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      Early dialysis initiation does not improve clinical outcomes in elderly end-stage renal disease patients: A multicenter prospective cohort study

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          Abstract

          Background

          The optimal timing for initiating dialysis in end-stage renal disease (ESRD) is controversial, especially in the elderly.

          Methods

          665 patients ≥65 years old who began dialysis from August 2008 to February 2015 were prospectively enrolled in the Clinical Research Center for End-Stage Renal Disease cohort study. Participants were divided into 2 groups based on the median estimated glomerular filtration rate at the initiation of dialysis. Propensity score matching (PSM) was used to compare the overall survival rate, cardiovascular events, Kidney Disease Quality of Life Short Form 36 (KDQOL-36) results, Karnofsky performance scale values, Beck’s depression inventory values, and subjective global assessments.

          Results

          The mean patient age was 72.0 years, and 61.7% of the patients were male. Overall, the cumulative survival rates were lower in the early initiation group, although the difference was not significant after PSM. Additionally, the survival rates of the 2 groups did not differ after adjusting for age, sex, Charlson comorbidity index and hemoglobin, serum albumin, serum calcium and phosphorus levels. Although the early initiation group showed a lower physical component summary score on the KDQOL-36 3 months after dialysis, the difference in scores was not significant 12 months after dialysis. Furthermore, the difference was not significant after PSM. The Karnofsky performance scale, Beck’s depression inventory, and subjective global assessments were not significantly different 3 and 12 months after dialysis initiation.

          Conclusions

          The timing of dialysis initiation is not associated with clinical outcomes in elderly patients with ESRD.

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          Most cited references31

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          A randomized, controlled trial of early versus late initiation of dialysis.

          In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause. Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis). In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)
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            Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/1.73 m2.

            The Modification of Diet in Renal Disease (MDRD) Study equation underestimates measured glomerular filtration rate (GFR) at levels>60 mL/min/1.73 m2, with variable accuracy among subgroups; consequently, estimated GFR (eGFR)>or=60 mL/min/1.73 m2 is not reported by clinical laboratories. Here, performance of a more accurate GFR-estimating equation, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, is reported by level of GFR and clinical characteristics. Test of diagnostic accuracy. Pooled data set of 3,896 people from 16 studies with measured GFR (not used for the development of either equation). Subgroups were defined by eGFR, age, sex, race, diabetes, prior solid-organ transplant, and body mass index. eGFR from the CKD-EPI and MDRD Study equations and standardized serum creatinine. Measured GFR using urinary or plasma clearance of exogenous filtration markers. Mean measured GFR was 68+/-36 (SD) mL/min/1.73 m2. For eGFR or=90 mL/min/1.73 m2. Limited number of elderly people and racial and ethnic minorities with measured GFR. The CKD-EPI equation is more accurate than the MDRD Study equation overall and across most subgroups. In contrast to the MDRD Study equation, eGFR>or=60 mL/min/1.73 m2 can be reported using the CKD-EPI equation. Copyright (c) 2010 National Kidney Foundation, Inc. All rights reserved.
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              Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?

              There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT). This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (> or =70 yr) patients who had ESRD and had chosen either MCM (n = 29) or RRT (n = 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.8 ml/min per 1.73 m(2). Median survival, including the first 90 d, was 37.8 mo (range 0 to 106 mo) for RRT patients and 13.9 mo (range 2 to 44) for MCM patients (P < 0.01). RRT patients had higher rates of hospitalization (0.069 [95% confidence interval (CI) 0.068 to 0.070]) versus 0.043 [95% CI 0.040 to 0.047] hospital days/patient-days survived) compared with MCM patients. MCM patients were significantly more likely to die at home or in a hospice (odds ratio 4.15; 95% CI 1.67 to 10.25). A survey of the literature describing elderly ESRD outcomes is also presented. Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                17 April 2017
                2017
                : 12
                : 4
                : e0175830
                Affiliations
                [1 ]Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Korea
                [2 ]Department of Internal Medicine, Dongguk University Medical Center, Gyeongsangbuk-do, Korea
                [3 ]Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
                [4 ]Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
                [5 ]Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
                [6 ]Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
                [7 ]Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
                [8 ]Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
                The University of Tokyo, JAPAN
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: JYP JPL.

                • Data curation: KDY.

                • Formal analysis: JYP.

                • Funding acquisition: YLK.

                • Investigation: KWJ.

                • Methodology: YCK.

                • Project administration: SWK.

                • Resources: CWY.

                • Software: NHK.

                • Supervision: YSK.

                • Validation: DKK.

                • Visualization: CSL.

                • Writing – original draft: JYP.

                • Writing – review & editing: JPL.

                Article
                PONE-D-16-39984
                10.1371/journal.pone.0175830
                5393880
                28414758
                242d5588-a752-49f0-9251-8ff54e283cb9
                © 2017 Park et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 7 October 2016
                : 1 April 2017
                Page count
                Figures: 2, Tables: 4, Pages: 14
                Funding
                Funded by: Ministry of Health and Welfare, Republic of Korea
                Award ID: HC15C1129
                This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HC15C1129).
                Categories
                Research Article
                Medicine and Health Sciences
                Nephrology
                Medical Dialysis
                Medicine and Health Sciences
                Geriatrics
                Geriatric Nephrology
                Medicine and Health Sciences
                Nephrology
                Geriatric Nephrology
                Medicine and Health Sciences
                Nephrology
                Chronic Kidney Disease
                Medicine and Health Sciences
                Geriatrics
                People and Places
                Population Groupings
                Age Groups
                Elderly
                Biology and Life Sciences
                Biochemistry
                Proteins
                Hemoglobin
                Biology and Life Sciences
                Anatomy
                Renal System
                Kidneys
                Medicine and Health Sciences
                Anatomy
                Renal System
                Kidneys
                Biology and Life Sciences
                Biochemistry
                Proteins
                Albumins
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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