title: Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation.
abstract: Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and Group Health Research Institute, Seattle, Washington Ann.OHare@va.gov.
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and.
authors.forename: Susan P
authors.initials: SP
authors.lastname: Wong
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and.
authors.forename: Margaret K
authors.initials: MK
authors.lastname: Yu
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington;
authors.forename: Bruce
authors.initials: B
authors.lastname: Wynar
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington;
authors.forename: Mark
authors.initials: M
authors.lastname: Perkins
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Health Services, University of Washington, Seattle, Washington; and.
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington;
authors.forename: Jaclyn M
authors.initials: JM
authors.lastname: Lemon
authors.affiliation: Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Health Services, University of Washington, Seattle, Washington; and.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hebert
mesh_terms: D000368:Aged; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000706:statistics & numerical data / Q000639:trends*; D012189:Retrospective Studies
keywords: Department of Veterans Affairs; dialysis initiation; eGFR; indications for dialysis