1
|
Elliott MJ, Ravani P, Quinn RR, Oliver MJ, Love S, MacRae J, Hiremath S, Friesen S, James MT, King-Shier KM. Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study. Am J Kidney Dis 2023; 81:48-58.e1. [PMID: 35870570 DOI: 10.1053/j.ajkd.2022.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/30/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE & OBJECTIVE Collaborative approaches to vascular access selection are being increasingly encouraged to elicit patients' preferences and priorities where no unequivocally superior choice exists. We explored how patients, their caregivers, and clinicians integrate principles of shared decision making when engaging in vascular access discussions. STUDY DESIGN Qualitative description. SETTING & PARTICIPANTS Semistructured interviews with a purposive sample of patients, their caregivers, and clinicians from outpatient hemodialysis programs in Alberta, Canada. ANALYTICAL APPROACH We used a thematic analysis approach to inductively code transcripts and generate themes to capture key concepts related to vascular access shared decision making across participant roles. RESULTS 42 individuals (19 patients, 2 caregivers, 21 clinicians) participated in this study. Participants identified how access-related decisions follow a series of major decisions about kidney replacement therapy and care goals that influence vascular access preferences and choice. Vascular access shared decision making was strengthened through integration of vascular access selection with dialysis-related decisions and timely, tailored, and balanced exchange of information between patients and their care team. Participants described how opportunities to revisit the vascular access decision before and after dialysis initiation helped prepare patients for their access and encouraged ongoing alignment between patients' care priorities and treatment plans. Where shared decision making was undermined, hemodialysis via a catheter ensued as the most readily available vascular access option. LIMITATIONS Our study was limited to patients and clinicians from hemodialysis care settings and included few caregiver participants. CONCLUSIONS Findings suggest that earlier, or upstream, decisions about kidney replacement therapies influence how and when vascular access decisions are made. Repeated vascular access discussions that are integrated with other higher-level decisions are needed to promote vascular access shared decision making and preparedness.
Collapse
Affiliation(s)
- Meghan J Elliott
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert R Quinn
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shannan Love
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Friesen
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn M King-Shier
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
2
|
Frazier R, Levine S, Porteny T, Tighiouart H, Wong JB, Isakova T, Koch-Weser S, Gordon EJ, Weiner DE, Ladin K. Shared Decision Making Among Older Adults With Advanced CKD. Am J Kidney Dis 2022; 80:599-609. [PMID: 35351579 DOI: 10.1053/j.ajkd.2022.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown. STUDY DESIGN A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM. SETTING & PARTICIPANTS Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD. PREDICTORS Decisional readiness factors, treatment options education, and care partner support. OUTCOMES Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSIONS Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
Collapse
Affiliation(s)
- Rebecca Frazier
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois; Jesse Brown Veterans Administration Medical Center, Chicago, Illinois.
| | - Sarah Levine
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Thalia Porteny
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Tufts University School of Medicine, Boston, Massachusetts
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Elisa J Gordon
- Department of Surgery-Division of Transplantation, Center for Health Services and Outcomes Research, Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel E Weiner
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| |
Collapse
|
3
|
Peng Y, Ye H, Yi C, Xiao X, Huang X, Liu R, Diao X, Mao H, Yu X, Yang X. Early initiation of PD therapy in elderly patients is associated with increased risk of death. Clin Kidney J 2020; 14:1649-1656. [PMID: 34084460 PMCID: PMC8162869 DOI: 10.1093/ckj/sfaa214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
Background The effect of early initiation of dialysis on outcomes of patients with end-stage renal disease (ESRD) remains controversial. We conducted this study to investigate the association between the timing of peritoneal dialysis (PD) initiation and mortality in different age groups. Methods In this single-centre cohort study, incident patients receiving PD from 1 January 2006 to 31 December 2016 were enrolled. Patients were categorized into three groups according to the estimated glomerular filtration rate (eGFR) at the initiation of PD, with early, mid and late initiation of PD defined as eGFR ≥7.5, 5–7.5 and <5 mL/min/1.73 m2, respectively. Results A total of 2133 incident patients receiving PD were enrolled with a mean age of 47.1 years, 59.6% male and 25.3% with diabetes, of whom 1803 were young (age <65 years) and 330 were elderly (age ≥65 years). After multivariable adjustment, the overall and cardiovascular (CV) mortality risks for young patients receiving PD were not significantly different between these three groups. However, for elderly patients, early initiation of PD therapy was associated with increased risks of all-cause {hazard ratio [HR} 1.54 [95% confidence interval (CI) 1.06–2.25]} and CV [HR 2.07 (95% CI 1.24–3.48)] mortality compared with late initiation of PD, while no significant difference was observed in overall or CV mortality between the mid- and late-start groups. Conclusions No significant difference in mortality risk was found among the three levels of eGFR at PD therapy initiation in young patients, while early initiation of PD was associated with a higher risk of overall and CV mortality among elderly patients.
