Death and Dialysis Following Discharge From Chronic Kidney Disease Clinic: A Retrospective Cohort Study

Implementation of the Kidney Failure Risk Equation in a United States Nephrology Clinic

Introduction

The kidney failure risk equation (KFRE) estimates a person's risk of kidney failure and has great potential utility in clinical care.

Methods

We used mixed methods to explore implementation of the KFRE in nephrology clinics.

Results

KFRE scores were integrated into the electronic health record at Johns Hopkins Medicine and were displayed to nephrology providers. Documentation of KFRE scores increased over time, reaching 25% of eligible outpatient nephrology clinic notes at month 11. Three providers documented KFRE scores in >75% of notes, whereas 25 documented scores in <10% of notes. Surveys and focus groups of nephrology providers were conducted to probe provider views on the KFRE. Survey respondents (n = 25) reported variability in use of KFRE for decisions such as maintaining nephrology care, referring for transplant evaluation, or providing dialysis modality education. Provider perspectives on the use of KFRE, assessed in 2 focus groups of 4 providers each, included 3 common themes as follows: (i) KFRE scores may be most impactful in the care of specific subsets of people with chronic kidney disease (CKD); (ii) there is uncertainty about KFRE risk-based thresholds to guide clinical care; and (iii) education of patients, nephrology providers, and non-nephrology providers on appropriate interpretations of KFRE scores may help maximize their utility.

Conclusion

Implementation of the KFRE was limited by non-uniform provider adoption of its use, and limited knowledge about utilization of the KFRE in clinical decisions.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study

Background

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting.

Objective

Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes.

Design

Population-based descriptive cohort study.

Setting

Alberta Kidney Care South.

Patients

Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019.

Measurements

Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations.

Methods

We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios.

Results

Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting.

Limitations

The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics.

Conclusions

Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events.

Trial registration

Not applicable.

Balance ability and all-cause death in middle-aged and older adults: A prospective cohort study

Objective

The present study aimed to explore the relationship between balance ability and all-cause death in middle-aged and elderly people and to provide a basis for formulating a balanced training plan for middle-aged and older people in China.

Methods

Based on data from the China Health and Retirement Longitudinal Study (CHARLS) carried out in the years 2011, 2013, 2015, and 2018, 18,888 participants aged 45 years and above were included. Cox proportional hazard models were designed to evaluate the effect of balance ability on death events.

Results

The present study found that there was an association between balance ability and death among middle-aged and older people. Multivariate Cox proportional hazard regression model analysis showed that the risk of death decreased by 10% (HR = 0.90,95% CI: 0.85-0.95) for every second increase in balance ability. With balance ability <10 s as the reference group, the adjusted HRs were 0.61 (0.44-0.85) among middle-aged and elderly people. The death density of balance ability of <10 s was 73.87 per thousand person-years higher than that of ≥10 s. There was no interaction between balance ability and chronic disease, overweight, and obesity (P > 0.05).

Conclusion

The risk of all-cause death in middle-aged and older people increased with the decrease in balance ability and showed no statistical significance between chronic disease, overweight, and obesity, as corroborated by the present study.