FC 118DIALYSIS WITHDRAWAL IN THE NETHERLANDS BETWEEN 2000-2020: TIME TRENDS AND CENTRE VARIATION

Background and Aims Treatment withdrawal is an important cause of death among dialysis-dependent patients. Widely variable withdrawal rates were reported in studies using varying designs and definitions in culturally different regions of the world, limiting comparability of individual studies. Cessation of life-prolonging treatment is a well-accepted option in the Netherlands, however it is unclear if these premises result in higher dialysis withdrawal rates and if this effect is generalisable. This study aims to describe dialysis withdrawal practice in the Netherlands, focussing on time trends and practice variation between centres. Method Patient data was retrieved from RENINE, the Dutch national registration which includes nearly all patients requiring dialysis for at least 28 days. All patients who initiated maintenance dialysis from January 1, 2000, to December 31, 2020, and died within this period were included for analysis. Since the primary aim of this study concerned cause of death on dialysis, data of patients in whom dialysis was stopped due to kidney transplantation or recovery of kidney function, were excluded. Main outcome was death by dialysis withdrawal, as registered by the treating physician using ERA-EDTA codes. Other causes of death were used as comparison. Time trends for dialysis withdrawal were first analysed as unadjusted data (proportion per year). Univariable logistic regression analyses were then used to identify factors associated with dialysis withdrawal, including year of death in five-year strata. A multivariable model was subsequently used to determine risks, adjusting for factors associated with dialysis withdrawal. Centre variation was compared visually by using funnel plots. Results A total of 34.692 patients commenced maintenance dialysis of which 20.389 died. After applying exclusion criteria, a cohort of 18.412 patients was used for analysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 13.5% in 2000 to 31.2% in 2019 (22.1% overall). In multivariable analysis, increasing age, female sex, increasing dialysis vintage, haemodialysis as treatment modality, and year of death were independent factors associated with death by dialysis withdrawal. Centre variation was large, even after correction for confounding factors (36.6% outside 95% control limits). Conclusion Treatment withdrawal has become the main cause of death in the Netherlands among dialysis-dependent patients during 2000-2020. Large practice variations were observed between centres, even after correction for confounding factors. These findings emphasize the need for timely advance care planning and urge treating health care professionals to better inform their patients when choosing to start dialysis or not.

Encapsulating peritoneal sclerosis: from early diagnosis to successful kidney transplantation

Encapsulating peritoneal sclerosis is an uncommon but serious complication of peritoneal dialysis. In most cases, the symptoms appear after peritoneal dialysis withdrawal, which hampers its diagnosis. We present the case of a 44-years-old Caucasian male who had been on peritoneal dialysis for 6 years and 3 months and was switched to hemodialysis due to ultrafiltration failure. During his last months on peritoneal dialysis, he developed anorexia and asthenia, which were initially attributed to dialysis inadequacy. After hemodialysis induction, the patient developed abdominal pain, increased abdominal volume, obstipation alternating with diarrhea, and weight loss. Computed tomography showed de novo ascites. A diagnosis of early encapsulating peritoneal sclerosis was considered, and treatment was promptly initiated with nutritional support, oral prednisolone, and tamoxifen for one year. The patient progressed with resolution of the symptoms. One month after the end of the treatment, he underwent a successful kidney transplant and remain without any major intercurrences. A high level of clinical suspicion is crucial for the early diagnosis of encapsulating peritoneal sclerosis as the disease can be fatal in advanced stages. This case highlights that with early treatment, kidney transplantation can be successfully performed after an episode of encapsulating peritoneal sclerosis.

Predialysis Serum Lactate Levels Can Predict Dialysis Withdrawal in Type 1 Cardiorenal Syndrome Patients

Type 1 cardiorenal syndrome (CRS) is a complication with grave outcomes, and renal replacement therapy (RRT) is an effective rescue therapy. Serum lactate has been correlated with the risk of mortality in patients with sepsis. However, the association between serum lactate level and the prognosis of type 1 CRS patients requiring RRT is unknown. We prospectively enrolled 500 type 1 CRS patients who received RRT from August 2011 to January 2018. The 90-day mortality rate was 52.8% and the incidence rate of RRT independence was 34.8%. Lower pre-dialysis lactate was correlated with a higher rate of dialysis withdrawal and lower rate of mortality. A generalized additive model showed that 4.2 mmol/L was an adequate cut-off value of lactate to predict renal recovery. Taking mortality as a competing risk, Cox proportional hazards analysis indicated that a low lactate level (≦ 4.2 mmol/L) was an independent prognostic factor for the possibility of dialysis withdrawal, as also shown in external validation. The interaction of quick Sequential Organ Failure Assessment score and lactate was associated with dialysis dependence in a disease severity-dependent manner. In summary, we identified that pre-dialysis serum lactate level could predict the possibility of dialysis withdrawal in type 1 CRS patients.

