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 |
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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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