Timing and costs of dialysis procedures need reconsideration

1. Early Dialysis Recommendations May Cause More Harm than Good
Starting Dialysis when Kidney Function is High Increases Risk of Premature Death

Recent guidelines that recommend that kidney disease patients start dialysis before their kidney function has significantly declined may potentially cause harm to patients. When William Clark, MD (Scientist at Lawson Health Research Institute and Professor at The University of Western Ontario, in London, Canada) and his colleagues studied 25,901 patients who started dialysis in Canada between 2001 and 2007, they found that patients have been initiating dialysis at increasingly higher levels of kidney function; however, patients who started dialysis early during their disease had an 18% increased risk of dying prematurely compared with patients who started dialysis late in their disease and this increased risk cannot be entirely explained by an imbalance in baseline characteristics. Death rates were significantly different at 6, 12, 30, and 36 months between the two groups. "This research indicates that a well intentioned rising trend of early initiation of hemodialysis in patients shows no benefit and possible harm," said Dr. Clark. "Hopefully this information will curb the rising trend in early dialysis initiation and stimulate research to determine the optimal time for initiation of dialysis therapy."

Study co-authors include Yingbo Na (Canadian Institute of Health Information); Steven Rosansky, MD, Kirby Jackson (University of South Carolina); Jessica Sontrop, PhD, Jennifer Macnab, PhD, Louise Moist, MD (The University of Western Ontario); Richard Glassock, MD (UCLA); and Paul Eggers, PhD (National Institute of Diabetes and Digestive and Kidney Diseases).

Disclosures: Dr. Glassock is a consultant for Aspreva, FibroGen, Genentech, Bristol-Myers-Squibb, BioMarin, Wyeth, Eli Lilly, Novartis, Gilead Sciences, QuestCor, UpToDate, and Lighthouse Learning; he holds ownership in La Jolla Pharm and Reata. All other authors reported no financial disclosures.

The study abstract, "Higher eGFR at Dialysis Initiation Is Associated with Increased Mortality," [TH-FC044] will be presented as an oral presentation on Thursday, November 18, 2010 at 5:06 PM MT in Room 203 of the Colorado Convention Center in Denver, CO.

2. Home Dialysis Saves Money Over In-Center Dialysis and Provides Potential Benefits

Home-based hemodialysis provides several potential benefits for kidney disease patients over traditional in-facility-based dialysis. It allows an increased dose of dialysis in addition to smoother removal of fluids; patients also potentially benefit from doing treatments in their own homes and on their own schedules. Paul Komenda, MD (University of Manitoba and the Seven Oaks General Hospital, in Winnipeg Canada) and his colleagues developed an economic model to compare the costs for providing three types of dialysis in Australia, Canada, and the United States: conventional in-center (ICHD), conventional home (CHHD), and nocturnal (nighttime) home hemodialysis (NHHD). The analysis, which included a systematic review of published and observational data, found that ICHD costs are stable over time and driven by staffing, medications, and infrastructure costs. CHHD and NHHD costs in the first year are driven by costs for medication, patient training, machines, consumables, and home preparation. Subsequent year costs are driven by medications, consumables, and hospitalization costs. Costs for CHHD and NHHD were comparable to ICHD in the first year and less than ICHD in subsequent years.

Study co-authors include Manish Sood, MD (University of Manitoba and the Seven Oaks General Hospital); and Susan Garfield, Amy White Poret, and Meghan Gavaghan (Bridgehead International).

Disclosures: The research was funded via an unrestricted research grant from Baxter Healthcare Corp. The authors reported no other financial disclosures.

The study abstract, "A Costing Model for Use in Evaluating the Fiscal Impact of Home Versus In-Center Dialysis within Various Healthcare Systems," [TH-FC124] will be presented as an oral presentation on November 18, 2010 at 5:42 PM MT in Korbel 4D of the Colorado Convention Center in Denver, CO.

Provided by American Society of Nephrology