Dialysis Initiation Consensus Developed in Canada

MONTREAL—New Canadian consensus guidelines emphasize deferred rather than early dialysis initiation.

The guideline's recommendations, which were presented at the Canadian Society of Nephrology's 2013 annual meeting, should help reduce the significant disparities in estimated glomerular filtration rate (eGFR) cutoffs for starting dialysis across the country.

These disparities were documented in a study that was also presented at the meeting. Manish Sood, MD, from the University of Manitoba in Winnipeg, and colleagues analyzed data from the Canadian Organ Replacement Registry from January 2001 to December 2009. They found a wide geographic variance in proportion of patients starting dialysis with an eGFR above 10.5 mL/min/1.73 m2, from 20.1% in Manitoba to 57.2% in some parts of British Columbia. The investigators also observed an increase in proportion over time, rising from 27.9% in 2001 to a peak of 40.5% in 2009.

The guideline, which is not yet published, is an update of a 1999 Canadian guideline. It was created under the aegis of the Canadian Society of Nephrology and CANN-NET (Canadian Kidney Knowledge Translation and Generation Network).

Gihad Nesrallah, MD, MSc, the lead author of the guideline, noted that there has been considerable dialogue and study on the optimal time to initiate chronic dialysis. Most recently, evidence has been accumulating that dialysis initiation at higher level of kidney function may reduce patients' survival and quality of life and increase their hospitalization rates.

Therefore, the team members decided not to align themselves with the controversial 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative, which recommends early initiation even in asymptomatic patients.

He and his coauthors recommend an “intent-to-defer' strategy” in which patients with stage 5 chronic kidney disease (an eGFR below 15 mL/min/1.73 m2) are closely monitored by a nephrologist for the emergence of uremic symptoms or complications, which would serve as indications for starting dialysis, said Dr. Nesrallah, a nephrologist at Western University in London, Ontario.

“Our recommendation places a high value on the avoidance of a burdensome and resource-intensive therapy that does not provide any measurable benefit when initiated prior to the emergence of a clinical indication.”

The guideline team – co-chaired by Louise M. Moist, MD, and William F. Clark, MD, both from Western University – unanimously came to this conclusion because they could not find evidence for any benefit from early initiation of dialysis. They also found early initiation significantly increases patients' duration of dialysis and associated resource use. Therefore, they assumed that patients would prefer to wait to start dialysis until it was clearly necessary.

“For an asymptomatic patient, an intent-to-defer approach avoids the burden and inconvenience of an early start, Dr. Nesrallah said. “Simultaneously, it allows for timely initiation of dialysis in patients with symptoms or other clinical indications. Based on the clinical experience of our panel, we concurred that patients place a high value on ameliorating symptoms associated with uremia and hypervolemia, and on avoiding the burden and inconvenience associated with initiating dialysis.”

Implementing an “intent-to-defer” dialysis strategy could also cut millions of dollars from annual health care spending in Canada, he and his team found.

Most die in acute-care facilities without accessing palliative-care services, she said. Fortunately, only 4.1% of the variation in eGFR at initiation occurred at the facility level; 95.7% of the variance was due to patient-specific factors.

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