Risk factors for unplanned dialysis initiation: final results of the Nordic peridialysis study

Abstract

Introduction: Unplanned dialysis initiation (UDI) is common, even though most patients are referred early to the nephrology department. It is associated with increased morbidity and mortality, and possibly reduced modality choice. We hypothesized that UDI is related to the predialysis care and the timing of DI. Methods: The Peridialysis study is an ongoing multinational, multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis. Clinical and biochemical patient data, physician education data and physician reasons for prescribing dialysis were registered during the predialytic period for all patients starting dialysis during the study period. Results: In 1,599 patients (mean age 63 years; 35% females; diabetic nephropathy 26%), DI was unplanned in 42%. Causes of UDI were “external” (acute uremia 9%, late referral 5%) in 14%, or “internal” in 28%. The commonest internal causes were acute uremia progression (14%) and delayed planning (5%). Risk factors for internal UDI were high age, diabetes, cachexia, high comorbidity, hypoalbuminemia and rapid uremia progression (eGFR decline >1 ml/min/1.73m2/month), the last three being independent predictors. Accelerated uremia progression for UDI was already present six to three months before DI. Polycystic renal disease had a lower incidence. Raised urea, C-reactive protein, acidosis and other electrolyte disorders were markers of increased UDI requirement, independently of estimated glomerular filtration rate (eGFR) at DI. eGFR in UDI patients was higher during the predialysis course, but lower at DI. It was of no value in predicting UDI. Patients with comorbidities had a higher eGFR at DI. Conclusions: 20% of patients had potentially preventable UDI. eGFR was of no value in identifying these patients, who were characterized by rapid uremia progression, hypoalbuminemia and high comorbidity. Identification of these [...].