Kidney Week

Abstract: TH-OR098

The Impact of the IDEAL Trial on Early Initiation of Dialysis

Session Information

• Outcomes and Trends in Dialysis
  October 25, 2018 | Location: 2, San Diego Convention Center
  Abstract Time: 05:54 PM - 06:06 PM

Category: Dialysis

• 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Ferguson, Thomas W., Seven Oaks General Hospital, Winnipeg, Manitoba, Canada

Thomas W. Ferguson, MS

• Garg, Amit X., London Health Sciences Centre, London, Ontario, Canada

Amit X. Garg,

• Sood, Manish M., Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Manish M. Sood,

• Komenda, Paul, University of Manitoba, Winnipeg, Manitoba, Canada

Paul Komenda,

• Alam, Ahsan, McGill University Health Centre, Montreal, Quebec, Canada

Ahsan Alam,

• Tangri, Navdeep, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada

Navdeep Tangri,

• Rigatto, Claudio, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada

Claudio Rigatto,

• Naimark, David M., Sunnybrook Health Science Centre, Toronto, Ontario, Canada

David M. Naimark,

• Beaulieu, Monica C., University of British Columbia, North Vancouver, British Columbia, Canada

Monica C. Beaulieu,

• Manns, Braden J., Foothills Medical Center, Calgary, Alberta, Canada

Braden J. Manns,

• Kim, Joseph, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada

Joseph Kim,

Background

In August 2010, the Initiating Dialysis Early and Late (IDEAL) trial was published and randomized patients with pre-dialysis CKD to planned initiation of dialysis in the eGFR range of 10 to 14 ml/min/1.73m² (early start) vs. 5 to 7 ml/min/1.73m² (late start). It concluded that earlier initiation was not associated with improved survival or clinical outcomes. The degree by which this information was disseminated and applied in practice is unknown. We aimed to determine the impact of the IDEAL trial on the proportion of patients who initiate dialysis early (eGFR > 10.5 ml/min/1.73m²).

Methods

A segemented regression analysis was performed including all incident adult dialysis patients from the Canadian Organ Replacement Register (CORR) with at least 90 days of nephrologist care before starting dialysis with a recorded eGFR at dialysis initiation.The primary outcome was the change in the proportion of early dialysis starts (eGFR at initiation > 10.5 ml/min/1.73m²). Secondary outcomes included the change in the proportion of acute inpatient dialysis initiations, the proportion of patients who received home dialysis as initial therapy, and the proportion of hemodialysis patients who started dialysis with an arteriovenous (AV) fistula.

Results

Following the IDEAL trial we observed an immediate decline in the proportion of early dialysis starts of 4.49% (95% confidence interval 1.24 to 7.74; p = 0.0080), and there was a significant decrease from the pre-trial annual slope of 2.76% (1.68 to 3.84; p = < 0.001), resulting in an annual decrease of 1.44% (0.84 to 2.16; p < 0.001) in the post-trial period. Acute inpatient dialysis initiations increased immediately following the publication by 2.86% (0.10 – 5.62; p = 0.0440), however there was no sustained change. The proportion of patients who received home dialysis as initial therapy and the proportion who initiated hemodialysis with an AV fistula did not have immediate or sustained differences.

Conclusion

The IDEAL trial had a strong and sustained impact on the timing of dialysis initiation in Canada. These changes were accompanied by no sustained effects on home dialysis as initial therapy, AV fistula construction, or acute inpatient dialysis initiation

Funding

• Government Support - Non-U.S.