GFR at dialysis initiation

GFR at dialysis initiation

With the release of the latest Management Indicator Report from the BC Provincial Renal Agency, the Fraser Health renal program was able to learn a tremendous amount about our performance.

In a future post, I’ll spend more time discussing other performance indicators.  One indicator that is fascinating to examine today is mean eGFR at dialysis initiation.

2015-05-24_22-12-13

On Feb 4, 2014, the CSN published the guideline “Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis.”

Primary recommendation of this guideline:

For adults (aged > 18 yr) with an estimated glomerular filtration rate (eGFR) of less than 15 mL/min per 1.73 m2, we recommend an “intent-to-defer” over an “intent-to-start-early” approach for the initiation of chronic dialysis. (Strong recommendation; moderate-quality evidence.)

With the intent-to-defer strategy, patients with an eGFR of less than 15 mL/min per 1.73 m2 are monitored closely by a nephrologist, and dialysis is initiated with the first onset of a clinical indication or a decline in the eGFR to 6 mL/min per 1.73 m2or less, whichever of these should occur first.

This guideline was based primarily on the results of the IDEAL study (A randomized, controlled trial of early versus late initiation of dialysis. NEJM 2010 12; 363 (7) :609-19) which showed no advantage to an earlier dialysis start.

Of note, the IDEAL study was published in 2010, while the CSN guideline was published in 2014.

While it generally takes a long time for clinical practice to adjust to new evidence/guidelines, it appears that eGFR at initiation of dialysis didn’t change after publication of IDEAL, but starting in the 2nd quarter of 2014 at around the time the CSN guideline was published, we saw a sustained drop in eGFR at dialysis start.

Previously, mean eGFR at initiation was 11-13 ml/min.  For the last 3 quarters, mean eGFR has ranged from 10-11 ml/min.

It will be interesting to see if this trend continues or is sustained.

An analysis of IDEAL also showed that patients randomized to a lower eGFR at dialysis initiation who intended to start peritoneal dialysis were less likely to actually start on PD that those with a higher eGFR at dialysis initiation (70% vs 80%, p = 0.01).

Given the slight decline in PD incidence/prevalence in FHA during this time period, one must consider whether the trend towards lower GFR at dialysis initiation is contributing.

References

 
Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, Quinn RR, Hiremath S, Ravani P, Sood MM, Moist LM; Canadian Society of Nephrology. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
 
Cooper BA1, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA; IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
 
Johnson DW1, Wong MG, Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA. Effect of timing of dialysis commencement on clinical outcomes of patients with planned initiation of peritoneal dialysis in the IDEAL trial. Perit Dial Int. 2012 Nov-Dec;32(6):595-604. PMID: 23212859.