Thread by @ManjulaKTamura

In my advanced CKD clinic, this is a common clinical encounter: Mr. Jones is 83 and has chronic kidney failure with a low eGFR. He’s not eligible for a transplant.

He has cognitive impairment that is worse now, he’s experiencing fatigue, and his family says he’s not eating well – all symptoms that could be related to his kidney failure or other medical problems.

We’ve been discussing dialysis but he’s undecided. Should we start dialysis soon, should we wait until his symptoms or kidney function worsen, or should he forego dialysis completely?

To inform these decisions, we designed this target trial emulation study.


@MontezRath
@vcharuMD
@DaceySeib
@ShipraAryaMD
@enricaf2
@annmohareannals.org/aim/article/do…

We found that older patients who start dialysis when eGFR <12 ml/min live longer by a week than those who continue medical mgmt and could start dialysis later, but they spend 2 weeks less at home. Compared to those who forego dialysis completely, . . .

those who started dialysis at this level of kidney function lived longer by 77 days, but they spent less time at home. The trade-offs between life expectancy and home time were more favorable for dialysis in groups who were older and had lower levels of kidney function.

Important caveat—like most observational studies on this topic, we don’t know if symptoms differed between the group who started dialysis and those who continued medical mgmt. Some might say we need a clinical trial to answer these questions. I agree!

I think these results, along with those of prior studies, are strong arguments that equipoise exists to test interventions like incremental dialysis start or responsive symptom management.

As the editorialists @SofiaAhmedMD and @VictoriaRiehlT noted, let’s do better for our patients and give them more choices for managing chronic kidney failure.


(my first tweet thread - hope I did it right)annals.org/aim/article/do…