Collapse
Affiliation(s)
- Yuan Peng
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xi Xiao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xuan Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Ruihua Liu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xiangwen Diao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Haiping Mao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| |
Collapse
|
4
|
Wetmore JB, Herzog CA, Sexter A, Gilbertson DT, Liu J, Kasner SE. Outcomes Following Ischemic Stroke in Older Patients With CKD Stages 4 and 5: A Retrospective Cohort Study. Am J Kidney Dis 2020; 76:784-793. [PMID: 32474166 PMCID: PMC8218249 DOI: 10.1053/j.ajkd.2020.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/17/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The associations between ischemic stroke and time to dialysis initiation and/or death in adults with late-stage chronic kidney disease (CKD) have not been explored. We sought to measure the rate and factors associated with stroke in CKD stages 4 and 5 (CKD4-5) and assess the association of stroke with initiation of dialysis and death. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS Patients with CKD4-5 in Medicare 2007 to 2014. EXPOSURE OR PREDICTOR Ischemic stroke in CKD4-5. OUTCOMES Initiation of maintenance dialysis or death. ANALYTICAL APPROACH Cox proportional hazard modeling assessed factors associated with ischemic stroke. A matched analysis (stroke/no stroke) estimated the cumulative incidence of incident kidney failure and death, treated as competing events. Simulations using a state transition model determined differences in expected time to kidney failure or death and death alone for patients with and without stroke with CKD5. RESULTS 123,251 patients with CKD4 and 22,054 with CKD5 were identified. Mean ages were 81.0 and 79.2 years, respectively. Female sex (HRs of 1.21 [95% CI, 1.12-1.31] and 1.39 [95% CI, 1.04-1.86] for CKD4 and CKD5, respectively) and black race (HRs of 1.25 [95% CI, 1.12-1.39] and 1.12 [95% CI, 0.80-1.58] for CKD4 and CKD5, respectively) were factors associated with ischemic stroke. Rates for 30-day mortality were 13.3% and 18.8%, and for 1-year mortality, 40.0% and 38.2%. For patients with CKD5, kidney failure or death occurred an average of 3.6 months sooner for patients with an ischemic stroke, and death (irrespective of kidney failure), a mean of 24.3 months sooner. LIMITATIONS Study design cannot determine causality; lack of data for stroke severity. CONCLUSIONS Female sex and black race were associated with increased risk for stroke in CKD4 and CKD5. In CKD5, stroke was associated with a shorter time to kidney failure or death by nearly 4 months, and to death, by more than 2 years.
Collapse
Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, Minneapolis, MN.
