Age at Starting Renal Replacement Therapy Rises in Canada

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OTTAWA—The age at which patients with end-stage renal disease (ESRD) start renal replacement therapy (RRT) in Canada is increasing, Canada, according to the 2009 annual report of the Canadian Organ Replacement Register (CORR).

According to the report, 54% of patients initiating RRT in 2007 were aged 65 years and older compared with 48% in 1998. Additionally, from 1998 to 2007, the highest rate of newly diagnosed ESRD was in patients aged 75 and older. This age group had a rate of 729.7 cases per million population in 2007.

During this period, ESRD prevalence in Canada increased 70% and the number of newly diagnosed cases of ESRD rose from 4,229 in 1998 to 5,434 in 2007, a 28% increase.

The report also shows that the number of Canadians starting dialysis or receiving a kidney transplant increased by only 1% between 2006 and 2007. “It appears that ESRD requiring dialysis or transplant is stabilizing   in Canada over the last few years after a period of increased growth,” commented nephrologist Louise Moist, MD, Vice President of CORR and Associate Professor of Medicine at the University of Western Ontario in London.

“The continued growth  is driven entirely by the aging of the Canadian population—we found that incidence rates are rising only in those aged 75 and over, while they are declining in those aged 20 to 40.”

In all age groups, hemodialysis is more common than either peritoneal dialysis or kidney transplantation. The highest rate of dialysis was among those aged 65 and older.

Among the 2,919 individuals in this age group with ESRD in 2007, 99.6% were on dialysis, with the remaining few receiving a transplant. Programs are being developed to increase to access to transplantation among those older than 65 years. A recent editorial indicates that these trends toward increased use of dialysis, along with the analogous data from the United States, represent a potential cause for concern.

In a paper published Kidney International (2009;76:257-261), Steven J. Rosansky, MD, of the William Jennings Bryan Dorn VA Hospital in Columbia, S.C., and colleagues document a rising tide of early dialysis initiation, which was largely spurred by 1997 and 2006 guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI). These guidelines raised the threshold for dialysis initiation to estimated glomerular filtration rates (GFRs) that are appropriate in most adults, but may be normal levels in the elderly.

The authors noted that no studies have shown any clear-cut benefits from starting dialysis early. Furthermore, they have completed a study indicating that people aged 65 to 74 who are started on dialysis with > 10% of kidney function remaining have nearly twice the chance of dying during the first year of dialysis as similarly aged people who are started on dialysis at with < 10% of remaining kidney function.

This mortality difference appears to be largely due to the fact that people who are started on dialysis early are older and sicker than those who start dialysis at lower eGFRs,” said one of the co-authors, William Clark, MD, Professor of Medicine at the University of Western Ontario.

“But several investigators in Canada and the United States are carefully analyzing data from CORR and the U.S. Renal Data System to clarify whether the early start initiative is associated with any significant increase in risk. This is a complex issue and may require a randomized controlled trial to resolve.”

The report is available at http://secure.cihi.ca/cihiweb/products/corr_annual_report_2009_en.pdf.

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