopulmonary and gastrointestinal signs and symptoms and weakness and/or fatigue were the most commonly documented. Also, while treatment decisions were occasionally driven by level of kidney function in the absence of other clinical signs or symptoms, this practice was no more common in recent compared with earlier years.
The results suggest that doctors’ practices have changed over the years to embrace higher levels of kidney function as being appropriate for dialysis initiation among symptomatic patients with advanced kidney disease. “Our findings seem to highlight the influential role of opinion-based clinical practice guidelines in promoting earlier initiation of dialysis across a wide range of different clinical contexts over this time period,” said Dr. O’Hare.
The authors noted that studies on the benefits and harms of dialysis compared with other approaches to managing cardiopulmonary, gastrointestinal, and other symptoms of patients with advanced kidney disease are needed.
Study co-authors include Susan Wong, MD, Margaret Yu, MD, MS, Bruce Wynar, PA, Mark Perkins, PharmD, Chuan-Fen Liu, PhD, and Jackie Lemon, BA.
Disclosures: This study was funded by the Department of Veterans Affairs. A.O., C.-F.L., and P.H. received research funding from the VA Health Services Research and Development Service. A.O. also received research funding from the Centers for Disease Control and the National Institutes of Health and has received royalties from UpToDate. S.W. is supported by the Clinical Scientist in Nephrology Fellowship of the American Kidney Fund.
The article: “Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation. Published online before print February 19, 2015, doi: 10.1681/ASN.2013050531 JASN