Abstract
BackgroundThe benefit of early dialysis initiation remains controversial with a paucity of data in Asians. Therefore, we undertook this study to investigate the association between timing of initiation of dialysis and mortality in Singapore.MethodsThe study used data from the Singapore Renal Registry database on 3286 patients with incident end-stage renal disease (ESRD) who commenced maintenance dialysis between January 2008 and December 2011. The data was further linked with the National Death Registry to acquire survival information until December 2013. We classified serum creatinine-based, estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation at the start of dialysis into 3 categories: Early (≥10 ml/min/1.73m2), intermediate (5 to <10 ml/min/1.73m2) and late (<5 ml/min/1.73m2).ResultsIn the unadjusted analysis, both early and intermediate dialysis initiation groups were at greater risk of death relative to late dialysis (Early: HR = 2.47; Intermediate: HR = 1.54). In the multivariate model, a significant interaction was detected between age and eGFR at dialysis initiation (p = 0.04). Adjusted mortality risk progressively increased with earlier initiation of dialysis for patients aged 18–54 years (p = 0.006) and aged 55 to 64 years (p < 0.001), and no statistically significant difference was observed for patients aged 65 years or older (p = 0.12).ConclusionsEarly versus later initiation of dialysis was associated with significantly higher risk of mortality in Singapore’s non-elderly population, and appeared to offer no survival advantage among the elderly.
Highlights
The benefit of early dialysis initiation remains controversial with a paucity of data in Asians
We found that early or intermediate initiation of dialysis conferred significantly increased risk of mortality compared to late initiation after adjusting for effects of demographic factors, co-morbidities, modality of dialysis, and nutritional parameter
In conclusion, we observed that the patients with advanced chronic kidney disease (CKD) who initiated dialysis early at higher levels of estimated glomerular filtration rate (eGFR) (≥10 ml/min/1. 73m2) had increased mortality risk compared to those who initiated dialysis at intermediate levels, with lowest risk of death among those initiating dialysis even later at eGFR
Summary
The benefit of early dialysis initiation remains controversial with a paucity of data in Asians. We undertook this study to investigate the association between timing of initiation of dialysis and mortality in Singapore. The Initiating Dialysis Early and Late (IDEAL) study, the only randomized controlled trial to date comparing survival between early (target eGFR: 10 to 14 ml/min) and late (target eGFR: 5 to 7 ml/min) dialysis initiation, did not find a significant difference in mortality risk [28]. In this trial, 76% patients in the late-start group started dialysis before the eGFR reached the target of
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