TY - JOUR
T1 - GFR at initiation of dialysis and mortality in CKD
T2 - A meta-analysis
AU - Susantitaphong, Paweena
AU - Altamimi, Sarah
AU - Ashkar, Motaz
AU - Balk, Ethan M.
AU - Stel, Vianda S.
AU - Wright, Seth
AU - Jaber, Bertrand L.
N1 - Funding Information:
Support: This work was made possible in part through Dr Susantitaphong's International Society of Nephrology–funded fellowship. This work was supported in part by grant UL1 RR025752 from the National Center for Research Resources (NCRR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCRR or the National Institutes of Health.
PY - 2012/6
Y1 - 2012/6
N2 - Background: The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis therapy at a higher glomerular filtration rate (GFR) has increased during the past decade. Recent data suggest that higher GFR may be associated with increased mortality. Study Design: A meta-analysis of cohort studies and trials. Setting & Population: Patients with advanced CKD. Selection Criteria for Studies: We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis therapy initiation and mortality. Predictor: Estimated or calculated GFR at dialysis therapy initiation. Outcome: Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality. Results: 16 cohort studies and 1 randomized controlled trial were identified (n = 1,081,116). By meta-analysis restricted to 15 cohorts (n = 1,079,917), higher GFR at dialysis therapy initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03-1.05; P < 0.001). However, there was significant heterogeneity (I 2 = 97%; P < 0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001; residual I 2 = 97%). The highest mortality risk was observed in hemodialysis cohorts (HR, 1.05; 95% CI, 1.02-1.08; P < 0.001), whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR, 1.04; 95% CI, 0.99-1.08, P = 0.1; residual I 2 = 98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR, 0.80; 95% CI, 0.71-0.91; P = 0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR, 1.04; 95% CI, 1.03-1.05; P < 0.001; residual I 2 = 97%). Limitations: Paucity of randomized controlled trials, different methods for determining GFR, and substantial heterogeneity. Conclusions: Higher estimated rather than calculated GFR at dialysis therapy initiation is associated with a higher mortality risk in patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study.
AB - Background: The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis therapy at a higher glomerular filtration rate (GFR) has increased during the past decade. Recent data suggest that higher GFR may be associated with increased mortality. Study Design: A meta-analysis of cohort studies and trials. Setting & Population: Patients with advanced CKD. Selection Criteria for Studies: We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis therapy initiation and mortality. Predictor: Estimated or calculated GFR at dialysis therapy initiation. Outcome: Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality. Results: 16 cohort studies and 1 randomized controlled trial were identified (n = 1,081,116). By meta-analysis restricted to 15 cohorts (n = 1,079,917), higher GFR at dialysis therapy initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03-1.05; P < 0.001). However, there was significant heterogeneity (I 2 = 97%; P < 0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001; residual I 2 = 97%). The highest mortality risk was observed in hemodialysis cohorts (HR, 1.05; 95% CI, 1.02-1.08; P < 0.001), whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR, 1.04; 95% CI, 0.99-1.08, P = 0.1; residual I 2 = 98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR, 0.80; 95% CI, 0.71-0.91; P = 0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR, 1.04; 95% CI, 1.03-1.05; P < 0.001; residual I 2 = 97%). Limitations: Paucity of randomized controlled trials, different methods for determining GFR, and substantial heterogeneity. Conclusions: Higher estimated rather than calculated GFR at dialysis therapy initiation is associated with a higher mortality risk in patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study.
KW - End-stage renal disease (ESRD)
KW - chronic kidney disease (CKD)
KW - early initiation
KW - glomerular filtration rate (GFR)
KW - hemodialysis
KW - late initiation
KW - mortality
KW - peritoneal dialysis
UR - http://www.scopus.com/inward/record.url?scp=84861340124&partnerID=8YFLogxK
U2 - 10.1053/j.ajkd.2012.01.015
DO - 10.1053/j.ajkd.2012.01.015
M3 - Article
C2 - 22465328
AN - SCOPUS:84861340124
SN - 0272-6386
VL - 59
SP - 829
EP - 840
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 6
ER -