Process of Dialysis Withdrawal for Patients Failing to Thrive on Dialysis

Dialysis therapy should be aligned with patient goals, values, and preferences. Withdrawal from dialysis is common, requiring kidney care professionals to recognize when the burden of dialytic therapies outweighs its benefit for any given patient. Informing patients early of the option to withdraw as part of periodic advance care planning can ease future conversations around withdrawal. A systematic approach to discussing withdrawal will address patient and family needs and includes assessing decision-making capacity, eliciting values, clarifying preferences, and educating patients and families about the physical, psychosocial, spiritual, and legal aspects of end-of-life care. All are key components of shared decision-making and the process of withdrawing from dialysis.

Factors Associated with Elective Withdrawal of Maintenance Hemodialysis: A Case-Control Analysis

Background: Associations of demographic factors with elective dialysis withdrawal and setting of death, patterns of illness trajectories preceding death, and how illness trajectories, particularly worsening putative disability, are associated with elective withdrawal are poorly understood. Methods: Using United States Renal Data System data, we performed a case-control analysis of hemodialysis patients who died in 2010–2015. A disability proxy score characterized disability; logistic regression identified characteristics associated with death from withdrawal and with death setting; and group-based trajectory models characterized the trajectory of disability in the months preceding death. Results: We identified 14,571 (9.2%) patients who withdrew and 144,305 (90.8%) who died of a non-withdrawal cause. Women were more likely than men to withdraw (OR 1.19, 95% CI 1.15–1.24). The most rural patients were more likely to withdraw than the most urban (OR 1.37, 95% CI 1.25–1.50). Medicaid coverage (a marker for impoverishment) was associated with less withdrawal (OR 0.90, 95% CI 0.86–0.94). Disability proxy score was strongly related to withdrawal: the OR for patients in the highest score category was 31.16 (95% CI 28.40–34.20) versus those with a score of 0. Women and whites (vs. blacks) were overrepresented in the worst, versus better, proxy disability score trajectory. In-hospital death and death in the intensive care unit were more common in women and minorities than in men and whites, but less common in the most rural patients. Conclusions: Important differences separate patients who electively withdraw from those who die of non-withdrawal causes. Worsening disability, in particular, may be a marker for withdrawal.

Factors Associated With Dialysis Withdrawal In Dialysis Patients

Background: Research on the factors associated with dialysis withdrawal in dialysis patients has been limited. Authors have used different definitions for dialysis withdrawal, resulting in inconsistent findings. The objective of this study was to determine the factors associated with dialysis withdrawal in dialysis patients.Methods: This retrospective study extracted patient information from the electronic renal patient management systems at the Grand River Hospital. A total of 723 patients who initiated renal dialysis therapy (> 30 days of duration) in the renal dialysis program at Grand River Hospital (GRH), Ontario, during the period from 1st January 2012 to 30th September 2017 were consecutively included in the study. Logistic regression was used to determine the factors: age, sex, modality, comorbidities, the cause of primary renal disease, dialysis modality, and duration of dialysis-associated with dialysis withdrawal. Dialysis withdrawal was defined as “patient declined further treatment or voluntary withdrawal from the dialysis program”.Results: The mean age of the sample was 64.86 ± 14.89 years, and 62.8% (n = 454) were males. The prevalence of dialysis withdrawal was 9.41% (n = 68). The logistic regression model showed that factors associated with dialysis withdrawal were as follows: cardiac disease [Adjusted Odds Ratio (AOR)= 1.921; 95% CI= 1.126–3.278], hypertension [AOR = 5.711; 95% CI = 1.322- 24.676], dementia [AOR = 3.042; 95% CI = 1.325–6.983], age [AOR = 1.035; 95% CI = 1.012– 1.058] and duration of dialysis [AOR = 0.999; 95% CI = 0.999–1.00].Conclusion: In this study we show that age, cardiac disease, hypertension, and dementia are significant predictors related to dialysis withdrawal. The findings might help in identifying patients who are more likely to withdraw from dialysis at the start of dialysis. Future researchers and nephrologists should design and conduct intervention studies focusing on strategies controlling the severity of comorbidities (cardiac disease and hypertension), regular assessment and monitoring of the progression of dementia, and other dialysis program changes to help patients make more informed decisions regarding dialysis withdrawal. Keywords: dialysis, dialysis withdrawal, maintenance dialysis, hemodialysis, peritoneal dialysis, dementia.