The Canadian Society of Nephrology recommends an “intent to defer” rather than an “intent to start early” approach to dialysis initiation for patients with chronic kidney disease (CKD) in a new clinical practice guideline focused on timing the initiation of chronic dialysis.
In the intent-to-defer strategy, patients with an estimated glomerular filtration rate (eGFR) below 15 mL/min/1.73m2 are closely monitored by a nephrologist. Dialysis is initiated when clinical indications emerge or when the eGFR is 6 mL/min/1.73m2 or less—whichever occurs first, according to a report in the Canadian Medical Association Journal (2014;186:112-117).
In the guideline, developed by a panel nominated by the Canadian Society of Nephrology Clinical Practice Guidelines Committee, clinical indications for the initiation of dialysis include symptoms of uremia, fluid overload, refractory hyperkalemia or acidemia, or other conditions or symptoms that are likely to be ameliorated by dialysis.
“Our recommendation places a high value on the avoidance of a burdensome and resource-intensive therapy that does not provide measurable benefit when started before the development of a clinical indication, such as uremic symptoms,” wrote guideline chair Louise M. Moist, MD, MSc, a professor of medicine and epidemiology at the Schulich School of Medicine and Dentistry at Western University in London, Ontario, and coauthors.
The group based the recommendation on findings from the Initiating Dialysis Early and Late (IDEAL) clinical trial as well as 22 other studies. Neither the randomized controlled trials nor the observational studies yielded any detectable evidence that early initiation of dialysis improved survival, quality of life, or hospital admission rates compared with late or deferred initiation.
Patient education and modality selection, trajectory and severity of existing uremic symptoms, rate of decline in renal function, are among other factors that may affect the timing of dialysis initiation.
“The intent-to-defer strategy pertains specifically to dialysis initiation, and does not imply that patients should be referred to nephrologists at a lower level of kidney function,” the authors wrote. “Patients should be referred according to previously published guidelines.”
Separately, in a recently published study, researchers in Norway found that an early dialysis start—defined as an eGFR of 10 mL/min/1.73 m2 or higher—was not associated with improved quality of life. Inger Karin Lægreid, MD, of the Norwegian University of Science and Technology in Trondheim, and colleagues assessed QoL in 194 patients aged 75 years and older, 52 of whom started dialysis early and 142 started late (at an eGFR below 10 mL/min/1.73 m2).
Previously, a meta-analysis of data from 15 studies totaling 1,285,747 patients indicated that early initiation of dialysis was associated with an increased risk of death. The researchers, who published their findings in Nephron Clinical Practice (2012;120:c121-c131), concluded that older age, greater likelihood of diabetes, and the presence of severe comorbid diseases partly explain this effect.