Supplementary Material for: Factors Affecting the Decision to Initiate Dialysis: A National Survey of United States Nephrologists

Introduction The percentage of patients initiating dialysis at an estimated glomerular filtration rate (eGFR) ≤9 mL/min/1.73 m2 decreased between 2000 and 2018 in the United States. Clinical practice guidelines recommend basing the decision to initiate dialysis primarily on uremic signs and symptoms, rather than on a particular level of kidney function. However, what signs and symptoms currently practicing nephrologists consider “uremic”, how they weigh eGFR and other factors in the decision to initiate dialysis have not been reported. Methods The study was an online survey of 255 United States nephrologists, conducted between August and October 2021. Results Nearly half of respondents (49.8%) had an absolute lower eGFR (8.4 (95% CI: 7.6, 9.2) mL/min/1.73 m2) at which they would initiate dialysis in an asymptomatic patient. The top 5 symptoms that would trigger a recommendation to initiate dialysis were loss of appetite/nausea/vomiting (17%), low eGFR (10%), shortness of breath (10%), declining physical ability/function (9%), and generalized weakness (9%). Poor nutritional status and physical function decline were considered very important in the decision to initiate dialysis by 64% and 55% of respondents, respectively. Nephrologists surveyed significantly shortened the time to dialysis initiation in response to declining physical function in an otherwise asymptomatic (hypothetical) patient. Conclusions Nearly half of nephrologists sometimes based their decision to initiate dialysis on eGFR alone. The eGFR threshold at which they did so was lower than has been examined in randomized controlled trials of dialysis initiation. Initiatives designed to safely delay dialysis through aggressive medical management could focus on modifiable factors that are the most important drivers of the decision to initiate dialysis.

引言：2000年至2018年间，美国启动透析时估算肾小球滤过率（estimated glomerular filtration rate, eGFR）≤9 mL/min/1.73m²的患者占比有所下降。临床实践指南建议，启动透析的决策应主要基于尿毒症体征与症状，而非特定的肾功能水平。然而，目前在职的肾内科医师将哪些体征与症状视为"尿毒症相关"，以及他们在启动透析的决策中如何权衡eGFR与其他因素，目前尚无相关报道。
方法：本研究于2021年8月至10月间开展，针对255名美国肾内科医师进行了在线调查。
结果：近半数受访者（49.8%）在无症状患者中启动透析的eGFR阈值为8.4（95%置信区间（confidence interval, CI）：7.6、9.2）mL/min/1.73m²。位列前五的会触发透析启动建议的症状依次为：食欲减退/恶心/呕吐（17%）、eGFR降低（10%）、呼吸困难（10%）、体力/功能下降（9%）以及全身乏力（9%）。64%与55%的受访者分别认为，营养状况不佳与体力功能下降在透析启动决策中极为重要。受访肾内科医师在面对仅存在体力功能下降的无症状假想患者时，会显著缩短透析启动的时间间隔。
结论：近半数肾内科医师有时会仅依据eGFR做出启动透析的决策。他们所采用的这一eGFR阈值低于现有透析启动随机对照试验中所考察的阈值水平。旨在通过积极内科治疗安全延缓透析的相关举措，可聚焦于那些对透析启动决策影响最大的可干预因素。