TY - JOUR
T1 - Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease
T2 - Nationwide cohort study
AU - Fu, Edouard L
AU - Evans, Marie
AU - Carrero, Juan-Jesus
AU - Putter, Hein
AU - Clase, Catherine M
AU - Caskey, Fergus J
AU - Szymczak, Maciej
AU - Torino, Claudia
AU - Chesnaye, Nicholas C
AU - Jager, Kitty J
AU - Wanner, Christoph
AU - Dekker, Friedo W
AU - van Diepen, Merel
N1 - Publisher Copyright: © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2021/11/29
Y1 - 2021/11/29
N2 - Objective To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease. Design Nationwide observational cohort study. Setting National Swedish Renal Registry of patients referred to nephrologists. Participants Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m 2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017. Main outcome measures The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m 2 in increments of 1 mL/min/1.73 m 2. An eGFR between 6 and 7 mL/min/1.73 m 2 (eGFR 6-7) was taken as the reference. Results Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m 2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR 15-16. Compared with dialysis initiation at eGFR 6-7, initiation at eGFR 15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR 10-14 v eGFR 5-7) and the achieved eGFRs in IDEAL (eGFR 7-10 v eGFR 5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial. Conclusions Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.
AB - Objective To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease. Design Nationwide observational cohort study. Setting National Swedish Renal Registry of patients referred to nephrologists. Participants Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m 2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017. Main outcome measures The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m 2 in increments of 1 mL/min/1.73 m 2. An eGFR between 6 and 7 mL/min/1.73 m 2 (eGFR 6-7) was taken as the reference. Results Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m 2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR 15-16. Compared with dialysis initiation at eGFR 6-7, initiation at eGFR 15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR 10-14 v eGFR 5-7) and the achieved eGFRs in IDEAL (eGFR 7-10 v eGFR 5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial. Conclusions Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.
KW - Aged
KW - Cardiovascular Diseases/etiology
KW - Cohort Studies
KW - Female
KW - Glomerular Filtration Rate
KW - Humans
KW - Male
KW - Nephrology/statistics & numerical data
KW - Practice Patterns, Physicians'/statistics & numerical data
KW - Proportional Hazards Models
KW - Registries
KW - Renal Dialysis/methods
KW - Renal Insufficiency, Chronic/complications
KW - Sweden
KW - Time Factors
KW - Time-to-Treatment/statistics & numerical data
UR - https://www.scopus.com/inward/record.uri?partnerID=HzOxMe3b&scp=85121032235&origin=inward
UR - https://www.ncbi.nlm.nih.gov/pubmed/34844936
U2 - https://doi.org/10.1136/bmj-2021-066306
DO - https://doi.org/10.1136/bmj-2021-066306
M3 - Article
C2 - 34844936
SN - 0959-8138
VL - 375
JO - BMJ (Clinical research ed.)
JF - BMJ (Clinical research ed.)
M1 - e066306
ER -