Semelhantemente ao observado por Muntner et al. Am J Kidney Dis ;S J Bras Nefrol ; Principles of screening for chronic kidney disease. Clin J Am Soc Nephrol ;

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Repercussions of early versus late initiation of dialysis. Division of Nephrology and Hypertension. University of Miami Miller School of Medicine. Miami, Florida USA. Despite the widespread use of chronic dialysis, there remains a lack of consensus about the optimal time for initiation of renal replacement therapy.

This has resulted in a trend in the past decade toward earlier initiation of dialysis, especially in the elderly. The associated burden of comorbidities in the elderly population has resulted in greatly reduced survival outcomes. Here, the data obtained from retrospective cohort studies have been corroborated with a recent randomized control trial conducted in Australia and New Zealand IDEAL study. There are limitations to consider from the IDEAL study that originate from different confounding factors that intervene in the test population.

The present paper is an evidence-based review of the literature, focusing on diminution of survival outcomes following the early initiation of dialysis. Los datos de estudios de cohorte retrospectivos han sido corroborados por el ensayo controlado aleatorizado que se ha realizado recientemente en Australia y Nueva Zelanda, el estudio IDEAL.

Hemodialysis therapy assists patients in the management of uremia and volume control through diffusion and convection. This approach purports to lead to decreased morbidity and mortality, as well as to improve the quality of life. This approximated an estimated glomerular filtration rate e GFR of Therefore, the goal of this review is to evaluate current literature which describes observational and retrospective studies that were conducted to compare early or late initiation of dialysis, and the influence of these practices in survival in the ESRD population.

Early or late initiation of dialysis table 1. Table 1. The suggestion that early initiation of dialysis was beneficial was first given support by Bonomini, et al. However, the study did not adjust for age or other comorbidities.

A study published by Fink, et al. Creatinine levels correlated inversely with mortality risk. In the Netherlands, Korevaar, et al. The mean follow-up time was months.

There was an increased mortality risk for late starters, although not statistically significant adjusted HR 1. Traynor corroborated this data, evaluating patients from the Glasgow Royal Infirmary registry. Retrospective studies have described an increased risk of death in patients starting dialysis at higher glomerular filtration rates.

Beddhu, et al. Higher eGFR at initiation of dialysis was associated with increased risk of death. In a later study, Kazmi, et al. The outcomes discussed above correlated with three recently published studies. In the first, Wright, et al. A second study by Rosansky, et al. The goal was to determine if early initiation had survival benefit. Mortality was There was a 3.

High levels of hemoglobin A third retrospective study by Clark, et al. Of those patients, Median follow-up 2. The early group had higher incidence of coronary artery disease, peripheral vascular and, cerebrovascular disease, diabetes mellitus, and lung disease early group: The adjusted mortality differential between patients with early and late initiation narrowed after one year of follow-up, but the mortality rates never converged, and the differential began to widen again after two years in the Kaplan-Meier survival curves.

After three years, there were 27 more deaths per 1, patient-years in the group with early initiation. The literature presented here compared early retrospective studies that associated patient survival with early initiation of dialysis, in disagreement with later data. Since most of the information was retrospective in nature, it is subject to limitations in interpretation of the different covariants that are important in these studies. In order to obtain a clearer picture it would be necessary to carry out randomized control trials.

The Initiating Dialysis Early and Late study IDEAL 17 was designed as a randomized controlled trial to determine whether initiating dialysis early in individuals with stage V chronic kidney disease reduced the rate of death from any cause. Secondary aims were to determine whether early initiation of dialysis was associated with reduction in cardiovascular and infectious events, and in complications of dialysis.

Between July and November , patients were recruited at 32 centers in Australia and New Zealand. The eGFR was determined using the Cockcroft-Gault equation, after correction for body-surface area The MDRD equation was used for comparison. Median duration of follow-up averaged 3. In the early and late-start groups, and patients initiated renal replacement therapy with peritoneal dialysis.

