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Practicing health equity in involuntary discharges to overcome disparities in dialysis and kidney patient care. Curr Opin Nephrol Hypertens 2023; 32:49-57. [PMID: 36444662 DOI: 10.1097/mnh.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Potential causes and consequences of involuntary discharge (IVD) of patients from dialysis facilities are widely unknown. So, also are the extent of racial disparities in IVDs and their impact on health equity. RECENT FINDINGS Under the current End-Stage Renal Disease (ESRD) programConditions for Coverage (CFC), there are limited justifications for IVDs. The ESRD Networks oversee dialysis quality and safety including IVDs in US dialysis facilities, with support from the Agency for Healthcare Quality and Research (AHRQ) and other stakeholders. Whereas black Americans constitute a third of US dialysis patients, they are even more overrepresented in the planned and executed IVDs. Cultural gaps between patients and dialysis staff, psychosocial and regional factors, structural racism in kidney care, antiquated ESRD policies, unintended consequences of quality incentive programs, other perverse incentives, and failed patient-provider communications are among potential contributors to IVDs. SUMMARY Practicing health equity in kidney care may be negatively impacted by IVDs. Accurate analyses of patterns and trends of involuntary discharges, along with insights from well designed AHRQ surveys and qualitative research with mixed method approaches are urgently needed. Pilot and feasibility programs should be designed and tested, to address the root causes of IVDs and related racial disparities.
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Briguori C, Mathew RO, Huang Z, Mavromatis K, Hickson LJ, Lau WL, Mathew A, Mahajan S, Wheeler DC, Claes KJ, Chen G, Nolasco FEB, Stone GW, Fleg JL, Sidhu MS, Rockhold FW, Chertow GM, Hochman JS, Maron DJ, Bangalore S. Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD. J Am Heart Assoc 2022; 11:e022003. [PMID: 35261290 PMCID: PMC9075321 DOI: 10.1161/jaha.121.022003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023]
Abstract
Background In participants with concomitant chronic coronary disease and advanced chronic kidney disease (CKD), the effect of treatment strategies on the timing of dialysis initiation is not well characterized. Methods and Results In ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease), 777 participants with advanced CKD and moderate or severe ischemia were randomized to either an initial invasive or conservative management strategy. Herein, we compare the proportion of randomized participants with non-dialysis-requiring CKD at baseline (n=362) who initiated dialysis and compare the time to dialysis initiation between invasive versus conservative management arms. Using multivariable Cox regression analysis, we also sought to identify the effect of invasive versus conservative chronic coronary disease management strategies on dialysis initiation. At a median follow-up of 23 months (25th-75th interquartile range, 14-32 months), dialysis was initiated in 18.9% of participants (36/190) in the invasive strategy and 16.9% of participants (29/172) in the conservative strategy (P=0.22). The median time to dialysis initiation was 6.0 months (interquartile range, 3.0-16.0 months) in the invasive group and 18.2 months (interquartile range, 12.2-25.0 months) in the conservative group (P=0.004), with no difference in procedural acute kidney injury rates between the groups (7.8% versus 5.4%; P=0.26). Baseline clinical factors associated with earlier dialysis initiation were lower baseline estimated glomerular filtration rate (hazard ratio [HR] associated with 5-unit decrease, 2.08 [95% CI, 1.72-2.56]; P<0.001), diabetes (HR, 2.30 [95% CI, 1.28-4.13]; P=0.005), hypertension (HR, 7.97 [95% CI, 1.09-58.21]; P=0.041), and Hispanic ethnicity (HR, 2.34 [95% CI, 1.22-4.47]; P=0.010). Conclusions In participants with non-dialysis-requiring CKD in ISCHEMIA-CKD, randomization to an invasive chronic coronary disease management strategy (relative to a conservative chronic coronary disease management strategy) is associated with an accelerated time to initiation of maintenance dialysis for kidney failure. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01985360.
