For asymptomatic adults with chronic kidney disease who will need dialysis, an intent-to-defer approach is recommended over an earlier start, according to a new guideline from the Canadian Society of Nephrology published in CMAJ (Canadian Medical Association Journal).
The guideline panel recommends an "intent-to-defer" strategy over an "intent-to-start" early approach, in which patients with an estimated glomerular filtration rate (eGFR) below 15 mL/ min per 1.73 m2 are closely monitored by a nephrologist. Dialysis is initiated when clinical indications emerge or the eGFR is 6 mL/min per 1.73 m2 or less, whichever of these occurs first.
The recommendation is based on evidence from 23 studies, including the Initiating Dialysis Early and Late (IDEAL) study, a large recent clinical trial that looked at survival rates, costs and other factors in early versus deferred start of dialysis. The study also found that there were substantially higher costs per patient with early initiation of dialysis.
"There was no detectable evidence of benefit with intent-to-start-early as compared with intent-to-defer dialysis for mortality, quality of life or hospital admission in either the RCT or the observational studies," writes Dr. Louise Moist, guideline chair, professor of medicine and epidemiology at the Schulich School of Medicine & Dentistry at Western University and a scientist with the Lawson Health Research Institute, London, Ontario. "Time on dialysis and associated resource use were significantly greater in the intent-to-start-early group. For an asymptomatic patient, an intent-to-defer approach avoids the burden and inconvenience of an early start."
Chronic kidney disease impairs patients' quality of life, and dialysis places substantial burdens on both the patient and the health care system. "This later start of dialysis will place less burden on [patients and their families] as it can delay the start of dialysis in asymptomatic patients for approximately six months," states Dr. Moist.
Previous guidelines placed more emphasis on lab tests than on patients' symptoms to determine when to begin dialysis. They also recommended starting dialysis earlier (at higher eGFR rates) for people with diabetes. This new guideline places the emphasis on symptoms and other complications of kidney disease as reasons for starting dialysis.
"Delaying dialysis in people without symptoms appears to be safe, as long as they are closely followed by their kidney specialist," says Dr. Gihad Nesrallah, lead author and associate scientist at the Li Ka Shing Knowledge Institute, St. Michael's Hospital and a nephrologist at the Humber River Hospital, Toronto, Ontario. "This approach is sure to be preferred by patients, who generally enjoy a better quality of life off dialysis than on it. Many recommended treatments require a trade-off between a beneficial effect and a potential risk or side-effect. In this case there don't appear to be any trade-offs, as long as dialysis can be started promptly once it is needed."
Although the guideline panel did not consider costs in formulating the recommendation, it did note that an intent-to-defer strategy would most likely result in substantial cost savings.
The new recommendation targets adults aged 18 years and older with stage 5 chronic kidney disease, also known as end-stage-kidney disease, in which kidney function is so impaired that the organs cannot keep people alive without dialysis.
The guideline was created by a working group of the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) and the Canadian Society of Nephrology.
To communicate this new guideline, CANN-NET has created infographics (Appendix 6, available at http://www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.130363/-/DC1 and at http://www.knowingkidneys.ca for physicians and patients as part of a strategy to put the guideline into practice). These links will be active after publication at noon February 3, 2014.
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