Canada Guidelines Call for Kidney Dialysis Delay

Laird Harrison

February 03, 2014

Symptoms and complications should weigh more heavily than laboratory tests in deciding when to initiate dialysis in patients with chronic kidney disease, according to new guidelines from the Canadian Society of Nephrology.

Kidney patients should not begin dialysis until their glomerular filtration rate (eGFR) drops to 6 mL/minute per 1.73 m2 or below or clinical indications emerge, say the guidelines, published in the February 4 issue of the Canadian Medical Association Journal.

At 15 mL/minute per 1.73 m2, nephrologists should begin close monitoring, they recommend.

"Delaying dialysis in people without symptoms appears to be safe, as long as they are closely followed by their kidney specialist," lead author Gihad Nesrallah, MD, associate scientist at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, London, Ontario, Canada, said in a journal news release. "This approach is sure to be preferred by patients, who generally enjoy a better quality of life off dialysis than on it."

He added that there did not seem to be any downside to starting dialysis later, as long as dialysis can be started promptly once it is needed.

Although the guideline panel did not consider costs in formulating the recommendation, it did note that an intent-to-defer strategy would most likely result in substantial cost savings.

Previous guidelines placed more emphasis on laboratory tests than on patients' symptoms and recommended starting dialysis at higher eGFR rates for people with diabetes or a decline in nutritional status.

The society based its recommendations on 23 studies, including the Initiating Dialysis Early and Late (IDEAL) study, a large recent clinical trial conducted in Australia and New Zealand that looked at survival rates, costs, and other factors in early vs deferred start of dialysis. The study found that there were substantially higher costs per patient with early initiation of dialysis.

The guideline comes on the heels of a controversy over screening for chronic kidney disease. On October 21, the American College of Physicians recommended against screening adults who have neither symptoms nor risk factors.

In the absence of evidence showing either benefits or harm for systematic screening, clinicians should err on the side of avoiding false-positives, disease labeling, and unnecessary treatment, the American College of Physicians argued.

However, the American Society of Nephrology responded the next day with a recommendation for the screening of adults regardless of risk factors, arguing that screening is not expensive but has the potential to catch kidney disease early, when it is relatively easy to treat.

The Canadian Society of Nephrology's new guidelines appear less likely to rock anyone's boat. The authors write that they are "consistent with...Caring for Australians with Renal Impairment published in 2006 and the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative published in 2006."

Joseph Vassalotti, MD, chief medical officer at the National Kidney Foundation, told Medscape Medical News that he agreed that the Canadian recommendations square with the foundation's position and also cited the Kidney Disease Outcomes Quality Initiative's clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.

"I would commend the authors for doing an excellent job of reviewing the literature, and I think this guideline certainly makes clinical sense," he said.

However, he faulted the Canadian group's guideline for not offering recommendations on children, acute kidney disease, preemptive kidney transplants, and patients with short life expectancy, such as someone with metastatic cancer or someone of advanced age with multiple medical problems.

He added that clinicians in the United States also may have to consider some factors that Canadians do not. For example, some US patients without healthcare insurance may become eligible for Medicare only once they start dialysis.

Dr. Vassalotti also points out that evaluating patients at a higher eGFR may get them on the waiting list for a kidney transplant sooner.

The authors and Dr. Vassalotti have disclosed no relevant financial relationships.

CMAJ. 2014;186:112-117. Full text

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