title: Predialysis health, dialysis timing, and outcomes among older United States adults.
abstract: Studies of dialysis initiation timing have not accounted for predialysis clinical factors that could impact postdialysis outcomes. We examined the association of predialysis health with timing of dialysis initiation in older adult patients in the United States and contrasted morbidity and mortality outcomes among patients with early [estimated GFR (eGFR)≥10 ml/min per 1.73 m(2)] versus later (eGFR<10 ml/min per 1.73 m(2)) initiation. We included all patients from the US Renal Data System who initiated dialysis between 2006 and 2008, were ≥67 years old, and had ≥2 years of prior Medicare coverage (n=84,654). We calculated patients' propensity to initiate dialysis early and matched patients by propensity scores. Cox models were used to compare risks of mortality and hospitalization among initiation groups. The majority (58%) of patients initiated dialysis early. Early initiators were more likely to have had AKI, multiple congestive heart failure admissions, and other hospitalizations preceding initiation. Among propensity-matched patients (n=61,930), early initiation associated with greater all-cause (hazard ratio [HR], 1.11; 95% confidence interval [95% CI], 1.08 to 1.14), cardiovascular (CV; HR, 1.13; 95% CI, 1.09 to 1.17), and infectious (HR, 1.13; 95% CI, 1.06 to 1.22) mortality and greater all-cause (HR, 1.03; 95% CI, 1.01 to 1.05) and infectious (HR, 1.10; 95% CI, 1.07 to 1.13) hospitalizations. There was no difference in CV hospitalizations. Among these older adults, early dialysis initiation associates with greater mortality and hospitalizations, even after accounting for predialysis clinical factors. These findings do not support the common practice of early dialysis initiation in the United States.
authors.affiliation: Division of Nephrology, Department of Medicine.
authors.forename: Deidra C
authors.initials: DC
authors.lastname: Crews
authors.forename: Julia J
authors.initials: JJ
authors.lastname: Scialla
authors.forename: Jiannong
authors.initials: J
authors.lastname: Liu
authors.forename: Haifeng
authors.initials: H
authors.lastname: Guo
authors.forename: Karen
authors.initials: K
authors.lastname: Bandeen-Roche
authors.forename: Patti L
authors.initials: PL
authors.lastname: Ephraim
authors.forename: Bernard G
authors.initials: BG
authors.lastname: Jaar
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Sozio
authors.forename: Dana C
authors.initials: DC
authors.lastname: Miskulin
authors.forename: Navdeep
authors.initials: N
authors.lastname: Tangri
authors.forename: Tariq
authors.initials: T
authors.lastname: Shafi
authors.forename: Klemens B
authors.initials: KB
authors.lastname: Meyer
authors.forename: Albert W
authors.initials: AW
authors.lastname: Wu
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
authors.forename: L Ebony
authors.initials: LE
authors.lastname: Boulware
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D006947:Hyperkalemia / Q000453:epidemiology; D007326:Institutionalization / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009735:Nursing Homes; D010530:Peritoneal Dialysis / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D044469:Racial Groups / Q000706:statistics & numerical data; D012042:Registries / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000379:methods / Q000706:statistics & numerical data*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014511:Uremia / Q000453:epidemiology / Q000628:therapy