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Association between estimated glomerular filtration rate at initiation of dialysis and mortality.
CMAJ. 2011 Jan 11; 183(1):47-53.CMAJ

Abstract

BACKGROUND

Recent studies have reported a trend toward earlier initiation of dialysis (i.e., at higher levels of glomerular filtration rate) and an association between early initiation and increased risk of death. We examined trends in initiation of hemodialysis within Canada and compared the risk of death between patients with early and late initiation of dialysis.

METHODS

The analytic cohort consisted of 25 910 patients at least 18 years of age who initiated hemodialysis, as identified from the Canadian Organ Replacement Register (2001-2007). We defined the initiation of dialysis as early if the estimated glomerular filtration rate was greater than 10.5 mL/min per 1.73 m². We fitted time-dependent proportional-hazards Cox models to compare the risk of death between patients with early and late initiation of dialysis.

RESULTS

Between 2001 and 2007, mean estimated glomerular filtration rate at initiation of dialysis increased from 9.3 (standard deviation [SD] 5.2) to 10.2 (SD 7.1) (p < 0.001), and the proportion of early starts rose from 28% (95% confidence interval [CI] 27%-30%) to 36% (95% CI 34%-37%). Mean glomerular filtration rate was 15.5 (SD 7.7) mL/min per 1.73 m² among those with early initiation and 7.1 (SD 2.0) mL/min per 1.73 m² among those with late initiation. The unadjusted hazard ratio (HR) for mortality with early relative to late initiation was 1.48 (95% CI 1.43-1.54). The HR decreased to 1.18 (95% CI 1.13-1.23) after adjustment for demographic characteristics, serum albumin, primary cause of end-stage renal disease, vascular access type, comorbidities, late referral and transplant status. The mortality differential between early and late initiation per 1000 patient-years narrowed after one year of follow-up, but never crossed and began widening again after 24 months of follow-up. The differences were significant at 6, 12, 30 and 36 months.

INTERPRETATION

In Canada, dialysis is being initiated at increasingly higher levels of glomerular filtration rate. A higher glomerular filtration rate at initiation of dialysis is associated with an increased risk of death that is not fully explained by differences in baseline characteristics.

Authors+Show Affiliations

Division of Nephrology, University of Western Ontario, London Ont., Canada. William.Clark@lhsc.on.caNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

21135082

Citation

Clark, William F., et al. "Association Between Estimated Glomerular Filtration Rate at Initiation of Dialysis and Mortality." CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, vol. 183, no. 1, 2011, pp. 47-53.
Clark WF, Na Y, Rosansky SJ, et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ. 2011;183(1):47-53.
Clark, W. F., Na, Y., Rosansky, S. J., Sontrop, J. M., Macnab, J. J., Glassock, R. J., Eggers, P. W., Jackson, K., & Moist, L. (2011). Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 183(1), 47-53. https://doi.org/10.1503/cmaj.100349
Clark WF, et al. Association Between Estimated Glomerular Filtration Rate at Initiation of Dialysis and Mortality. CMAJ. 2011 Jan 11;183(1):47-53. PubMed PMID: 21135082.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association between estimated glomerular filtration rate at initiation of dialysis and mortality. AU - Clark,William F, AU - Na,Yingbo, AU - Rosansky,Steven J, AU - Sontrop,Jessica M, AU - Macnab,Jennifer J, AU - Glassock,Richard J, AU - Eggers,Paul W, AU - Jackson,Kirby, AU - Moist,Louise, Y1 - 2010/12/06/ PY - 2010/12/8/entrez PY - 2010/12/8/pubmed PY - 2011/2/25/medline SP - 47 EP - 53 JF - CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne JO - CMAJ VL - 183 IS - 1 N2 - BACKGROUND: Recent studies have reported a trend toward earlier initiation of dialysis (i.e., at higher levels of glomerular filtration rate) and an association between early initiation and increased risk of death. We examined trends in initiation of hemodialysis within Canada and compared the risk of death between patients with early and late initiation of dialysis. METHODS: The analytic cohort consisted of 25 910 patients at least 18 years of age who initiated hemodialysis, as identified from the Canadian Organ Replacement Register (2001-2007). We defined the initiation of dialysis as early if the estimated glomerular filtration rate was greater than 10.5 mL/min per 1.73 m². We fitted time-dependent proportional-hazards Cox models to compare the risk of death between patients with early and late initiation of dialysis. RESULTS: Between 2001 and 2007, mean estimated glomerular filtration rate at initiation of dialysis increased from 9.3 (standard deviation [SD] 5.2) to 10.2 (SD 7.1) (p < 0.001), and the proportion of early starts rose from 28% (95% confidence interval [CI] 27%-30%) to 36% (95% CI 34%-37%). Mean glomerular filtration rate was 15.5 (SD 7.7) mL/min per 1.73 m² among those with early initiation and 7.1 (SD 2.0) mL/min per 1.73 m² among those with late initiation. The unadjusted hazard ratio (HR) for mortality with early relative to late initiation was 1.48 (95% CI 1.43-1.54). The HR decreased to 1.18 (95% CI 1.13-1.23) after adjustment for demographic characteristics, serum albumin, primary cause of end-stage renal disease, vascular access type, comorbidities, late referral and transplant status. The mortality differential between early and late initiation per 1000 patient-years narrowed after one year of follow-up, but never crossed and began widening again after 24 months of follow-up. The differences were significant at 6, 12, 30 and 36 months. INTERPRETATION: In Canada, dialysis is being initiated at increasingly higher levels of glomerular filtration rate. A higher glomerular filtration rate at initiation of dialysis is associated with an increased risk of death that is not fully explained by differences in baseline characteristics. SN - 1488-2329 UR - https://www.unboundmedicine.com/medline/citation/21135082/Association_between_estimated_glomerular_filtration_rate_at_initiation_of_dialysis_and_mortality_ L2 - http://www.cmaj.ca/cgi/pmidlookup?view=long&amp;pmid=21135082 DB - PRIME DP - Unbound Medicine ER -