title: Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD.
abstract: BACKGROUND
  Previous observational studies examining outcomes associated with the timing of dialysis therapy initiation in the United States have often been limited by lead time and survivor bias.
  
  
  METHODS
  Retrospective cohort study comparing the effectiveness of early versus later (conventional) dialysis therapy initiation in advanced chronic kidney disease (CKD). The analysis used inverse probability weighting to account for an individual's contribution to different exposure groups over time in a pooled logistic regression model. Patients contributed risk to both exposure categories (early and later initiation) until there was a clear treatment strategy (ie, dialysis therapy was initiated early or estimated glomerular filtration rate [eGFR] decreased to <10mL/min/1.73m(2)).
  
  
  METHODS
  Patients with CKD who had at least one face-to-face outpatient encounter with a Cleveland Clinic health care provider as of January 1, 2005, and at least 3 eGFRs in the range of 20-30mL/min/1.73m(2) measured at least 180 days apart.
  
  
  METHODS
  Timing of dialysis therapy initiation as determined using model-based interpolation of eGFR trajectories over time. Timing was defined as early (interpolated eGFR at dialysis therapy initiation≥10mL/min/1.73m(2)) or later (eGFR < 10mL/min/1.73m(2)) and was time-varying.
  
  
  RESULTS
  Death from any cause occurring from the time that eGFR was equal to 20mL/min/1.73m(2) through September 15, 2009.
  
  
  RESULTS
  The study population consisted of 652 patients meeting inclusion criteria. Most (71.3%) of the study population did not initiate dialysis therapy during follow-up. Patients who did not initiate dialysis therapy (n=465) were older, more likely to be white, and had more favorable laboratory profiles than those who started dialysis therapy. Overall, 146 initiated dialysis early and 80 had eGFRs decrease to <10mL/min/1.73m(2). Many participants (n=426) were censored prior to attaining a clear treatment strategy and were considered undeclared. There was no statistically significant survival difference for the early compared with later initiation strategy (OR, 0.85; 95% CI, 0.65-1.11).
  
  
  CONCLUSIONS
  Interpolated eGFR, moderate sample size, and likely unmeasured confounders.
  
  
  CONCLUSIONS
  In patients with advanced CKD, timing of dialysis therapy initiation was not associated with mortality when accounting for lead time bias and survivor bias.
authors: Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD. Electronic address: dcrews1@jhmi.edu.
authors: Deidra C
authors: DC
authors: Crews
authors: Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL.
authors: Julia J
authors: JJ
authors: Scialla
authors: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC.
authors: L Ebony
authors: LE
authors: Boulware
authors: Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.
authors: Sankar D
authors: SD
authors: Navaneethan
authors: Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.
authors: Joseph V
authors: JV
authors: Nally
authors: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
authors: Xiaobo
authors: X
authors: Liu
authors: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
authors: Susana
authors: S
authors: Arrigain
authors: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
authors: Jesse D
authors: JD
authors: Schold
authors: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors: Patti L
authors: PL
authors: Ephraim
authors: Department of General Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH.
authors: Stacey E
authors: SE
authors: Jolly
authors: Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD.
authors: Stephen M
authors: SM
authors: Sozio
authors: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, the Netherlands.
authors: Wieneke M
authors: WM
authors: Michels
authors: Division of Nephrology, Tufts University School of Medicine, Boston, MA.
authors: Dana C
authors: DC
authors: Miskulin
authors: Division of Nephrology, Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
authors: Navdeep
authors: N
authors: Tangri
authors: Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD.
authors: Tariq
authors: T
authors: Shafi
authors: Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health, Policy, and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors: Albert W
authors: AW
authors: Wu
authors: Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors: Karen
authors: K
authors: Bandeen-Roche
mesh_terms: D000368:Aged; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Kidney disease trajectory; decreased glomerular filtration rate (GFR); dialysis initiation; early-start dialysis; end-stage renal disease (ESRD); prognosis; renal disease progression; renal replacement therapy (RRT); timing of dialysis