Study: ESRD Patients Starting Dialysis Earlier

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Patients with end-stage renal disease (ESRD) are starting dialysis earlier now than in the past, according to researchers.

A team led by Ann M. O'Hare, MD, Associate Professor of Medicine at the University of Washington in Seattle, estimated that patients initiating chronic dialysis in 2007 did so a mean 147 days earlier than in 1997, after accounting for changing characteristics of new U.S. dialysis patients.

The shift in timing “most likely reflects a shift in dialysis initiation practices during this time period,” the authors noted in a report in Archives of Internal Medicine (2011;171:1663-1669).

The difference in the mean number of days increased with age. Patients younger than 60 years initiated dialysis 95 days earlier in 2007 compared with 1997. Those aged 60-75 years and 75 years and older, respectively, initiated dialysis 139 and 233 days earlier.

Dr. O'Hare and her colleagues estimated that the difference in timing translates into 63 additional hemodialysis treatments, 189 or more hours of treatment, and approximately $14,490 in additional payments for dialysis for each patient, or more than $1.5 billion if extrapolated to patients in the study who initiated dialysis in 2007.

Dr. O'Hare said the findings are important in light of other recent research showing that starting dialysis earlier does not improve a range of health outcomes. “Patients are starting chronic dialysis significantly earlier, but there is no real evidence that it is beneficial,” she said.

For the study, the investigators analyzed data from the U.S. Renal Data System, which is a national registry for ESRD. The 1997 cohort included 75,572 patients and the 2007 cohort included 104,711.

Most observational studies have demonstrated increased rather than decreased mortality among patients who initiate chronic dialysis at higher levels of kidney function, they noted.

“The dearth of evidence available to suggest that this practice [earlier dialysis initiation] is beneficial and the sizable potential effect on treatment burden and costs support the need for careful evaluation of contemporary dialysis initiation practices in this country,” the researchers concluded.

Dr. O'Hare's group discussed factors that may have contributed to the change in U.S. dialysis initiation practices between 1997 and 2007. For example, they pointed out that opinion-based practice guidelines have endorsed successively higher threshold levels of renal function as being appropriate for dialysis initiation. They also cited studies showing that Medicare, which is the primary payer for chronic dialysis in the United States, “now provides significantly less oversight regarding the level of renal function among new dialysis patients compared with earlier years.”

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