title: Structured clinical follow-up for CKD stage 5 may safely postpone dialysis.
abstract: OBJECTIVE
  The optimal timing of dialysis initiation is still unclear. We aimed to ascertain whether a strict clinical follow-up can postpone need for dialysis in chronic kidney disease (CKD) stage 5 patients.
  
  
  METHODS
  We reviewed records of all consecutive adult patients attending our conservative CKD stage 5 outpatient clinic from 2001 to 2010. Chronicity was defined as two consecutive estimated glomerular filtration rate (eGFR) measurements below 15 ml/min/1.73 m(2). Characteristics of subjects, including comorbidities, were assessed at baseline; blood pressure and serum markers of uremia were assessed both at first and last visit. GFR was estimated by the 4-variable Modification of Diet in Renal Disease (MDRD) formula.
  
  
  RESULTS
  In the 312 patients analyzed baseline eGFR was 9.7 ± 2.7 ml/min, which declined by 1.93 ± 4.56 ml/min after 15.6 ± 18.2 months. Age was inversely related to eGFR decline (r -0.27, p = 0.000). During conservative follow-up 55 subjects (18%) died. In comparison with those eventually entering dialysis, deceased subjects were older and had a longer follow-up with no CKD progression. Multivariate analysis identified age, proteinuria and lower baseline K values as the only independent determinants of death. One hundred ninety-four subjects (66%) started dialysis with an average eGFR of 6.1 ± 1.9 ml/min. During 35.8 ± 24.7 months of dialysis follow-up, 84 patients died. Multivariate analysis identified age as the main determinant of death (hazard ratio [HR] for every year 1.07, 95% confidence interval [CI] 1.04-1.11, p 0.000). Patients starting dialysis with eGFR below the median, e.g. <5.7 ml/min, showed a better survival (HR for mortality 0.52, 95% CI 0.30-0.89, p 0.016) than the other group.
  
  
  CONCLUSIONS
  A well-organized nephrological outpatient clinic for conservative follow-up of CKD stage five patients can delay dialysis entry as long as 1 year. Starting dialysis with eGFR lower than 6 ml/min does not confer any increased risk of death in selected early-referral patients.
authors.affiliation: Nephrology and Dialysis Unit, SM Annunziata Hospital, Florence, Italy, pierodattolo@tin.it.
authors.forename: Pietro
authors.initials: P
authors.lastname: Dattolo
authors.forename: Stefano
authors.initials: S
authors.lastname: Michelassi
authors.forename: Marco
authors.initials: M
authors.lastname: Amidone
authors.forename: Marco
authors.initials: M
authors.lastname: Allinovi
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Vignali
authors.forename: Giulia
authors.initials: G
authors.lastname: Antognoli
authors.forename: Rosa
authors.initials: R
authors.lastname: Roperto
authors.forename: Francesco
authors.initials: F
authors.lastname: Pizzarelli
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome