https://immattersacp.org/weekly/archives/2010/11/16/4.htm

Early hemodialysis initiation may be harmful to patients

Intensive statin therapy lowered risk even for low LDL patients


Guidelines and current practice have been leading patients to begin hemodialysis at higher estimated glomerular filtration rates (eGFRs) but the earlier initiation may actually be increasing mortality, according to a new study.

The observational study included more than 80,000 nondiabetic hemodialysis patients who had no comorbidities other than hypertension and were relatively young—between 20 and 64 years old. The patients were divided by their eGFR at initiation of dialysis. Among patients with a eGFR below 5.0 mL/min/1.73 m2, one-year mortality was 6.8%. In the highest eGFR group (>15.0 mL/min/1.73 m2), the mortality rate was 20.1%. After adjustment and compared with the lowest eGFR group, patients starting with a eGFR of 5.0 to 9.9 mL/min/1.73 m2 had a 23% increased risk for mortality over two years, while those with an eGFR between 10 and 15 mL/min/1.73 m2 had a 47% increased risk and those with an eGFR over 15 mL/min/1.73 m2 had a 74% risk.

The researchers also stratified patients based on serum albumin concentrations, and found the same increased mortality risk even in the healthiest patients, who had serum albumin above 3.5 g/dL. The study authors offered several possible mechanisms for the effect, including myocardial ischemia and “stunning” and changes resulting from fixed systolic dysfunction induced by hemodialysis. They concluded that initiation of hemodialysis “should not be based on an arbitrary level of eGFR or serum creatinine level unless this measure is accompanied by definitive end-stage renal failure-related indications.”

Current guidelines recommend that dialysis be started when eGFR falls below 10.5 mL/min/1.73 m2, and the average eGFR and serum creatinine of patients initiating dialysis have increased substantially over the last 15 years, noted an accompanying editorial. The current study, and the recent IDEAL trial, do not support that practice, the editorialist concluded. She called for changing practice and starting dialysis only when patients' symptoms are worse than the side effects of dialysis are likely to be. The study and editorial were published online by Archives of Internal Medicine on Nov. 8.