Risk Factors for Suboptimal Dialysis Initiation

Suboptimal dialysis initiation is common and is associated with increased morbidity and mortality.

Lower hemoglobin and higher comorbidity were risk factors for suboptimal dialysis initiation, but health literacy and kidney disease knowledge were not.

Modifiable patient risk factors for suboptimal dialysis initiation were not found. Our study highlights the complexity of preventing this outcome.

Suboptimal dialysis initiation is common and is associated with increased morbidity and mortality. We sought to determine risk factors for suboptimal dialysis initiation among patients with advanced CKD.

This was a prospective cohort study that enrolled English-speaking patients without cognitive impairment followed in multidisciplinary kidney clinics across four regional kidney programs in Ontario, Canada. Patients completed a 6-month follow-up visit with further follow-up using health care administrative data. The primary outcome was suboptimal dialysis initiation defined by dialysis initiation with a central venous catheter, in patients younger than 75 years, or during a hospitalization. Adjusted cause-specific hazard models were used to examine the association of prespecified characteristics with suboptimal dialysis initiation.

Three hundred and sixty-six patients were included; 122 (33%) patients had a suboptimal dialysis start (69% of dialysis starts) over a median follow-up of 1.9 (interquartile range, 0.7–2.5) years. Higher hemoglobin (time varying) was associated with a lower risk of suboptimal dialysis initiation (adjusted hazard ratio, 0.96; 95% confidence interval [CI], 0.95 to 0.98). The mean (SD) hemoglobin in those with suboptimal dialysis initiation was 10.7 (1.5) g/dl. Higher comorbidity index and greater number of nephrologist visits within the past 6 months were associated with a higher risk of suboptimal dialysis initiation (adjusted hazard ratio, 1.17 [95% CI, 1.01 to 1.35] and 1.70 [95% CI, 1.39 to 2.08]; respectively). Measures of health literacy, kidney disease knowledge, and influenza vaccination were not associated with suboptimal dialysis initiation. A secondary analysis defining suboptimal dialysis initiation by dialysis initiation during a hospitalization showed similar results.

Suboptimal dialysis initiation was common despite established nephrology follow-up. Our study did not find readily modifiable patient-related risk factors for suboptimal dialysis initiation.