What drives early dialysis initiation and how do we optimize timing of RRT?

Abstract

Timing of dialysis initiation has been in the spotlight in recent years (1). During the last decade, there has been a trend toward initiation of chronic dialysis at higher levels of eGFR (2). The reason for increased attention to the topic is accumulating evidence that early dialysis initiation does not improve patient outcomes and results in unwarranted costs. In observational studies, higher eGFR at dialysis initiation has been associated with higher mortality risk after initiation, independent of patient characteristics including nutritional status (1,3). The Initiating Dialysis Early and Late (IDEAL) trial recently reported that compared with a strategy of delayed dialysis initiation, earlier initiation in patients with advanced CKD was not associated with improved survival (4) or quality of life, but was associated with increased costs (5). The percentage of patients who initiate RRT at higher eGFR values continued to rise through 2009, both in the United States (6) as well as in Canada. Several factors have been hypothesized to contribute to the reported increase in eGFR at dialysis initiation, including greater acceptance of older and sicker patients with multiple comorbidities for dialysis intervention, a belief that of earlier dialysis initiation is associated with patient benefit, eGFR reporting and reliance on eGFR values to guide timing of dialysis initiation, misinterpretation of clinical practice guidelines, a desire to simplify management of CKD complications, and a greater financial reimbursement to providers associated with dialysis compared with CKD care (1,2). Prior studies have evaluated both patient and provider characteristics associated with timing of dialysis initiation (2,7). In this issue of CJASN, Sood et al. aimed to determine how patient, facility, and geographic characteristics influence the variation of eGFR at dialysis initiation across Canada (8).