Tangri Navdeep, Garg Amit X, Ferguson Thomas W, Dixon Stephanie, Rigatto Claudio, Allu Selina, Chau Elaine, Komenda Paul, Naimark David, Nesrallah Gihad E, Soroka Steven D, Beaulieu Monica, Alam Ahsan, Kim S Joseph, Sood Manish M, Manns Braden
Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada.
Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.
J Am Soc Nephrol. 2021 Jul;32(7):1791-1800. doi: 10.1681/ASN.2020091254. Epub 2021 Apr 15.
The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise.
To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting.
The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient.
A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics.
ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.
2009年发表的“早期与晚期开始透析（IDEAL）试验”发现，与延迟开始透析相比，早期开始透析在死亡率风险或早期并发症方面没有可临床测量的益处。基于这些发现，指南推荐采用延迟透析起始的方法，目标是将透析推迟到临床症状出现时。
为评估一项旨在促进延迟透析起始策略的四部分知识转化干预措施，我们于2014年10月至2015年11月在加拿大进行了一项整群随机试验。我们将55家诊所随机分组，27家为干预组，28家为对照组。使用知识转化工具的教育干预包括知识转化经纪人进行的电话调查、为期1年的针对各中心的审计及反馈、提供指南套餐以及一次学术详述访问。参与者包括接受至少3个月透析前护理且在干预后第一年开始透析的成年人。主要疗效结局是早期开始透析（估算肾小球滤过率>10.5 ml/分钟/1.73 m²）的患者比例。次要结局是在急性住院环境中开始透析的患者比例。
分析纳入了在1年随访期内开始透析的3424例患者。其中，干预组1592例中有509例（32.0%）早期开始透析，对照组1832例中有605例（33.0%）早期开始透析。早期开始透析的个体比例或作为急性住院患者开始透析的个体比例没有差异。
多方面的知识转化干预未能降低多学科诊所中慢性肾脏病患者早期开始透析的比例。
ClinicalTrials.gov，NCT02183987。可在以下网址获取：https://clinicaltrials.gov/ct2/show/NCT02183987 。
