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Early Dialysis Treatment Increases Mortality Risk

 |  By cclark@healthleadersmedia.com  
   November 10, 2010

Patients who begin dialysis earlier in the development of their renal disease have a higher risk of death in the following year than patients who start later, according to a study in the Archives of Internal Medicine.

Researchers at the William Jennings Bryan Dorn Veterans Hospital and the University of South Carolina reviewed United States Renal Data Systemfrom 81,176 non-diabetic patients between the ages of 20 to 64 who began dialysis between 1996 and 2008.

The study "raises a concern that hemodialysis may be providing more harm than benefit," says Steven Rosansky, MD, principal author of the report.

Findings show that patients who had an early start based on their estimated glomerular filtration rate (eGFR) were 10.6% more likely to die in their first year of treatment compared with patients who started treatment later.

The authors say that the higher death rates may reflect a practice pattern in which renal disease practitioners now start dialysis earlier in the course of patients' disease process in order to thwart nonspecific symptoms, such as fatigue, anorexia, nausea, symptoms associated with low serum albumin.

"This trend has occurred despite no substantial evidence of benefit of early initiation of hemodialysis and many recent publications suggesting potential harm. Hemodialysis is an invasive, lifelong, potentially dangerous intervention."

"According to USRDS data, between 1996 and 2008 the fraction of patients initiating hemodialysis with an eGFR higher than 10 mL/min/1.73m2 increased from 20% to 52% and the fraction of those with a starting eGFR of 15 mL/min/1.73m2 or higher increased from 4% to 17% of the incident hemodialysis population," researchers say.

Reasons for the higher rate of death might include:

  • Drops in blood pressure
  • Heart irregularities
  • Ischemia "with fixed dystolic function induced by conventional three-weekly hemodialysis"
  • Increasing age
  • Being black or male
  • Having a lower weight BMI

In a related editorial entitled "Time to Rethink the Timing of Dialysis Initiation," Kirsten Johansen, MD, of the San Francisco VA Medical Center suggests that clinicians take a close look at the data and re-evaluate the timing of initial dialysis.

"I am not advocating that we require months of nausea and vomiting before initiating dialysis," she wrote. "But I am suggesting that (in the absence of urgent indications) we shift our paradigm to consider starting dialysis when the symptoms are worse than the anticipated lifestyle burden and effects of dialysis, which are considerable and include a substantial time commitment, frequent fatigue and infections, among other things."

Consumer groups, researchers and payers have been increasing efforts to understand reasons behind the wide variation in death rates for dialysis patients, which range from 10% at some centers to 30% at others. It's a key priority for federal payers, who spend billions on the procedure for more than 400,000 patients each year.

Patients with lower levels of the liver protein albumin had higher risk of death in the first year compared with those who had higher albumin levels (21% vs 4.7%).

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