Dialysis timing may be deferred toward very late initiation: An observational study

Area of Science:

• Nephrology
• Internal Medicine
• Public Health

Background:

• Optimal timing for initiating dialysis in patients with estimated glomerular filtration rate (eGFR) <5 mL/min/1.73 m2 remains unclear.
• High uremic burden often prompts early dialysis initiation, but evidence for deferral is limited.

Purpose of the Study:

• To investigate the safety and feasibility of deferring dialysis initiation in patients with advanced chronic kidney disease (CKD) and significant uremic burden.
• To determine if delaying dialysis initiation impacts all-cause mortality in this patient population.

Main Methods:

• A case-crossover study involving 1,079 hemodialysis patients (aged 18-90) was conducted.
• Uremic burden was assessed using seven key indicators (hemoglobin, albumin, BUN, creatinine, potassium, phosphorus, bicarbonate).
• Dialysis timing was categorized as standard, late, or very late based on the number of uremic indicators met before initiation.

Main Results:

• Median eGFR at dialysis initiation was 3.4 mL/min/1.73 m2, with very late initiators having a median eGFR of 2.7 mL/min/1.73 m2.
• No significant increase in all-cause mortality was observed for late (HR 0.97) or very late (HR 0.83) dialysis initiation groups compared to the standard group.
• Increased use of antibiotics, diuretics, antihypertensives, and NSAIDs was noted in the period preceding dialysis initiation.

Conclusions:

• Deferring dialysis initiation is safe for CKD patients with eGFR <5 mL/min/1.73 m2, even with multiple biochemical uremic burdens.
• Focusing on infection prevention, fluid management, and avoiding NSAIDs can help prolong dialysis-free survival.
• These findings support a more conservative approach to dialysis timing in select advanced CKD patients.