SEATTLE—When is the optimal time to initiate maintenance dialysis in individual patients?

An article published in JAMA Internal Medicine pointed out that little medical evidence exists to guide the decision.1

A study team led by researchers from the University of Washington and VA Puget Sound Healthcare System set out to gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice.

The qualitative analysis was conducted using VA’s electronic medical records from a national random sample of 1,691 patients for whom the decision to initiate maintenance dialysis occurred between Jan. 1, 2000, and Dec. 31, 2009. Data analysis was performed from June 1 to Nov. 30, 2014.

Researchers were looking for central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records.

Results indicate that, of the 1691 patients, 74.7% initiated dialysis as inpatients and 72.6% initiated dialysis with a hemodialysis catheter. The study noted that cohort members had met with a nephrologist during an outpatient clinic visit a median of three times in the year prior to initiation of dialysis. At the time of dialysis initiation, the mean estimated glomerular filtration rate was 10.4 mL/min/1.73 m2.

Study authors explained that the timing of initiation of dialysis involved at least three interrelated and dynamic processes:

  • Physician practices, which ranged from intending to prepare patients for dialysis to those intending to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions;
  • Sources of momentum, where clinical events involving acute illness or medical procedures appeared to allow the imperative to treat to override patient choice; and
  • Patient-physician dynamics, which were sometimes adversarial, and where physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities.

“The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians and the complex interplay of these dynamic processes over time,” study authors concluded. “Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences.”

  1.  Wong SP, Vig EK, Taylor JS, Burrows NR, Liu CF, Williams DE, Hebert PL, O’Hare AM. Timing of Initiation of Maintenance Dialysis: A Qualitative Analysis of the Electronic Medical Records of a National Cohort of Patients From the Department of Veterans Affairs. JAMA Intern Med. 2016 Feb;176(2):228-35. doi: 10.1001/jamainternmed.2015.7412. PubMed PMID: 26809745; PubMed Central PMCID: PMC4758379.