Unplanned dialysis initiation in patients known to renal services: A case-control study

Dialysis initiation during an emergency hospital admission is associated with increased complications, more temporary access, and higher mortality. Even in patients known to nephrologists, more than one-third start dialysis in an unplanned fashion. This retrospective case-control study sought to identify features of the pre-dialysis period that are associated with unplanned dialysis initiation in patients known to nephrology services. 40 consecutive patients (median age 61, 85% male) who underwent unplanned dialysis initiation (cases) were individually matched by age and sex with patients who started dialysis in a planned fashion during a similar period (controls). Clinical and laboratory data were collected from electronic patient records and correspondence. Across the pre-dialysis year, cases had a faster estimated glomerular filtration rate (eGFR) decline, greater weight gain, missed more nephrology clinic appointments, and had more emergency hospital admissions compared to controls. In multivariable analysis, predictors of unplanned dialysis initiation were eGFR trajectory (OR 1.91 per -1 mL/min/1.73m²/month, 95% CI 1.10 - 3.30, p = 0.021), weight gain (OR 1.97 per +1%/month, 95% CI 1.33 - 2.93, p < 0.001), and clinic non-attendance (OR 1.54 per clinic, 95% CI 1.09 - 2.18, p = 0.015). The findings of this study suggest that to better identify individuals nearing dialysis who are at high risk for unplanned initiation, nephrologists need to move away from traditional markers of disease progression, such as latest eGFR and proteinuria, and instead look at trends in eGFR, trends in weight, and levels of patient engagement with pre-dialysis care.