Urgent-start dialysis in patients referred early to a nephrologist—the CKD-REIN prospective cohort study
Victor Fages, Natália Alencar de Pinho, Aghilès Hamroun, Céline Lange, Christian Combe, Denis Fouque, Luc Frimat, Christian Jacquelinet, Maurice Laville, Carole Ayav, Sophie Liabeuf, Roberto Pecoits‐Filho, Ziad A Massy, Julie Boucquemont, Bénédicte Stengel, the CKD-REIN study collaborators, Natália Alencar de Pinho, Carole Ayav, Serge Briançon, Dorothée Cannet, Christian Combe, Denis Fouque, Luc Frimat, Yves-Édouard Herpe, Christian Jacquelinet, Maurice Laville, Ziad A Massy, Christophe Pascal, Bruce Robinson, Bénédicte Stengel, Céline Lange, Karine Legrand, Sophie Liabeuf, Marie Metzger, Élodie Speyer, Thierry Hannedouche, Bruno Moulin, Sébastien Mailliez, Gaëtan Lebrun, Éric Magnant, Gabriel Choukroun, Benjamin Deroure, Adeline Lacraz, G Lambrey, Jean Philippe Bourdenx, Marie Essig, Thierry Lobbedez, Raymond Azar, Hacène Sekhri, Mustafa Smati, Mohamed Jamali, Alexandre Klein, Michel Delahousse, Christian Combe, Séverine Martin, Isabelle Landru, Éric Thervet, Ziad A Massy, Philippe Lang, Xavier Belenfant, Pablo Ureña, Carlos Vela, Luc Frimat, Dominique Chauveau, Viktor Panescu, Christian Noël, François Glowacki, Maxime Hoffmann, Maryvonne Hourmant, Dominique Besnier, Angelo Testa, F Kuentz, Philippe Zaoui, Charles Chazot, Laurent Juillard, Stéphane Burtey, Adrien Keller, Nassim Kamar, Denis Fouque, Maurice Laville
Abstract
BACKGROUND: The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists. METHODS: The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that 'initiated imminently or <48 hours after presentation to correct life-threatening manifestations' according to the Kidney Disease: Improving Global Outcomes 2018 definition. RESULTS: Over a 4-year (interquartile range 3.0-4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08-4.25] or with low health literacy [2.22 (95% CI 1.28-3.84)], heart failure [2.60 (95% CI 1.47-4.57)] or hyperpolypharmacy [taking >10 drugs; 2.14 (95% CI 1.17-3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19-1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70-0.94)] for each visit. CONCLUSIONS: This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.