For Dialysis Patients, No Survival Gain with Earlier Nephrologist Care

In older adults starting dialysis, earlier initiation of nephrology care hasn’t led to improved first-year survival, reports a study in the Archives of Internal Medicine.

The researchers analyzed U.S. Renal Data System data on 323,977 patients aged 67 or older who started dialysis between 1996 and 2006. Trends in the timing of the earliest identifiable nephrology visit and in one-year mortality after dialysis initiation were analyzed, with consideration of changes in case mix.

In 2006, about 35 percent of patients first saw a nephrologist less than three months before the start of dialysis, compared to nearly 50 percent in 1996. Mean estimated glomerular filtration rate at the start of dialysis was 12 mL/min/1.73 m2 in 2006, compared to 8 mL/min/1.73 m2 in 1996. Rates of anemia and initial peritoneal dialysis also decreased during the period studied.

Despite these trends, there was no reduction in mortality during the first year on dialysis. With adjustment for shifts in sociodemographic characteristics and comorbidity, the estimated annual reduction in one-year mortality was 0.9 percent. The change was even smaller, 0.4 percent per year, after adjustment for earlier nephrology consultation.

Consistent with current recommendations, there is a trend toward earlier nephrology care before the start of dialysis. However, this trend does not appear to have resulted in any substantial improvement in survival during the first year on dialysis. The results highlight the need to test the benefits versus costs of earlier dialysis and other “nephrologist-driven health care interventions.” [Winkelmayer WC, et al: Predialysis nephrology care of older patients approaching end-stage renal disease. Arch Intern Med 2011; 171: 1371–1378].

October-November 2011 (Vol. 3, Number 10 & 11)