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Anne Sexter
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
5
|
Zhou H, Sim JJ, Shi J, Shaw SF, Lee MS, Neyer JR, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis. Am J Kidney Dis 2020; 77:704-712. [PMID: 33010357 DOI: 10.1053/j.ajkd.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/12/2020] [Indexed: 11/11/2022]
Abstract
RATIONAL & OBJECTIVE Beta-blockers are recommended for patients with heart failure (HF) but their benefit in the dialysis population is uncertain. Beta-blockers are heterogeneous, including with respect to their removal by hemodialysis. We sought to evaluate whether β-blocker use and their dialyzability characteristics were associated with early mortality among patients with chronic kidney disease with HF who transitioned to dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adults patients with chronic kidney disease (aged≥18 years) and HF who initiated either hemodialysis or peritoneal dialysis during January 1, 2007, to June 30, 2016, within an integrated health system were included. EXPOSURES Patients were considered treated with β-blockers if they had a quantity of drug dispensed covering the dialysis transition date. OUTCOMES All-cause mortality within 6 months and 1 year or hospitalization within 6 months after transition to maintenance dialysis. ANALYTICAL APPROACH Inverse probability of treatment weights using propensity scores was used to balance covariates between treatment groups. Cox proportional hazard analysis and logistic regression were used to investigate the association between β-blocker use and study outcomes. RESULTS 3,503 patients were included in the study. There were 2,115 (60.4%) patients using β-blockers at transition. Compared with nonusers, the HR for all-cause mortality within 6 months was 0.79 (95% CI, 0.65-0.94) among users of any β-blocker and 0.68 (95% CI, 0.53-0.88) among users of metoprolol at transition. There were no observed differences in all-cause or cardiovascular-related hospitalization. LIMITATIONS The observational nature of our study could not fully account for residual confounding. CONCLUSIONS Beta-blockers were associated with a lower rate of mortality among incident hemodialysis patients with HF. Similar associations were not observed for hospitalizations within the first 6 months following transition to dialysis.
Collapse
Affiliation(s)
- Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA.
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Jonathan R Neyer
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, CA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| |
Collapse
|
6
|
Yoshida H, Inaguma D, Koshi-Ito E, Ogata S, Kitagawa A, Takahashi K, Koide S, Hayashi H, Hasegawa M, Yuzawa Y, Tsuboi N. Extreme hyperuricemia is a risk factor for infection-related deaths in incident dialysis patients: a multicenter prospective cohort study. Ren Fail 2020; 42:646-655. [PMID: 32662307 PMCID: PMC7470168 DOI: 10.1080/0886022x.2020.1788582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction There are few studies on the association between serum uric acid (UA) level and mortality in incident dialysis patients. We aimed to clarify whether the serum UA level at dialysis initiation is associated with mortality during maintenance dialysis. Methods We enrolled 1486 incident dialysis patients who participated in a previous multicenter prospective cohort study in Japan. We classified the patients into the following five groups according to their serum UA levels at dialysis initiation: G1 with a serum UA level <6 mg/dL; G2, 6.0–8.0 mg/dL; G3, 8.0–10.0 mg/dL; G4, 10.0–12.0 mg/dL; and G5, ≥12.0 mg/dL. We created three models (Model 1: adjusted for age and sex, Model 2: adjusted for Model 1 + 12 variables, and Model 3: stepwise regression adjusted for Model 2 + 13 variables) and performed a multivariate Cox proportional hazard regression analysis to examine the association between the serum UA level and outcomes, including infection-related mortality. Results Hazard ratios (HRs) were calculated relative to the G2, because the all-cause mortality rate was the lowest in G2. For Models 1 and 2, the all-cause mortality rate was significantly higher in G5 than in G2 (HR: 1.63, 95% confidence interval [CI]: 1.14–2.33 and HR: 1.78, 95% CI: 1.19–2.68, respectively). For Models 1, 2, and 3, the infection-related mortality rate was significantly higher in G5 than in G2 (HR: 2.75, 95% CI: 1.37–5.54, HR: 3.09, 95% CI: 1.45–6.59, HR: 3.37, and 95% CI: 1.24–9.15, respectively). Conclusions Extreme hyperuricemia (serum UA level ≥12.0 mg/dL) at dialysis initiation is a risk factor for infection-related deaths.
