Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study

Autor: Nicholas C. Chesnaye, Fergus Caskey, Marie Evans, Juan Jesus Carrero, Claudia Torino, Friedo W. Dekker, Christoph Wanner, Catherine M. Clase, Maciej Szymczak, Edouard L Fu, Merel van Diepen, Hein Putter, Kitty J Jager
Přispěvatelé: Medical Informatics, APH - Methodology, APH - Aging & Later Life, ACS - Pulmonary hypertension & thrombosis, APH - Quality of Care, APH - Global Health, APH - Health Behaviors & Chronic Diseases
Rok vydání: 2021
Předmět:
Male
Chronic/complications
medicine.medical_specialty
Time Factors
Renal Insufficiency
Chronic/complications
medicine.medical_treatment
Practice Patterns
Time-to-Treatment/statistics & numerical data
Lower risk
Time-to-Treatment
Cohort Studies
Physicians'/statistics & numerical data
Renal Dialysis
Internal medicine
medicine
Humans
Practice Patterns
Physicians'/statistics & numerical data
Registries
Renal Insufficiency
Practice Patterns
Physicians'
Renal Insufficiency
Chronic
Cardiovascular Diseases/etiology
Dialysis
Aged
Proportional Hazards Models
Nephrology/statistics & numerical data
Sweden
business.industry
Research
Hazard ratio
Absolute risk reduction
General Medicine
medicine.disease
Confidence interval
Lead time bias
Cardiovascular Diseases
Nephrology
Renal Dialysis/methods
Female
business
Glomerular Filtration Rate
Cohort study
Kidney disease
Zdroj: BRITISH MEDICAL JOURNAL, 375. BMJ PUBLISHING GROUP
BMJ (Clinical research ed.), 375:e066306. British Medical Association
Fu, E L, Evans, M, Carrero, J J, Putter, H, Clase, C M, Caskey, F J, Szymczak, M, Torino, C, Chesnaye, N C, Jager, K, Wanner, C, Dekker, F W & van Diepen, M 2021, ' Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease : nationwide cohort study ', BMJ . https://doi.org/10.1136/bmj-2021-066306
The BMJ
ISSN: 1756-1833
0959-8138
Popis: ObjectiveTo identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease.DesignNationwide observational cohort study.SettingNational Swedish Renal Registry of patients referred to nephrologists.ParticipantsPatients had a baseline eGFR between 10 and 20 mL/min/1.73 m2and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017.Main outcome measuresThe 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 m2in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2(eGFR6-7) was taken as the reference.ResultsAmong 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 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 eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16was 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 (eGFR10-14veGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10veGFR5-7), 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.ConclusionsVery 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.
Databáze: OpenAIRE
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