Some one-fifth of patients who recover kidney function and discontinue dialysis subsequently restart dialysis, a new study finds. The risk for dialysis reinitiation is higher for patients who are older at first dialysis start or who have cystic conditions, diabetes, or hypertension.
“Understanding the most important risk factors prior to the decision to undergo a trial of dialysis discontinuation could help clinicians and patients make shared decisions surrounding timing of removal of dialysis access, proximity of follow-up following dialysis discontinuation, and in the longer term, timing of permanent access placement and kidney transplant candidacy evaluation,” Elaine Ku, MD, of the University of California, San Francisco, and colleagues concluded in a paper published in the Clinical Journal of the American Society of Nephrology.
Among 34,530 adult Medicare beneficiaries who started dialysis (96% hemodialysis) but had recovery of kidney function, 7217 patients (21%) restarted dialysis within 3 years of recovery (absolute rate of 11.5 per 100 person-years), Dr Ku’s team reported. At any point during follow-up, 26.4% restarted dialysis (absolute rate of 8.8 per 100 person-years). The investigators defined kidney function recovery as 90 days or more without dialysis.
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In multivariable Cox models, each 1-year increase in age at first dialysis initiation was significantly associated with a 2% lower risk of returning to dialysis, the investigators reported. Black and Hispanic adults had significant 36% and 28% increased risks of restarting dialysis, respectively, compared with White adults. Using acute tubular necrosis as the reference (the initial cause of kidney failure in 17% of the cohort), patients with cystic conditions, diabetes, glomerulonephritis, hypertension, and urologic conditions had significant 4.3-, 2.4-, 1.9-, 1.7-, and 1.4-fold increased risks of dialysis reinitiation, respectively. Heart failure significantly increased the risk of return to dialysis by 1.4-fold.
Higher chronic kidney disease (CKD) stage at kidney function recovery correlated with dialysis reinitiation. Using CKD stage 1 or 2 at recovery as the reference, patients with CKD stage 3, 4, or 5 had significant 1.5-, 2.6-, and 3.8-fold increased risks of dialysis reinitiation, respectively. The study lacked data on patients’ estimated glomerular filtration rate and degree of proteinuria.
Compared with no history of nephrology care prior to the first dialysis initiation, nephrology care within 6 months and 6-12 months was significantly associated with 1.3- and 1.6-fold increased risks of restarting dialysis after kidney function recovery, respectively. Patients with inpatient care or primary care prior to the first dialysis initiation had lower risks of restarting dialysis.
A model incorporating all of these risk factors predicted with modest discrimination (0.72) the risk of restarting dialysis, the investigators reported.
Overall, the risk of death was 34% among patients who had recovery of kidney function.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Reference
Ku E, Hsu RK, McCulloch CE, et al. Incidence and risk factors for dialysis reinitiation among patients with a history of dialysis dependency. Clin J Am Soc Nephrol. Published online August 11, 2022. doi:10.2215/CJN.01870222
