Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial
Authors: Tangri Navdeep , Garg Amit X. , Ferguson Thomas W. , Dixon Stephanie , Rigatto Claudio , Allu Selina , Chau Elaine , Komenda Paul , Naimark David , Nesrallah Gihad E. , Soroka Steven D. , Beaulieu Monica , Alam Ahsan , Kim S. Joseph , Sood Manish M. , Manns Braden 
Published: April 2021

Significance Statement
In 2009, the Initiating Dialysis Early and Late (IDEAL) trial found no clinically measurable benefit with early dialysis initiation, but whether these findings were widely adopted was unknown. The authors conducted a cluster randomized trial, with 55 clinics randomized to the intervention (a multifaceted knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation) and control. In their analysis, which included 3424 patients initiating dialysis in the 1-year follow-up period, they found no statistically significant difference between the two groups in the proportion of patients who initiated dialysis early (at eGFR>10.5ml/min per 1.73m2) or in the proportion of patients who initiated dialysis as an acute inpatient. The knowledge translation intervention failed to further reduce the proportion of early dialysis starts in multidisciplinary CKD clinics.

Background
The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise.

Methods
To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting.

Results
The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient.

Conclusions
A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics.

Clinical Trial registry name and registration number:

ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987