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Structured clinical follow-up for CKD stage 5 may safely postpone dialysis

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Abstract

Background and objectives

The optimal timing of dialysis initiation is still unclear. We aimed to ascertain whether a strict clinical follow-up can postpone need for dialysis in chronic kidney disease (CKD) stage 5 patients.

Design, setting, participants and measurements

We reviewed records of all consecutive adult patients attending our conservative CKD stage 5 outpatient clinic from 2001 to 2010. Chronicity was defined as two consecutive estimated glomerular filtration rate (eGFR) measurements below 15 ml/min/1.73 m2. Characteristics of subjects, including comorbidities, were assessed at baseline; blood pressure and serum markers of uremia were assessed both at first and last visit. GFR was estimated by the 4-variable Modification of Diet in Renal Disease (MDRD) formula.

Results

In the 312 patients analyzed baseline eGFR was 9.7 ± 2.7 ml/min, which declined by 1.93 ± 4.56 ml/min after 15.6 ± 18.2 months. Age was inversely related to eGFR decline (r −0.27, p = 0.000). During conservative follow-up 55 subjects (18 %) died. In comparison with those eventually entering dialysis, deceased subjects were older and had a longer follow-up with no CKD progression. Multivariate analysis identified age, proteinuria and lower baseline K values as the only independent determinants of death. One hundred ninety-four subjects (66 %) started dialysis with an average eGFR of 6.1 ± 1.9 ml/min. During 35.8 ± 24.7 months of dialysis follow-up, 84 patients died. Multivariate analysis identified age as the main determinant of death (hazard ratio [HR] for every year 1.07, 95 % confidence interval [CI] 1.04–1.11, p 0.000). Patients starting dialysis with eGFR below the median, e.g. <5.7 ml/min, showed a better survival (HR for mortality 0.52, 95 % CI 0.30–0.89, p 0.016) than the other group.

Conclusions

A well-organized nephrological outpatient clinic for conservative follow-up of CKD stage five patients can delay dialysis entry as long as 1 year. Starting dialysis with eGFR lower than 6 ml/min does not confer any increased risk of death in selected early-referral patients.

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Acknowledgments

We would like to thank Dr Sergio Sisca, who organized and was clinical head of our outpatient clinic. Dr Sisca’s clinical contribution was of fundamental support for this manuscript.

Conflict of interest

The authors declare no conflict of interest.

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Authors and Affiliations

  1. Nephrology and Dialysis Unit, SM Annunziata Hospital, Florence, Italy

    Pietro Dattolo, Stefano Michelassi, Marco Amidone, Marco Allinovi, Lorenzo Vignali, Giulia Antognoli, Rosa Roperto & Francesco Pizzarelli

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  1. Pietro Dattolo
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  2. Stefano Michelassi
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  3. Marco Amidone
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  4. Marco Allinovi
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  5. Lorenzo Vignali
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  6. Giulia Antognoli
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  7. Rosa Roperto
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  8. Francesco Pizzarelli
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Correspondence to Pietro Dattolo.

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Dattolo, P., Michelassi, S., Amidone, M. et al. Structured clinical follow-up for CKD stage 5 may safely postpone dialysis. J Nephrol 28, 463–469 (2015). https://doi.org/10.1007/s40620-014-0123-7

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  • DOI: https://doi.org/10.1007/s40620-014-0123-7

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