Of all the patients, died during the follow-up period, in the early-start group and in the late-start group cardiovascular death was the most common event. There was no significant difference in survival between the two groups HR in the early-start group 1.

The time of dialysis did not influence secondary events cardiovascular, infectious or quality of life. The conclusion from the study was that early initiation of dialysis had no significant effect on the rate of death from any cause.

This represents a necessary protocol violation. Also the mean difference of eGFR between both groups was only 2. The reality is that waiting to initiate dialysis until signs of uremia appear does not jeopardize the patient. The results of the study are difficult to compare with previous registry studies since it considers both eGFR and symptoms.

There were no reports of baseline GFR prior to the initiation of dialysis, quality of life scores, differences in survival outcomes between young, elderly patients, and types of dialysis techniques hemodialysis vs peritoneal dialysis. This data echoes a previous study by Korevar, et al.

In conclusion, early initiation of dialysis is not associated with improved survival. Lead-time bias, the interval between the start of a study and a defined event, is a limitation in these studies. An error in the conclusions may occur if patients are entered at different stages in the course of the illness. A prolonged survival may be due to early registration of the patient. In dialysis, measuring survival from the start of the treatment increases apparent survival of those started with more residual renal function Other limitations include age older men started at higher GFR of the study population 22 , sex with lower survival rates in female patients and comorbidities like diabetes mellitus, all of which may influence survival.

The type of dialysis modality may also influence outcomes, with peritoneal dialysis showing better outcomes initially Incomplete information should also be considered because of primary data errors at the time of dialysis.

Another important factor is the non-standardized methods of measuring serum creatinine, and the subsequent calculated results of eGFR. The MDRD formula has not been validated in patients with advanced renal failure. For example, the four-variable MDRD equation was developed from non-Asian subjects, and it may hamper results in some studies The result was a spurious association of malnutrition with higher MDRD GFR due to low creatinine production, which can lead to an erroneous interpretation of the effect of timing of dialysis on mortality Different confounding variables, similar to those listed above, should be considered in order to clearly interpret the present data.

The optimal time for initiation of chronic dialysis remains unknown. There is a trend in the nephrology literature toward earlier initiation of dialysis However, prospective data that could guide physicians are not available. Dialysis has many side effects, and it was not possible to predict that starting dialysis earlier failed to improve survival. Previous studies have been confounded by lead-time bias.

If early initiation of dialysis did improve survival, then the effect would need to be sufficiently large to justify its use for patients, and for healthcare funding. The practice of earlier initiation of dialysis for ESRD has enormous personal, social and economic implications, with no survival advantage. The latest IDEAL study corroborated the need to reconsider early initiation, except in situations of failed attempts to control volume and electrolyte abnormalities related to uremic conditions.

National Kidney Foundation. European Best Practice Guidelines for haemodialysis. NDT ; Churchill DN. An evidence-based approach to early initiation of dialysis. Am J Kidney Dis ; Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial.

J Am Soc Nephrol ; Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med ; National Kidney Fondation. United States Renal Data System. Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful? Kidney Int ; Early dialysis in renal substitutive programs.

Kidney Int Suppl ;SS


Clinical trials

Quality of life in paediatric patients with Chronic Renal Disease. Aims: To look for the scientific literature in the last six years about the quality of life of pediatric patients with chronic kidney disease. Only scientific papers written either in English or Spanish as well as having a cross-sectional design were considered. The main variables affecting the quality of life, amongst which stand out therapeutics, were analyzed. Also, the different ways for measuring the quality of life as well as differences in its perception between patients and their families were studied. Results: Thirteen papers were found: only one of them used specifically prepared questionnaire for this type of patients, ten used general questionnaires and the last two papers mixed both types. The general questionnaires studied the variable "therapeutic modality" used as well as other factors affecting the quality of life such as dream and mental disorders; on the other side, the specific questionnaire only studied the variable "therapeutic modality".


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