Original Investigations
Evaluation of DOQI guidelines: Early start of dialysis treatment is not associated with better health-related quality of life*,**,*,**

https://doi.org/10.1053/ajkd.2002.29896Get rights and content

Abstract

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI) guideline, which is largely opinion based, promotes an earlier initiation of dialysis treatment than usual. Implementation of this guideline would require an expansion of dialysis capacity, leading to a considerable increase in costs. Such an expansion can only be justified by an improvement in patient outcome. We studied the effect of late versus timely initiation of dialysis treatment on the course of health-related quality of life (HRQOL) in new dialysis patients. As part of a large Dutch prospective multicenter study (Netherlands Cooperative Study on the Adequacy of Dialysis-2), we consecutively included all new patients with end-stage renal disease for whom residual renal function could be obtained 0 to 4 weeks before the start of dialysis therapy. HRQOL was assessed by means of the Kidney Disease and Quality of Life Short Form at regular intervals during the first year of chronic dialysis treatment. According to the DOQI guideline, 90 of the 237 included patients (38%) started dialysis treatment too late. All patients showed marked improvement in HRQOL during the first 6 months after the start of dialysis treatment. Compared with patients who started dialysis treatment too late, patients who started in time had significantly higher HRQOL for a number of dimensions immediately after the start of treatment. After 12 months of dialysis treatment, these differences had disappeared. An evidence-based recommendation on an early start of dialysis treatment is still difficult to give. In the short term, an earlier start resulted in better HRQOL. However, within 1 year, this advantage had disappeared. It is unclear whether this short-term benefit outweighs the extra restrictions associated with earlier initiation of dialysis therapy. Consequently, only the patient, in consultation with the nephrologist, is able to weigh both sides. © 2002 by the National Kidney Foundation, Inc.

Section snippets

Patients

All new patients with end-stage renal disease (ESRD) from 29 Dutch dialysis centers were consecutively invited to participate in the study. These patients participated in The Netherlands Cooperative Study on the Adequacy of Dialysis-2 (NECOSAD-2), a large multicenter prospective study. The aim of this study was to monitor the quality and adequacy of dialysis treatment in The Netherlands. Eligibility criteria for the cohort were: 18 years or older, availability of residual renal function data 0

Results

Three hundred eighteen patients satisfied the criteria for inclusion. We excluded 14 patients because of inaccurate urine collection, 20 patients because they had malignancy, and another 31 patients because they did not receive predialysis care. In addition, 13 patients did not want to participate in the HRQOL assessment. Three patients did not complete an HRQOL questionnaire at any scheduled measurement.

Two hundred thirty-seven patients were available for analysis, of which 90 patients (38%)

Discussion

This prospective multicenter study of dialysis patients showed that patients starting late with chronic dialysis treatment had lower perceived HRQOL for a number of dimensions at dialysis therapy initiation. For the majority of dimensions, a substantial improvement in HRQOL was observed in all groups of patients during the first 6 months of chronic dialysis treatment. Any differences that existed at the start of dialysis treatment were caught up within 12 months. As a result, after 1 year of

Acknowledgements

The authors thank the nursing staff of the dialysis centers, who collected most of the data, and A. Feller, A. Houweling, C. Janssen, B. Nijman, L. Ten Brinke, K. Voss, and R. Wisse, for their assistance in the logistics of this study.

References (32)

  • C Jacobs

    At which stage of renal failure should dialysis be started?

    Nephrol Dial Transplant

    (2000)
  • J Tattersall et al.

    Urea kinetics and when to commence dialysis

    Am J Nephrol

    (1995)
  • National Kidney Foundation

    DOQI Clinical Practice Guidelines for Hemodialysis and Peritoneal Dialysis Adequacy

    Am J Kidney Dis

    (1997)
  • TA Ikizler et al.

    Spontaneous dietary protein intake during progression of chronic renal failure

    J Am Soc Nephrol

    (1995)
  • LM Moist et al.

    Predictors of loss of residual renal function among new dialysis patients

    J Am Soc Nephrol

    (2000)
  • W van Biesen et al.

    The referral pattern of end-stage renal disease patients and the initiation of dialysis: A European perspective

    Perit Dial Int

    (1999)
  • Cited by (58)

    • Timing of peritoneal dialysis initiation and mortality: Analysis of the canadian organ replacement registry

      2014, American Journal of Kidney Diseases
      Citation Excerpt :

      Nonetheless, even if it were demonstrated that early dialysis therapy initiation confers no true increased mortality risk, the benefits of early initiation are questionable. Recent studies suggest that early initiation might not improve quality of life and could actually worsen it.42-45 The IDEAL trial demonstrated no difference in quality of life between the early- and late-start groups.46

    • Chronic Kidney Disease: Pathophysiology and the Influence of Dietary Protein

      2012, Seldin and Giebisch's The Kidney: Physiology and Pathophysiology
    • Approach to Renal Replacement Therapy

      2010, Comprehensive Clinical Nephrology: Fourth Edition
    View all citing articles on Scopus
    *

    For the Netherlands Cooperative Study on the Adequacy of Dialysis study group: Apperloo AJ, Barendregt JNM, Birnie RJ, Boekhout M, Boer WH, van Bommel EFH, Büller HR, de Charro Fth, Doorenbos CJ, van Dorp WT, van Es A, Fagel WJ, Feith GW, Franssen CFM, Frenken LAM, van Geelen JACA, Geerlings W, Gerlag PGG, Gorgels JPMC, Grave W, Huisman RM, Jager KJ, Jie K, Koning-Mulder WAH, Koolen MI, Kremer Hovinga TK, Lavrijssen ATJ, van Manen JG, Mulder AW, Parlevliet KJ, Rosman JB, van Saase JLCM, Schonk MJM, Schuurmans MMJ, Stevens P, Tijssen JGP, Valentijn RM, Vastenburg G, Verburg CA, Verhagen CE, Verstappen VMC, Vincent HH, Vos P.

    **

    Supported in part by grant no. E.018 from The Dutch Kidney Foundation and grant no. OG97/005 from the Dutch National Health Insurance Board.

    *

    Address reprint requests to Johanna C. Korevaar, MSc, Department of Clinical Epidemiology and Biostatistics, J2-211, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail: [email protected]

    **

    0272-6386/02/3901-0015$35.00/0

    View full text