A Research Blog

That is the question. As the number of end-stage renal disease (ESRD) patients rises rapidly in Asia, the need for dialysis grows with it, along with a trend to start dialysis earlier in the management of ESRD. The situation in Singapore is similarly bleak. It is imperative to determine if the benefits of starting dialysis earlier is worth the high cost and inconvenience that accompanies it, especially when evidence supporting those benefits is limited and controversial.

Team Photo

The research team (L-R): Dr Feng Liang, Professor Tazeen Hasan Jafar, Dr John Carsen Allen.

In an attempt to answer this question, Professor Tazeen Jafar and her team from the Health Services and Systems Research Programme at Duke-NUS Medical School contributes to the growing body of evidence that supports delaying dialysis to when kidney function is more highly impaired. Following 3,268 ESRD patients from the Singapore Renal Registry over 4 years, the team showed that starting dialysis earlier when renal function is less highly impaired (estimated glomerular filtration rate (eGFR) ≥ 10 ml/min/1.73m2)  could increase the death risk by up to 75%. The elevated risk of death from early- compared with late-start dialysis could not be explained by a variety of demographic factors, co-morbidities, nutritional status, anaemia parameters and markers of bone and mineral metabolism, which were accounted for in the analysis. Moreover, this detriment for starting dialysis earlier is especially evident in ESRD patients younger than 65 years, while patients older than 65 years showed no differences in mortality regardless of when they started dialysis. The researchers caution that the Renal Registry and their analysis do not include information on compelling clinical indication mandating an early dialysis initiation potentially also associated with mortality.

“Our work supports the 2015 update of Kidney Disease Outcomes Quality Initiative guidelines, and indicates that ESRD patients starting dialysis earlier, without compelling clinical indication, enjoy no benefit, and it may instead be detrimental to their survival if they are younger than 65 years,” commented Professor Jafar, who is also senior author of the study. She added that “it is also important to underscore that all individuals with earlier stages of chronic kidney disease need to be monitored and managed optimally to slow progression to ESRD.”

So maybe, the answer to the question with respect to the level of kidney function is to start dialysis late. While the definitive answer to this question remains elusive, Professor Jafar and her team have provided robust evidence to support delaying dialysis initiation as much as possible.

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