Predictors of Residual Renal Function Loss in Patients New to Dialysis

Moist et al. studied the predictors of RRF loss in patients initiating either HD or PD using patients from the Dialysis Morbidity and Mortality Study (DMMS) which uses a randomly selected subset of dialysis patients from the U.S. Renal Data System (USRDS) (1). The predictors of more rapid RRF loss and adjusted odds ratios (AOR) are shown in the table below (n=1843).

Predictor AOR p value
Female 1.4 <0.001
Non-white 1.57 <0.001
History of diabetes 1.82 =0.006
History of CHF 1.32 =0.03
Time to follow-up (per month) 1.06 =0.03

PD patients had a 65% lower risk of RRF loss than those on HD (AOR = 0.35; p <0.001). Patients with higher serum calcium (AOR = 0.81 per mg/dl; p = 0.05), those who used an angiotensin-converting enzyme inhibitor (AOR = 0.68; p< 0.001), or who used a calcium channel blocker (AOR = 0.77; p = 0.01) were independently associated with decreased risk of RRF loss.

Another study that investigated possible predictors of RRF loss in incident PD patients (N=146), demonstrated that decline of RRF was independent of age, gender, dialysis modality, urgency of initiation of dialysis, smoking, vascular disease, blood pressure, medications (including angiotensin-converting enzyme inhibitors), duration of follow-up and peritonitis rate (2). The presence of a higher baseline RRF (mean: 6.2 ± 2.2 mL/min/1.73 m2) (AOR: 1.83, 95% CI: 1.39-2.40) and high dialysate to plasma (D/P) creatinine ratio (mean: 0.7 ± 0.11) at the start of PD were risk factors for rapid loss of RRF (AOR: 44.6, 95% CI: 1.05-1900). In addition, patients with a lower baseline RRF (mean: 3.7 ± 1.7 mL/min/1.73 m2), increased body surface area, high dietary protein intake and diabetes mellitus also had a faster onset of anuria.  A small study by Caravaca et al. (3) reported that heart failure and creatinine clearance at PD initiation are a strong predictors of RRF loss. This study also suggested that chronic interstitial nephropathy is the strongest predialysis predictor for the preservation of RRF after onset of PD.

In a study of 522 incident PD and HD patients, Jansen and colleagues identified that higher diastolic blood pressure (P < 0.001) and a higher urinary protein loss (P < 0.001) were the primary factors negatively associated with loss of RRF at 12 months (4). They concluded that primary kidney disease did not affect the residual glomerular filtration rate. In agreement with prior studies, they showed that PD patients had a higher rGFR (P < 0.001) than HD patients, and the relative difference increased over time (P = 0.04), and drop outs from PD were handled according to previously published studies (5-7). Investigation of possible effects of the dialysis procedure on the rate of decline in RRF between 0 and three months showed that intradialytic hypotension (P = 0.02) contributed to RRF decline in in HD and the presence of episodes with dehydration contributed in PD (P = 0.004).

References:

  1. Moist LM, Port FK, Orzol SM, Young EW, Ostbye T, Wolfe RA, Hulbert-Shearon T, Jones CA, Bloembergen WE. Predictors of loss of residual renal function among new dialysis patients. J Am Soc Nephrol. 2000 Mar;11(3):556-64. https://www.ncbi.nlm.nih.gov/pubmed/10703680
  2. Johnson DW, Mudge DW, Sturtevant JM, Hawley CM, Campbell SB, Isbel NM, Hollett P. Predictors of decline of residual renal function in new peritoneal dialysis patients. Perit Dial Int. 2003 May-Jun;23(3):276-83. https://www.ncbi.nlm.nih.gov/pubmed/12938830
  3. Caravaca F, Dominguez C, Arrobas M. Predictors of loss of residual renal function in peritoneal dialysis patients. Perit Dial Int. 2002 May-Jun;22(3):414-7. https://www.ncbi.nlm.nih.gov/pubmed/12227403
  4.  Jansen MA, Hart AA, Korevaar JC, Dekker FW, Boeschoten EW, Krediet RT; NECOSAD Study Group. Predictors of the rate of decline of residual renal function in incident dialysis patients. Kidney Int. 2002 Sep;62(3):1046-53. https://www.ncbi.nlm.nih.gov/pubmed/12164889
  5. Lysaght MJ, Vonesh EF, Gotch F, Ibels L, Keen M, Lindholm B, Nolph KD, Pollock CA, Prowant B, Farrell PC. The influence of dialysis treatment modality on the decline of remaining renal function. ASAIO Trans. 1991 Oct-Dec;37(4):598-604. https://www.ncbi.nlm.nih.gov/pubmed/1768496
  6. Misra M, Vonesh E, Van Stone JC, Moore HL, Prowant B, Nolph KD. Effect of cause and time of dropout on the residual GFR: a comparative analysis of the decline of GFR on dialysis. Kidney Int. 2001 Feb;59(2):754-63. https://www.ncbi.nlm.nih.gov/pubmed/11168959
  7. Misra M, Vonesh E, Churchill DN, Moore HL, Van Stone JC, Nolph KD. Preservation of glomerular filtration rate on dialysis when adjusted for patient dropout. Kidney Int. 2000 Feb;57(2):691-6. https://www.ncbi.nlm.nih.gov/pubmed/10652048

P/N 101801-01 Rev A 6/2012