ST. JOHN'S, NEWFOUNDLAND—Recent study findings add to mounting evidence of the deleterious consequences of early dialysis initiation, prompting researchers to question this approach, especially among older patients.

Investigators documented a doubling of the withdrawal rate from 1.5 to 3.0 per 100 patient-years of dialysis in the Canadian Organ Replacement Registry (CORR) from 2001 and 2009. Each 10-year increase in age was associated with an 84 percent greater likelihood of withdrawal, and early-start dialysis is associated with a 15 percent greater probability of withdrawal than late starts. Meanwhile, the researchers observed a sharp rise in the proportion of deaths due to withdrawal among deceased dialysis patients, from 7.9 percent in 2001 to 19.5 percent in 2009.

“More and more patients are starting dialysis early, especially elderly patients, with higher residual renal function, and then a lot of them go on to just withdraw,” said Amanda Ellwood, MD, who led the study while she was completing her nephrology fellowship at the University of Western Ontario in London. “So the question is, should we be starting them on dialysis or should we be considering another approach, such as multidisciplinary conservative management?”

Working under Louise Moist, MD, associate professor of nephrology at the university, and in conjunction with other researchers, Ellwood examined CORR data from 2001-2009. They focused on patients who started dialysis in that period.

The 3,339 patients who withdrew from dialysis and the 42,842 who did not had divergent demographic and medical characteristics. For example, the mean age of those who stopped dialysis was 73.2 years compared with 63 years for those who remained on dialysis, with 51.5 percent and 26.9 percent of the two groups, respectively, aged 75 or older. Furthermore, 39.8 percent of the withdrawal subjects had early dialysis initiation compared with 34.4 percent in the no-withdrawal group. The only statistically significant similarities between the two groups were their rates of hypertension and diabetes, at about 80 percent and 45 percent, respectively.

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