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Affiliation(s)
| | | | - Zhen Huang
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | - Kreton Mavromatis
- Atlanta VA Healthcare System and Emory University School of MedicineAtlantaGA
| | | | - Wei Ling Lau
- Division of NephrologyDepartment of MedicineUniversity of California‐IrvineIrvineCA
| | - Anoop Mathew
- University of Alberta HospitalEdmontonAlbertaCanada
| | | | | | | | - Gang Chen
- Peking Union Medical College HospitalBeijingChina
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount SinaiNew YorkNY
- Cardiovascular Research FoundationNew YorkNY
| | | | | | - Frank W. Rockhold
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
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Kalantar-Zadeh K, Kovesdy CP, Streja E, Rhee CM, Soohoo M, Chen JL, Molnar MZ, Obi Y, Gillen D, Nguyen DV, Norris KC, Sim JJ, Jacobsen SS. Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease. Nephrol Dial Transplant 2017; 32:ii91-ii98. [PMID: 28201698 PMCID: PMC5837675 DOI: 10.1093/ndt/gfw357] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/06/2016] [Indexed: 12/11/2022] Open
Abstract
In patients with advanced (estimated glomerular filtration rate <25 mL/min/1.73 m2) non-dialysis-dependent chronic kidney disease (CKD) the optimal transition of care to renal replacement therapy (RRT), i.e. dialysis or transplantation, is not known. Mortality and hospitalization risk are extremely high upon transition and in the first months following the transition to dialysis. Major knowledge gaps persist pertaining to differential or individualized transitions across different demographics and clinical measures during the 'prelude' period prior to the transition, particularly in several key areas: (i) the best timing for RRT transition; (ii) the optimal RRT type (dialysis versus transplant), and in the case of dialysis, the best modality (hemodialysis versus peritoneal dialysis), format (in-center versus home), frequency (infrequent versus thrice-weekly versus more frequent) and vascular access preparation; (iii) the post-RRT impact of pre-RRT prelude conditions and events such as blood pressure and glycemic control, acute kidney injury episodes, and management of CKD-specific conditions such as anemia and mineral disorders; and (iv) the impact of the above prelude conditions on end-of-life care and RRT decision-making versus conservative management of CKD. Given the enormous changes occurring in the global CKD healthcare landscape, as well as the high costs of transitioning to dialysis therapy with persistently poor outcomes, there is an urgent need to answer these important questions. This review describes the key concepts and questions related to the emerging field of 'Transition of Care in CKD', systematically defines six main categories of CKD transition, and reviews approaches to data linkage and novel prelude analyses along with clinical applications of these studies.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | | | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Daniel Gillen
- University of California Irvine Program for Public Health, Irvine, CA, USA
| | - Danh V. Nguyen
- General Internal Medicine, University of California Irvine Medical Center, Orange, CA, USA
- Biostatistics, Epidemiology and Research Design, University of California Irvine, Irvine, CA, USA
| | - Keith C. Norris
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - John J. Sim
- Kaiser Permanente of Southern California, Pasadena, CA, USA
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Jing J, Ravel VA, Soohoo M, Rhee CM, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of Slopes of Estimated Glomerular Filtration Rate With Post-End-Stage Renal Disease Mortality in Patients With Advanced Chronic Kidney Disease Transitioning to Dialysis. Mayo Clin Proc 2016; 91:196-207. [PMID: 26848002 PMCID: PMC4748393 DOI: 10.1016/j.mayocp.2015.10.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 10/09/2015] [Accepted: 10/26/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the association of estimated glomerular filtration rate (eGFR) slopes before dialysis initiation with cause-specific mortality after dialysis initiation. PATIENTS AND METHODS In this retrospective cohort study of 18,874 US veterans who had transitioned to dialysis from October 1, 2007, through September 30, 2011, we examined the association of pre-end-stage renal disease (ESRD) eGFR slopes with all-cause, cardiovascular, and infection-related mortality during the post-ESRD period over a median follow-up of 2.0 years (interquartile range, 1.1-3.2 years). Associations were examined using Cox models with adjustment for potential confounders. RESULTS Before the 18,874 patients transitioned to dialysis, 4485 (23.8%), 5633 (29.8%), and 7942 (42.1%) experienced fast, moderate, and slow eGFR decline, respectively, and 814 (4.3%) had increasing eGFR (defined as eGFR slopes of less than -10, -10 to less than -5, -5 to <0, and ≥0 mL/min per 1.73 m(2) per year). During the study period, a total of 9744 all-cause, 2702 cardiovascular, and 604 infection-related deaths were observed. Compared with patients with slow eGFR decline, those with moderate and fast eGFR decline had a higher risk of all-cause mortality (adjusted hazard ratio [HR], 1.06; 95% CI, 1.00-1.11; and HR, 1.11; 95% CI, 1.04-1.18, respectively) and cardiovascular mortality (HR, 1.11; 95% CI, 1.01-1.23 and HR, 1.13; 95% CI, 1.00-1.27, respectively). In contrast, increasing eGFR was only associated with higher infection-related mortality (HR, 1.49; 95% CI, 1.03-2.17). CONCLUSION Rapid eGFR decline is associated with higher all-cause and cardiovascular mortality, and increasing eGFR is associated with higher infection-related mortality among incident dialysis cases.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Jennie Jing
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange; Veterans Affairs Long Beach Healthcare System, Long Beach, CA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis; Nephrology Section, Memphis VA Medical Center, Memphis, TN.
