Early start of hemodialysis may be harmful.
BACKGROUND
A dramatic increase in the "early start" of dialysis with an estimated glomerular filtration rate (eGFR) at least 10 mL/min/1.73 m(2) has occurred in the United States since at least 1996. Several recent studies have reported a comorbidity-adjusted survival disadvantage of early start of dialysis. The current study examines a relatively "healthy" dialysis cohort to minimize confounding issues and determine whether early initiation of hemodialysis is associated with a survival benefit or harm.


METHODS
We examined demographics, year of dialysis initiation, primary etiology of renal failure, and body mass index, hemoglobin, and serum albumin levels in 81,176 nondiabetic, 20- to 64-year-old, in-center incident hemodialysis patients with no reported comorbidity besides hypertension. We compared survival, using a piecewise proportional hazards model to estimate covariate-adjusted mortality hazard ratios (HRs) for eGFR at the time of initiation of dialysis. We also performed time-dependent adjusted analysis stratified by initial serum albumin levels lower than 2.5 g/dL, 2.5 to 3.49 g/dL, and 3.5 g/dL or higher (the "healthiest" group [HG]).


RESULTS
Unadjusted 1-year mortality by eGFR ranged from 6.8% in the reference group (eGFR <5.0 mL/min/1.73 m(2)) to 20.1% in the highest eGFR group (≥15.0 mL/min/1.73 m(2)). Compared with the reference group, the HR for the HG was 1.27 (eGFR, 5.0-9.9 mL/min/1.73 m(2)), 1.53 (eGFR, 10.0-14.9 mL/min/1.73 m(2)), and 2.18 (eGFR ≥15.0 mL/min/1.73 m(2)) and ranged from 1.50 to 3.53 mL/min/1.73 m(2) in the first year of dialysis for the early-start group.


CONCLUSIONS
The increased HR during hemodialysis associated with early start in the healthiest group of patients undergoing dialysis indicates that early start of dialysis may be harmful.
Dorn Research Institute, Wm. Jennings Bryan Dorn Veterans Hospital, 526 N Trenholm Rd, Columbia, SC 29206, USA. sjrcra@yahoo.com
Steven J
SJ
Rosansky
Paul
P
Eggers
Kirby
K
Jackson
Richard
R
Glassock
William F
WF
Clark
D000328:Adult; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000401:mortality; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*; D014481:United States; D055815:Young Adult