Potential Benefit Associated With Delaying Initiation of Hemodialysis in a Japanese Cohort

INTRODUCTION: Late referral to a nephrologist, the type of vascular access, nutritional status, and the estimated glomerular filtration rate (eGFR) at the start of hemodialysis (HD) have been reported as independent risk factors of survival for patients who begin HD. The aim of this study was to clarify the influence of the HD-free interval from the time of an eGFR of 10 ml/min per 1.73 m(2) (I(GFR10-HD)) on patient outcome. METHODS: We enrolled 124 patients aged older than 20 years who had HD initiated in a general hospital. The predictive factor was the HD-free I(GFR10-HD). The primary outcome was the relationship of the HD-free interval on death or the onset of a cardiovascular event. Survival analysis was performed using the Cox regression model. RESULTS: The median I(GFR10-HD) was 159 days (range: 2–1687 days). The median eGFR at the initiation of HD was 5.48 ml/min per 1.73 m(2). Sixty-seven of 124 patients (54.0%) reached the primary outcome. Of these, 29 died and 38 experienced a cardiovascular event. In univariate analysis, older age, a history of cardiovascular disease, nephrologic care for <6 months, higher modified Charlson comorbidity index score, poor performance status, temporary catheter, edema, diabetic retinopathy, and nonuse of erythropoiesis-stimulating agent were statistically related to the primary outcome. The unadjusted hazard ratio per log-transformed I(GFR10-HD) was 0.393 (95% confidence interval [CI]; 0.244−0.635; P < 0.001) and the hazard ratio adjusted for confounding factors was 0.507 (95% CI: 0.267−0.956; P = 0.036). DISCUSSION: A longer HD-free I(GFR10-HD) was associated with a lower risk of death or a cardiovascular event. The interval could be considered an independent prognostic factor for outcomes in patients on HD.