Signs and symptoms associated with earlier dialysis initiation in nursing home residents.
BACKGROUND
Factors driving the trend of earlier dialysis initiation for persons with end-stage renal disease are unknown. We wanted to determine the association of the number and type of signs and symptoms with timing of initiation of dialysis in US nursing home residents.


METHODS
Observational study.


METHODS
We used data from the US Renal Data System linked with the Minimum Data Set, a national registry of nursing home residents. The cohort consisted of 2,402 nursing home residents who initiated dialysis between 1998 and 2000 and had at least 2 recorded clinical assessments in the year before dialysis initiation.


METHODS
We evaluated 7 clinical signs and symptoms: dependence in activities of daily living, cognitive function, edema, dyspnea, nutritional problems, vomiting, and body size.


RESULTS
Earlier dialysis initiation was defined as estimated glomerular filtration rate ≥ 1 5 mL/min/1.73 m² at the start of dialysis.


RESULTS
Median estimated glomerular filtration rate at the start of dialysis was 9.8 (25th-75th percentile, 7.4-13.4) mL/min/1.73 m². After adjustment for age, sex, race, and comorbid conditions, each additional sign or symptom was associated with a higher odds for earlier dialysis initiation (OR, 1.16 per symptom; 95% CI, 1.06-1.28), as was each adversely changing sign or symptom (OR, 1.26 per symptom; 95% CI, 1.16-1.38). The population-attributable risk for earlier dialysis initiation associated with having one or more signs and symptoms of volume overload, cognitive decline, increasing activities of daily living dependence, and weight loss was 31%; volume overload had the largest aggregate population-attributable risk.


CONCLUSIONS
We lacked information about metabolic indications for dialysis initiation.


CONCLUSIONS
Volume overload, cognitive decline, increasing activities of daily living dependence, and weight loss were associated with earlier dialysis initiation; however, these factors explained less than one-third of cases of earlier dialysis initiation in nursing home residents.
Kurella Tamura
Manjula
M
Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA. mktamura@stanford.edu
O'Hare
Ann M
AM
McCulloch
Charles E
CE
Johansen
Kirsten L
KL
D000203:Activities of Daily Living / Q000523:psychology; D000368:Aged; D000369:Aged, 80 and over; D049628:Body Size / Q000502:physiology; D003072:Cognition Disorders / Q000503:physiopathology; D004417:Dyspnea / Q000503:physiopathology; D004487:Edema / Q000503:physiopathology; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000503:physiopathology* / Q000523:psychology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes; D006435:Renal Dialysis; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014839:Vomiting / Q000503:physiopathology