Quick dialysis may be most beneficial to some kidney patients

Washington: According to one study, people with acute kidney impairment who require outpatient dialysis after being discharged from the hospital receive the same care as those with the more common end-stage kidney disease.

However, some dialysis patients with acute kidney injury may be able to recover. Patients with the latter diagnosis, which is generally caused by long-standing hypertension or diabetes, must either remain on dialysis for the rest of their lives or obtain a replacement kidney.

The findings were reported in the Journal of the American Society of Nephrology.

“For those who have the potential to recover, remaining on dialysis may place them at unnecessary risk for heart disease, infection, organ damage, and death,” said first author Ian E. McCoy, MD, of the UCSF Division of Nephrology.

Less than a quarter of patients in a typical midsize dialysis centre have acute kidney injury. It may result from acute infection or shock, causing reduced blood flow to the kidneys, as well as major surgeries and chemotherapy agents that are toxic to the kidneys.

In the study, researchers tracked data from 1,754 patients with acute kidney injury and 6,197 patients with end-stage kidney disease at outpatient dialysis centres. Although lab tests suggested acute kidney injury patients needed less dialysis, the two groups were treated largely the same. Both were started on thrice-weekly dialysis, and the large majority of patients in both groups were not tested for kidney functioning in the first month of treatment.

 “More research is needed on safe weaning strategies,” said McCoy. “If a patient is weaned off too quickly, they could become short of breath, or they could develop c that can increase the risk of dangerous heart rhythms.

“On the other hand, continuing dialysis unnecessarily is also risky, since patients experience high rates of heart disease, infection, and mortality,” he said.

For kidney specialists taking care of acute kidney injury patients and dialysis providers operating the patient-centers and outpatient centres, there are powerful disincentives to wean patients off dialysis, McCoy said. “Deprescribing benefits the health care system, but not the dialysis provider, who will have an empty chair that is not easy to fill. At the same time, kidney specialists lose a multidisciplinary support team of nurses, dieticians, and social workers when a patient recovers enough to discontinue dialysis.

“Kidney specialists are also paid less by insurance for non-dialysis care even though managing a patient with borderline kidney function is more time-consuming and riskier than managing them on thrice-weekly dialysis. For these reasons, the default path of least resistance may be to continue dialysis.”

Approximately half of the patients neither died nor discontinued dialysis by the end of the study. For them, the future looked uncertain, said Chi-yuan Hsu, MD, senior author and chief of the UCSF Division of Nephrology. “After about three months of dialysis, they almost always are treated like they will remain on dialysis indefinitely,” he said.