Collapse
Affiliation(s)
- Hiroyuki Yoshida
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Daijo Inaguma
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Eri Koshi-Ito
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Soshiro Ogata
- Faculty of Nursing, School of Health Sciences, Fujita Health University, Toyoake, Japan.,Department of Preventive Medicine & Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akimitsu Kitagawa
- Department of Nephrology, Fujita Health University, Bantane Hospital, Nagoya, Japan
| | - Kazuo Takahashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shigehisa Koide
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| |
Collapse
|
7
|
Timofte D, Dragos D, Balcangiu-Stroescu AE, Tanasescu MD, Gabriela Balan D, Raducu L, Jecan CR, Stiru O, Medrihan L, Ionescu D. Characteristics of patients at initiation of renal replacement therapy - experience of a hemodialysis center. Exp Ther Med 2020; 20:103-108. [PMID: 32509001 PMCID: PMC7271700 DOI: 10.3892/etm.2020.8608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 01/25/2023] Open
Abstract
The monitoring and care of patients with chronic kidney disease (CKD) before the dialysis initiation contribute to a better survival rate and an improvement in quality of life. The patients who do not benefit from a good predialysis management have a worse short and long-term prognosis. A retrospective, unicentric study was performed to evaluate the status of patients with stage 5 CKD at the time of initiation of renal replacement treatment. A total of 109 patients were included in the study. The evaluation of the patients included the clinical manifestations leading to hemodialysis initiation, the clinical and laboratory data of the patients when the hemodialysis was started. Based on the obtained data, a statistical analysis was performed using the Chi-square test, Fisher's exact test, ANOVA, and Kruskal-Wallis H test. The mean age of the patients was 64.61±13.59 years. Of the patients 51.38% were women. Vascular nephropathies and diabetes mellitus dominated the etiology of CKD. The comorbidities were high blood pressure, ischemic heart disease, history of myocardial infarction, heart failure, history of stroke, peripheral artery disease or atrial fibrillation. Only 43 (39.45%) of our patients were monitored before the hemodialysis initiation. Hemodialysis was initiated on central venous catheter (in most cases non-tunneled) in 78.90% of the patients. Most of the patients had an altered general status, fatigue/tiredness with poor exercise capacity when hemodialysis was initiated. Most of the patients (98.17%) had anemia, the average level of hemoglobin being 8.69±1.85 g/dl. In conclusion, careful monitoring of patients in the early stages of CKD would result in lower morbidity and mortality. These objectives can be achieved by implementing screening programs and early interventions.
Collapse
Affiliation(s)
- Delia Timofte
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
| | - Dorin Dragos
- Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Andra-Elena Balcangiu-Stroescu
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Maria-Daniela Tanasescu
- Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Daniela Gabriela Balan
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Laura Raducu
- Discipline of Plastic and Reconstructive Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Plastic and Reconstructive Surgery, Clinical Emergency Hospital ‘Prof. Dr. Agrippa Ionescu’, 011356 Bucharest, Romania
| | - Cristian-Radu Jecan
- Discipline of Plastic and Reconstructive Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Plastic and Reconstructive Surgery, Clinical Emergency Hospital ‘Prof. Dr. Agrippa Ionescu’, 011356 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Cardiovascular Surgery, ‘Prof. Dr. C. C. Iliescu’ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Lavinia Medrihan
- Department of Diabetology-Endocrinology-Nutrition, Lille University, 59019 Lille, France
| | - Dorin Ionescu
- Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| |
Collapse
|
8
|
Kaja Kamal RM, Farrington K, Busby AD, Wellsted D, Chandna H, Mawer LJ, Sridharan S, Vilar E. Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function. Nephrol Dial Transplant 2020; 34:1017-1025. [PMID: 30357360 DOI: 10.1093/ndt/gfy321] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters. METHODS We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD). RESULTS The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight. CONCLUSION 2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.
