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. 2018 Dec 22;12(4):550-558.
doi: 10.1093/ckj/sfy118. eCollection 2019 Aug.

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study

Nish Arulkumaran  1 , Arunraj Navaratnarajah  1 , Camilla Pillay  1 , Wendy Brown  1 , Neill Duncan  1 , Adam McLean  1 , David Taube  1 , Edwina A Brown  1
Affiliations

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study

Nish Arulkumaran et al. Clin Kidney J. .

Abstract

Background: Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts.

Methods: We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters).

Results: In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001).

Conclusions: Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.

Keywords: acute dialysis start; renal replacement therapy; unplanned.

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Figures

FIGURE 1
FIGURE 1
Proportion of patients requiring planned, unplanned and urgent initiation of dialysis.
FIGURE 2
FIGURE 2
Rate of change of eGFR in the 12 months preceding dialysis initiation. Data represent mean and standard mean error. Compared with planned starters, unplanned starters with systemic illness (−4.5 ± 0.9, P < 0.001), unplanned starters with accelerated unexpected decline in renal function (−3.6 ± 1.2, P = 0.029), urgent starters with systemic illness (−26 ± 1.5, P < 0.001) and urgent starters with unexpected accelerated decline in renal function (−13 ± 2.4, P < 0.001) had a greater rate of eGFR decline in the 12 months preceding dialysis.
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