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Kalantar-Zadeh K, Casino FG. Let us give twice-weekly hemodialysis a chance: revisiting the taboo. Nephrol Dial Transplant 2014; 29:1618-20. [PMID: 24782534 PMCID: PMC4145868 DOI: 10.1093/ndt/gfu096] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 03/24/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology & Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, CA, USA
- Nephrology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Kalantar-Zadeh K, Unruh M, Zager PG, Kovesdy CP, Bargman JM, Chen J, Sankarasubbaiyan S, Shah G, Golper T, Sherman RA, Goldfarb DS. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. Am J Kidney Dis 2014; 64:181-6. [PMID: 24840669 PMCID: PMC4111970 DOI: 10.1053/j.ajkd.2014.04.019] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 04/03/2014] [Indexed: 11/11/2022]
Abstract
Mortality is highest in the first months of maintenance hemodialysis (HD) therapy. In many Western countries, patients who transition to kidney replacement therapy usually begin thrice-weekly HD regardless of their level of residual kidney function (RKF). RKF is a major predictor of survival. RKF may decline more rapidly with thrice-weekly HD treatments, is associated with a reduced need for dialytic solute clearance, and is an important factor in the prescription of peritoneal dialysis. In this article, we review the concept of incremental HD, in which weekly dialysis dose, in particular HD treatment frequency, is based on a variety of clinical factors, such as RKF (including urine output > 0.5 L/d), volume status, cardiovascular symptoms, body size, potassium and phosphorus levels, nutritional status, hemoglobin level, comorbid conditions, hospitalizations, and health-related quality of life. These 10 clinical criteria may identify which patients might benefit from beginning maintenance HD therapy twice weekly. Periodic monitoring of these criteria will determine the timing for increasing dialysis dose and frequency. We recognize that twice-weekly HD represents a major paradigm shift for many clinicians and jurisdictions. Therefore, we propose conducting randomized controlled trials of twice-weekly versus thrice-weekly HD to assess the potential of twice-weekly HD to improve survival and health-related quality of life while simultaneously reducing costs, protecting fragile vascular accesses, and optimizing resource use during the first year of hemodialysis therapy. Such incremental and individualized HD therapy may prove to be the most appropriate approach for transitioning to dialytic therapy.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange; Veterans Affairs Long Beach Healthcare System, Long Beach, CA.
| | - Mark Unruh
- Division of Nephrology, University of New Mexico, Albuquerque, NM
| | - Philip G Zager
- Division of Nephrology, University of New Mexico, Albuquerque, NM
| | - Csaba P Kovesdy
- University of Tennessee Health Science Center and Memphis VAMC, Memphis, TN
| | - Joanne M Bargman
- University Health Network and the University of Toronto, Toronto, Canada
| | | | | | - Gaurang Shah
- Veterans Affairs Long Beach Healthcare System, Long Beach, CA
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Corrigendum. Semin Dial 2014. [DOI: 10.1111/sdi.12192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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