CHRONIC DIALYSIS NOW STARTS EARLIER!

It has become increasingly clear that patients in the United States are starting dialysis at higher and higher levels of kidney function. A team of researchers, led by Ann O’Hare, MD, an associate professor of medicine at the University of Washington (UW) and affiliate investigator at Group Health Research Institute, set out recently to find out what this means for patients, and how much earlier patients are starting dialysis compared with past practices.

Researchers from Washington state and California found that over a 10-year period, from 1997 to 2007, patients are starting dialysis approximately five months earlier on average. Changes in measured patient characteristics do not explain the changes in timing, which most likely reflect a shift in dialysis initiation practices over this time, researchers said.

Dialysis is an intensive, time-consuming, and expensive procedure for patients, said Dr. O’Hare. "It’s a substantial commitment, taking place three times a week, for three or four hours per treatment, and costing several hundred dollars per treatment," she said. "When you look at the overall chronic dialysis population, our findings are significant."

The research team estimated that the difference in timing translates into 63 additional haemodialysis treatments, 189 or more hours of treatment, and approximately $14,490 in additional payments for dialysis for each patient, or more than $1.5 billion if extrapolated to patients in the study who initiated dialysis in 2007.

The researchers used two different data sources for the study: the United States Renal Data System, a national registry of end-stage renal disease; and a detailed renal database from Group Health Research Institute. The national registry contains details on the level of kidney function for patients starting dialysis. The Group Health data contain information on the rate of loss of kidney function before dialysis initiation, which was not available in the registry data.

Dr. O’Hare said the findings are also important in light of other recent research that found starting dialysis earlier did not improve a range of health outcomes. "Patients are starting chronic dialysis significantly earlier," she said, "but there is no real evidence that it is beneficial."

The researchers said the findings call for more careful evaluation of current dialysis initiation practices in the United States. "We really need to take a good critical look at what we’re doing," said Dr. O’Hare. "Our study did not reveal the rationale for initiating chronic dialysis sooner, nor did it provide details on circumstances, signs, and symptoms that might have prompted dialysis initiation. It’s an open question as to why this is happening, but these findings provide a rationale for more detailed study to better understand practices and what’s driving this trend."

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