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Original Investigation
October 12, 2020

Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease

Author Affiliations
  • 1Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco
  • 2Division of Research, Kaiser Permanente Northern California, Oakland
  • 3Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California
  • 4Division of Medical Education, Department of Medicine, University of California, San Francisco, San Francisco
  • 5Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
  • 6Department of Medicine, Stanford University, Stanford, California
  • 7Department of Health Research and Policy, Stanford University, Stanford, California
JAMA Intern Med. Published online October 12, 2020. doi:10.1001/jamainternmed.2020.5009
Key Points

Question  How are temporal changes in the level of estimated glomerular filtration rate (eGFR) at which long-term dialysis is initiated among at-risk patients associated with the number of patients with end-stage kidney disease in the population?

Findings  This cohort study of 983 122 individuals in the initial 3-year interval (2001-2003) to 1 844 317 individuals in the final interval (2016-2018) used data from a large, integrated health care delivery system in Northern California and found that an increase in the number of individuals starting dialysis with an eGFR of 10 to 24 mL/min/1.73 m2 was associated with changes over time in the likelihood of receiving dialysis at this eGFR independent of the number of people in the underlying population who had this same eGFR. Estimated incidence of new end-stage kidney disease cases would have been 16% lower with no changes in system-level practice patterns or other factors besides timing of long-term dialysis initiation.

Meaning  The timing of long-term dialysis initiation is associated with the number of individuals with end-stage kidney disease.

Abstract

Importance  In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined.

Objective  To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD.

Design, Setting, and Participants  Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year.

Main Outcomes and Measures  One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort.

Results  In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study.

Conclusions and Relevance  The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD.

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