Has the yearly increase in the renal replacement therapy population ended?

The recent decline in the number of new patients undergoing dialysis and transplantation in the United States may be linked to a reduction in the incidence of early-start dialysis, defined as the initiation of renal replacement therapy (RRT) at an estimated GFR ≥10 ml/min per 1.73 m(2). We examined the most recent data from the U.S. Renal Data System to determine how this trend will affect the future incidence of ESRD in the United States. The percentage of early dialysis starts grew from 19% to 54% of all new starts between 1996 and 2009 but remained stable between 2009 and 2011. Similarly, the incident RRT population increased substantially in all age groups between 1996 and 2005, with the largest increase occurring in patients aged ≥75 years. Early dialysis starts accounted for most of the increase in the incident RRT population in all age groups during this time period, and between 2005 and 2010, the increase slowed dramatically. Although the future incident RRT population will be determined in part by population growth, these results suggest that later dialysis starts and greater use of conservative and palliative care, which may improve quality of life for elderly patients with advanced renal failure, will continue to attenuate the increase observed in previous years.

Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful?

Over the past decade a trend of increasing estimated glomerular filtration rate (eGFR) at the initiation of dialysis for treatment of end-stage renal disease (ESRD) has been noted in the United States. In 1996, only 19% of patients began dialysis therapy with an eGFR of greater than 10 ml/min/1.73 m2 (denoted as 'early start'), but by 2005 the fraction of early start dialysis patients had risen to 45%. This review examines US dialysis data, national guidelines, and publications relevant to the early start phenomenon. It is not known whether early start of dialysis is beneficial, harmful or neutral with respect to the outcome of dialysis treatment for ESRD. Available data indicate that mortality while on dialysis therapy may be higher in those subjects with early start. Comorbidities present at the time of dialysis initiation do not appear to be a major driving force for early start patients. As well, residual kidney function in these patients is a major contributor to total urea or creatinine clearance. This can be a positive factor for patient outcomes and might be compromised by early start. Finally, we estimate the dollar cost of early start to the US Medicare-supported ESRD program. Properly designed, prospective and randomized studies may help to clarify the benefit or harm of early start of dialysis for ESRD.