Abrupt Decline in Kidney Function Predicts Early ESRD Mortality

A sudden drop in kidney function in the few months before starting hemodialysis is associated with a threefold increase in the risk of death within the first year on dialysis, reports a study in The American Journal of Kidney Diseases.

The prospective study included 661 patients with mild to moderate chronic kidney disease who developed chronic kidney failure requiring hemodialysis. Patients were drawn from the Chronic Renal Insufficiency Cohort (CRIC) Study. Using data on annual estimated glomerular filtration rate (eGFR), the researchers identified patients with an abrupt decline in kidney function, defined as an extrapolated eGFR of 30 mL/min/1.73 m2 at 3 months before the start of hemodialysis.

Abrupt decline in kidney function was evaluated as a predictor of death during the first year on dialysis. Multivariable analysis included adjustment for demographic factors, cardiovascular disease, diabetes, and cancer.

Fifty-six patients met the study definition of abrupt decline in kidney function—a rate of 8.5%. Sixty-nine patients died in the first year after starting hemodialysis. On adjusted analysis, patients with abrupt decline in kidney function were at increased risk of early death: hazard ratio 3.09. Patients with abrupt decline were more likely to have initial dialysis catheter access, but less likely to have nephrologist care before dialysis.

About 1 in 12 patients starting hemodialysis have an abrupt decline in kidney function during the preceding three months. The new analysis of CRIC data suggests that this pattern is associated with an increased risk of early death. The authors call for further study to evaluate the causes of such sudden drops in eGFR, and whether interventions can improve survival after starting dialysis [Hsu RK, et al. Abrupt decline in kidney function before initiating hemodialysis and all-cause mortality: the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2016; 68:193–202].