Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD

Deidra Crews, Julia J. Scialla, Leigh Boulware, Sankar D. Navaneethan, Joseph V. Nally, Xiaobo Liu, Susana Arrigain, Jesse D. Schold, Patti L Ephraim, Stacey E. Jolly, Stephen M Sozio, Wieneke M. Michels, Dana C. Miskulin, Navdeep Tangri, Tariq Shafi, Albert W Wu, Karen J Bandeen Roche

Research output: Contribution to journalArticle

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. Study Design 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 2). Setting & Participants 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 20-30 mL/min/1.73 m2 measured at least 180 days apart. Predictors 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 10 mL/min/1.73 m2) or later (eGFR <10 mL/min/1.73 m2) and was time-varying. Outcomes Death from any cause occurring from the time that eGFR was equal to 20 mL/min/1.73 m2 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 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). Limitations 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.

Original languageEnglish (US)
Pages (from-to)806-815
Number of pages10
JournalAmerican Journal of Kidney Diseases
Volume63
Issue number5
DOIs
StatePublished - 2014

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Chronic Renal Insufficiency
Dialysis
Glomerular Filtration Rate
Therapeutics
Survivors
Logistic Models
Health Personnel
Sample Size
Population
Observational Studies
Cause of Death
Cohort Studies
Outpatients
Retrospective Studies
Survival
Mortality

Keywords

  • decreased glomerular filtration rate (GFR)
  • dialysis initiation
  • early-start dialysis
  • end-stage renal disease (ESRD)
  • Index Words
  • Kidney disease trajectory
  • prognosis
  • renal disease progression
  • renal replacement therapy (RRT)
  • timing of dialysis

ASJC Scopus subject areas

  • Nephrology

Cite this

Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD. / Crews, Deidra; Scialla, Julia J.; Boulware, Leigh; Navaneethan, Sankar D.; Nally, Joseph V.; Liu, Xiaobo; Arrigain, Susana; Schold, Jesse D.; Ephraim, Patti L; Jolly, Stacey E.; Sozio, Stephen M; Michels, Wieneke M.; Miskulin, Dana C.; Tangri, Navdeep; Shafi, Tariq; Wu, Albert W; Bandeen Roche, Karen J.

In: American Journal of Kidney Diseases, Vol. 63, No. 5, 2014, p. 806-815.

Research output: Contribution to journalArticle

Crews, D, Scialla, JJ, Boulware, L, Navaneethan, SD, Nally, JV, Liu, X, Arrigain, S, Schold, JD, Ephraim, PL, Jolly, SE, Sozio, SM, Michels, WM, Miskulin, DC, Tangri, N, Shafi, T, Wu, AW & Bandeen Roche, KJ 2014, 'Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD', American Journal of Kidney Diseases, vol. 63, no. 5, pp. 806-815. https://doi.org/10.1053/j.ajkd.2013.12.010
Crews, Deidra ; Scialla, Julia J. ; Boulware, Leigh ; Navaneethan, Sankar D. ; Nally, Joseph V. ; Liu, Xiaobo ; Arrigain, Susana ; Schold, Jesse D. ; Ephraim, Patti L ; Jolly, Stacey E. ; Sozio, Stephen M ; Michels, Wieneke M. ; Miskulin, Dana C. ; Tangri, Navdeep ; Shafi, Tariq ; Wu, Albert W ; Bandeen Roche, Karen J. / Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD. In: American Journal of Kidney Diseases. 2014 ; Vol. 63, No. 5. pp. 806-815.
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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. Study Design 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 2). Setting & Participants 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 20-30 mL/min/1.73 m2 measured at least 180 days apart. Predictors 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 10 mL/min/1.73 m2) or later (eGFR <10 mL/min/1.73 m2) and was time-varying. Outcomes Death from any cause occurring from the time that eGFR was equal to 20 mL/min/1.73 m2 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 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). Limitations 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.",
keywords = "decreased glomerular filtration rate (GFR), dialysis initiation, early-start dialysis, end-stage renal disease (ESRD), Index Words, Kidney disease trajectory, prognosis, renal disease progression, renal replacement therapy (RRT), timing of dialysis",
author = "Deidra Crews and Scialla, {Julia J.} and Leigh Boulware and Navaneethan, {Sankar D.} and Nally, {Joseph V.} and Xiaobo Liu and Susana Arrigain and Schold, {Jesse D.} and Ephraim, {Patti L} and Jolly, {Stacey E.} and Sozio, {Stephen M} and Michels, {Wieneke M.} and Miskulin, {Dana C.} and Navdeep Tangri and Tariq Shafi and Wu, {Albert W} and {Bandeen Roche}, {Karen J}",
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T1 - Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD

AU - Crews, Deidra

AU - Scialla, Julia J.

AU - Boulware, Leigh

AU - Navaneethan, Sankar D.

AU - Nally, Joseph V.

AU - Liu, Xiaobo

AU - Arrigain, Susana

AU - Schold, Jesse D.

AU - Ephraim, Patti L

AU - Jolly, Stacey E.

AU - Sozio, Stephen M

AU - Michels, Wieneke M.

AU - Miskulin, Dana C.

AU - Tangri, Navdeep

AU - Shafi, Tariq

AU - Wu, Albert W

AU - Bandeen Roche, Karen J

PY - 2014

Y1 - 2014

N2 - 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. Study Design 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 2). Setting & Participants 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 20-30 mL/min/1.73 m2 measured at least 180 days apart. Predictors 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 10 mL/min/1.73 m2) or later (eGFR <10 mL/min/1.73 m2) and was time-varying. Outcomes Death from any cause occurring from the time that eGFR was equal to 20 mL/min/1.73 m2 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 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). Limitations 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.

AB - 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. Study Design 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 2). Setting & Participants 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 20-30 mL/min/1.73 m2 measured at least 180 days apart. Predictors 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 10 mL/min/1.73 m2) or later (eGFR <10 mL/min/1.73 m2) and was time-varying. Outcomes Death from any cause occurring from the time that eGFR was equal to 20 mL/min/1.73 m2 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 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). Limitations 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.

KW - decreased glomerular filtration rate (GFR)

KW - dialysis initiation

KW - early-start dialysis

KW - end-stage renal disease (ESRD)

KW - Index Words

KW - Kidney disease trajectory

KW - prognosis

KW - renal disease progression

KW - renal replacement therapy (RRT)

KW - timing of dialysis

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