Initiating dialysis early may decrease survival, investigators reported at the American Society of Nephrology’s Kidney Week 2021.

In the US, dialysis initiation has been trending at higher estimated glomerular filtration rates (eGFR; in mL/min/1.73 m2) over time, according to Connie Rhee, MD, MSc, of the University of California Irvine. From 2000 to 2018, dialysis initiation at an eGFR of 10 or higher increased from 23% to 38% of patients, including 11% who initiated at an eGFR of 15 or higher.

Among 309,163 patients with advanced CKD who transitioned to dialysis in her team’s study, 6%, 12%, 31%, 42%, and 9% initiated dialysis at stage 4B, 4C, 5A, 5B, and 5C, respectively, according to OptumLabs data. The corresponding eGFRs for these stages were 20 or higher but less than 25; 15-20; 10-15; 5-10; and less than 5, respectively.

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In 2020, 72% of the entire cohort initiated dialysis at an eGFR of 10 or higher, Dr Rhee reported. Early initiators were more likely to be older, male, and White and have more comorbidities and tobacco use.

All-cause mortality rates were incrementally higher when patients initiated dialysis at higher levels of kidney function, according to Dr Rhee. The crude mortality rate for patients who initiated dialysis at stage 5C vs 4B was 118 vs 164 deaths per 1000 person-years.

Lower survival was also observed in subgroup analyses of patients younger than 65 years — across age, race and ethnicity, diabetes status, and comorbidity burden. Among patients older than 65 years, prognoses differed in some subgroups.

“Future studies are needed to better phenotype which patients will most benefit from deferred initiation of dialysis using conservative and preservative strategies vs those who have optimal survival with an earlier transition,” Dr Rhee concluded.


Rhee C, Narasaki Y, You AS, et al. Real-world analysis of timing of dialysis transition and mortality in a nationally representative cohort of advanced CKD patients. Presented at: Kidney Week 2021; November 2-7, 2021. Presentation: FR-OR22.