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Early dialysis tied to increased death risk in non-elderly Singapore adults

Pearl Toh
13 Jun 2017

Early initiation of dialysis at higher eGFR* levels of ≥10 mL/min/1.73m2 was associated with a significantly increased risk of death compared with late initiation (at eGFR <5 mL/min/1.73m2) in non-elderly adults (<65 years) in Singapore, a new study has shown.

“Our findings suggest that early commencement of dialysis offers no advantage over late dialysis, especially for younger patients in Singapore with advanced chronic kidney disease, and possibly other Southeast Asian populations,” according to researchers led by Professor Tazeen Jafar from Duke-NUS Medical School in Singapore.

The study included data from 3,286 patients (mean age, 61.5 years) with new-onset end-stage renal disease in the Singapore Renal Registry database. Participants were divided into three categories based on their eGFR at the start of dialysis: early (≥10 mL/min/1.73m2), intermediate (5 to <10 mL/min/1.73m2), and late (<5 mL/min/1.73m2). [BMC Nephrology 2017;18:176-186]

Compared with patients who initiated dialysis later, a greater risk of death was observed in those who initiated dialysis early (hazard ratio [HR], 2.47, 95 percent confidence interval [CI], 2.04–2.99) and at intermediate stage (HR, 1.54, 95 percent CI, 1.37–1.72). The risk remained significant even after adjusting for comorbidities, demographic factors, nutritional parameter, and modality of dialysis (p<0.001).

A multivariate analysis revealed age as a significant modifier of the association between dialysis initiation and mortality risk (p=0.04), with the association being more prominent in patients <65 years.  

After stratifying the analysis by age, mortality risk was shown to increase progressively with earlier dialysis initiation for patients in the age groups of 18–54 years (p=0.006) and 55–64 years (p<0.001), but not >65 years (p=0.12).    

“It is possible that younger patients commencing dialysis have more aggressive underlying kidney disease with more rapid loss of residual renal function … [which] has been associated with increased mortality,” said the researchers. “[Early] initiation of dialysis … appeared to offer no survival advantage among the elderly.”

Being a registry-based observational study, the authors could not rule out the possibility of lead time bias and indication bias in their findings.

Noting an upward trend in average eGFR at dialysis initiation, which rose from 7.9 to 8.6 mL/min/1.73m2 in Europe between 1999 and 2003, [Nephrol Dial Transplant 2009;24:3175-3182] the researchers attributed this to the differences in recommendations for consideration of dialysis among different guidelines.

“In agreement with IDEAL study, our results do not support early initiation of maintenance dialysis in the absence of any compelling clinical indication. Our findings support the 2015 update of Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for initiation of maintenance dialysis which are based on compelling indications,” said Jafar and co-authors. [N Engl J Med 2010;363:609-619; https://www.kidney.org/sites/default/files/KDOQI-Clinical-Practice-Guideline-Hemodialysis-Update_Public-Review-Draft-FINAL_20150204.pdf. Last accessed 12 Jun 2017]

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Roshini Claire Anthony, 4 days ago

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