Urgent-start dialysis in patients referred early to a nephrologist—the CKD-REIN prospective cohort study
Authors: Fages Victor , de Pinho Natalia Alencar , Hamroun Aghilès , Lange Céline , Combe Christian , Fouque Denis , Frimat Luc , Jacquelinet Christian , Laville Maurice , Ayav Carole , Liabeuf Sophie , Pecoits-Filho Roberto , Massy Ziad A , Boucquemont Julie , Stengel Bénédicte ,   the CKD-REIN study collaborators, de Pinho Natalia Alencar , Ayav Carole , Briançon Serge , Cannet Dorothée , Combe Christian , Fouque Denis , Frimat Luc , Herpe Yves-Edouard , Jacquelinet Christian , Laville Maurice , Massy Ziad A , Pascal Christophe , Robinson Bruce M , Stengel Bénédicte , Lange Céline , Legrand Karine , Liabeuf Sophie , Metzger Marie , Speyer Elodie , Hannedouche Thierry , Moulin Bruno , Mailliez Sébastien , Lebrun Gaétan , Magnant Eric , Choukroun Gabriel , Deroure Benjamin , Lacraz Adeline , Lambrey Guy , Bourdenx Jean Philippe , Essig Marie , Lobbedez Thierry , Azar Raymond , Sekhri Hacène , Smati Mustafa , Jamali Mohamed , Klein Alexandre , Delahousse Michel , Combe Christian , Martin Séverine , Landru Isabelle , Thervet Eric , Massy Ziad A , Lang Philippe , Belenfant Xavier , Urena Pablo , Vela Carlos , Frimat Luc , Chauveau Dominique , Panescu Viktor , Noel Christian , Glowacki François , Hoffmann Maxime , Hourmant Maryvonne , Besnier Dominique , Testa Angelo , Kuentz François , Zaoui Philippe , Chazot Charles , Juillard Laurent , Burtey Stéphane , Keller Adrien , Kamar Nassim , Fouque Denis , Laville Maurice 
Published: May 2021

Abstract

Background
The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists.

Methods
The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that ‘initiated imminently or &lt;48 hours after presentation to correct life-threatening manifestations’ according to the Kidney Disease: Improving Global Outcomes 2018 definition.

Results
Over a 4-year (interquartile range 3.0–4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08–4.25] or with low health literacy [2.22 (95% CI 1.28–3.84)], heart failure [2.60 (95% CI 1.47–4.57)] or hyperpolypharmacy [taking &gt;10 drugs; 2.14 (95% CI 1.17–3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19–1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70–0.94)] for each visit.

Conclusions
This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.