Collapse
Affiliation(s)
- Raja Mohammed Kaja Kamal
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Amanda D Busby
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Humza Chandna
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Laura J Mawer
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Sivakumar Sridharan
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Enric Vilar
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| |
Collapse
|
9
|
Yang FJ, Hou YH, Chang RE. The Impact of a Social Networking Service-Enhanced Smart Care Model on Stage 5 Chronic Kidney Disease: Quasi-Experimental Study. J Med Internet Res 2020; 22:e15565. [PMID: 32200348 PMCID: PMC7189249 DOI: 10.2196/15565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 01/30/2020] [Accepted: 03/22/2020] [Indexed: 11/17/2022] Open
Abstract
Background Stage 5 chronic kidney disease (CKD) presents a high risk for dialysis initiation and for complications such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding, and infection. One of the most common barriers to health care for patients with stage 5 CKD is poor continuity of care due to unresolved communication gaps. Objective Our aim was to establish a powerful care model that includes the use of a social networking service (SNS) to improve care quality for patients with CKD and safely delay dialysis initiation. Methods We used a retrospective cohort of CKD patients aged 20-85 years who received care between 2007 and 2017 to evaluate the efficacy of incorporating an SNS into the health care system. In 2014, author F-JY, a nephrologist at the National Taiwan University Hospital Yunlin Branch, started to use an SNS app to connect with stage 5 CKD patients and their families. In cases of emergency, patients and families could quickly report any condition to F-JY. Using this app, F-JY helped facilitate productive interactions between these patients and the health care system. The intention was to safely delay the initiation of dialysis therapy. We divided patients into four groups: group 1 (G1) included patients at the study hospital during the 2007-2014 period who had contact only with nephrologists other than F-JY; group 2 (G2) included patients who visited F-JY during the 2007-2014 period before he began using the SNS app; group 3 (G3) included patients who visited nephrologists other than F-JY during the 2014-2017 period and had no interactions using the SNS; and group 4 (G4) included patients who visited F-JY during the 2014-2017 period and interacted with him using the SNS app. Results We recruited 209 patients with stage 5 CKD who had been enrolled in the study hospital’s CKD program between 2007 and 2017. Each of the four groups initiated dialysis at different times. Before adjusting for baseline estimated glomerular filtration rate (eGFR), the G4 patients had a longer time to dialysis (mean 761.7 days, SD 616.2 days) than the other groups (G1: mean 403.6 days, SD 409.4 days, P=.011 for G4 vs G1; G2: 394.8 days, SD 318.8 days, P=.04; G3: 369.1 days, SD 330.8 days, P=.049). After adjusting for baseline eGFR, G4 had a longer duration for each eGFR drop (mean 84.8 days, SD 65.1 days) than the other groups (G1: mean 43.5 days, SD 45.4 days, P=.005; G2: mean 42.5 days, SD 26.5 days, P=.03; G3: mean 3.8.7 days, SD 33.5 days, P=.002). Conclusions The use of an SNS app between patients with stage 5 CKD and their physicians can reduce the communication gap between them and create benefits such as prolonging time-to-dialysis initiation. The role of SNSs and associated care models should be further investigated in a larger population.
