Timing of commencement of maintenance dialysis and mortality in young and older adults in Singapore

Liang Feng, Ai Zhen Jin, John Carson Allen, Khuan Yew Chow, Tazeen Hasan Jafar

The benefit of early dialysis initiation remains controversial with a paucity of data in Asians. Therefore, we undertook this study to investigate the association between timing of initiation of dialysis and mortality in Singapore. The study used data from the Singapore Renal Registry database on 3286 patients with incident end-stage renal disease (ESRD) who commenced maintenance dialysis between January 2008 and December 2011. The data was further linked with the National Death Registry to acquire survival information until December 2013. We classified serum creatinine-based, estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation at the start of dialysis into 3 categories: Early (≥10 ml/min/1.73m(2)), intermediate (5 to <10 ml/min/1.73m(2)) and late (<5 ml/min/1.73m(2)). In the unadjusted analysis, both early and intermediate dialysis initiation groups were at greater risk of death relative to late dialysis (Early: HR = 2.47; Intermediate: HR = 1.54). In the multivariate model, a significant interaction was detected between age and eGFR at dialysis initiation (p = 0.04). Adjusted mortality risk progressively increased with earlier initiation of dialysis for patients aged 18-54 years (p = 0.006) and aged 55 to 64 years (p < 0.001), and no statistically significant difference was observed for patients aged 65 years or older (p = 0.12). Early versus later initiation of dialysis was associated with significantly higher risk of mortality in Singapore's non-elderly population, and appeared to offer no survival advantage among the elderly.