The Impact of Late Initiation of Chronic Dialysis on Mortality: A National Retrospective Cohort Study
Bibliographic record
Abstract
Background: Current Canadian guidelines recommend deferring dialysis initiation in asymptomatic patients until the glomerular filtration rate (GFR) reaches 6 mL/min/1.73m2, (an “intent-to-defer” strategy). However, little is known about how dialysis initiation and post dialysis outcomes are impacted when patients start at or below this threshold. Methods: We sought to characterize the impact of starting dialysis at or below 6 mL/min/1.73m2 in a national retrospective cohort study of incident dialysis patients from 2004-2019. Dialysis data (excluding Manitoba and Quebec) was acquired from the Canadian Organ Replacement Register (CORR) and linked to hospitalization data using the well-established discharge abstract database (DAD). The cohort was restricted to only those who initiated dialysis as an outpatient and with previous nephrology follow-up of three months or more. Time to death was compared for those starting at or below 6 ml/min/1.73m2 (using the CKD-EPI formula) to those initiating between an eGFR of 6-15 ml/min/1.73m2 and analyzed using an adjusted cox proportional hazard model. Results: A total of 63327 unique patients started dialysis from 2004-2019, of whom 39696 patients started dialysis as an outpatient after at least three months of nephrology follow-up. The mean age was 63+/-14, 68% were white, and 61% were male. 24% of the population started dialysis at an eGFR by CKD-EPI at or below 6 mL/min. Patients starting at 6 mL/min/1.73m2 or below were more likely to start dialysis with a CVC (59% vs 50%, p<0.001). During the study period 18979 patients died (48%). Starting dialysis at or below 6 mL/min/1.73m2 was associated with a longer time to death (HR 0.87; 95% CI 0.84,0.90) after adjusting for sex, race, age, dialysis access, diabetic kidney disease, and other comorbidities. Conclusions: In this cohort of incident dialysis patients, those with an eGFR at or below 6 mL/min/1.73m2 had a lower risk for mortality compared with those starting with a higher eGFR. These findings support deferral of dialysis initiation beyond the threshold of 6 mL/min/1.73m2 in the absence of traditional indications.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.002 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".