Collapse
Affiliation(s)
- Feng-Jung Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun Lin Branch, Douliu, Taiwan.,School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Hui Hou
- Department Health Industry Management, School of Healthcare Management, Kainan University, Taoyuan, Taiwan
| | - Ray-E Chang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
10
|
Raimann JG, Chu FI, Kalloo S, Zhang H, Maddux F, Wang Y, Kotanko P. Delayed conversion from central venous catheter to non-catheter hemodialysis access associates with an increased risk of death: A retrospective cohort study based on data from a large dialysis provider. Hemodial Int 2020; 24:299-308. [PMID: 32141219 PMCID: PMC7496403 DOI: 10.1111/hdi.12831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
Background Hemodialysis initiation using a central venous catheter (CVC) poses an increased risk of death. Conversion to an arterio‐venous graft or fistula (AVF, AVG) improves outcomes. The relationship of primary dialysis access and timing of conversion from CVC to either AVF or AVG to all‐cause mortality was investigated. Methods Two retrospective analyses in incident hemodialysis patients commencing treatment from January 2010 to December 2014 in dialysis clinics in the United States were conducted. Analysis 1 stratified as per access at initiation and those commencing with CVC were further stratified into (a) those that had a CVC, AVF, or AVG the entire year; (b) those that were converted to either AVF or AVG within either (i) the first or (ii) the second 6 months. Kaplan Meier analysis and Cox regression analysis were employed. Analysis 2 included all CVC patients investigating the relationship between access conversion time and mortality risk using a Cox proportional hazards model depicting the hazard ratio (HR) as a spline function over time. Results Two subsets from initial 78,871 patients were studied. In Analysis 1 both AVF (referent) and AVG [HR 1.12 (0.97 to 1.30)] associated with a better outcome than CVC [HR 1.55 (1.38 to 1.74)] during follow‐up. Lower mortality risk was seen for early switch from a CVC to AV access within the first 6 months [HR = 1.04 (0.97–1.13)] compared to a later switch [HR = 1.23 (1.10–1.38)]. Analysis 2 indicated that a CVC to AVF switch resulted in improved survival. Analysis 2 indicated early conversion to confer a survival benefit for CVC to AVG switch. Discussion and Conclusion AVF and AVG show a survival benefit over CVC. Early conversion from CVC to either access improves survival. This emphasizes the importance of early preparation for dialysis by creation of an AVF or AVG and to convert CVCs early.
Collapse
Affiliation(s)
- Jochen G Raimann
- Research Division, Renal Research Institute, New York, New York, USA
| | - Fang-I Chu
- Department Radiation Oncology, University of California-Los Angeles, Los Angeles, California, USA.,Department of Statistics & Applied Probability, University of California-Santa Barbara, Santa Barbara, California, USA
| | - Sean Kalloo
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Hanjie Zhang
- Research Division, Renal Research Institute, New York, New York, USA
| | - Frank Maddux
- Global Medical Office, Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Yuedong Wang
- Department of Statistics & Applied Probability, University of California-Santa Barbara, Santa Barbara, California, USA
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York, USA.,Department of Nephrology, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| |
Collapse
|
11
|
Wong SPY, Boyapati S, Engelberg RA, Thorsteinsdottir B, Taylor JS, O'Hare AM. Experiences of US Nephrologists in the Delivery of Conservative Care to Patients With Advanced Kidney Disease: A National Qualitative Study. Am J Kidney Dis 2019; 75:167-176. [PMID: 31570175 DOI: 10.1053/j.ajkd.2019.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/05/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE It is relatively unusual for US patients with advanced chronic kidney disease (CKD) to forgo initiation of maintenance dialysis. Our objective was to describe practice approaches of US nephrologists who have provided conservative care for members of this population. STUDY DESIGN Qualitative study using semi-structured interviews. SETTING & PARTICIPANTS A national sample of 21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis. ANALYTICAL APPROACH Grounded theory methods to identify dominant themes reflecting nephrologists' experiences with and approaches to conservative care for patients with advanced CKD. RESULTS Nephrologists who participated in this study were primarily from academic practices (n=14) and urban areas (n=15). Two prominent themes emerged from qualitative analysis reflecting nephrologists' experiences with and approaches to conservative care: (1) person-centered practices, which described a holistic approach to care that included basing treatment decisions on what mattered most to individual patients, framing dialysis as an explicit choice, being mindful of sources of bias in medical decision making, and being flexible to the changing needs, values, and preferences of patients; and (2) improvising a care infrastructure, which described the challenges of managing patients conservatively within health systems that are not optimally configured to support their needs. Participating nephrologists described cobbling together resources, assuming a range of different health care roles, preparing patients to navigate health systems in which initiation of dialysis served as a powerful default, and championing the principles of conservative care among their colleagues. LIMITATIONS The themes identified likely are not generalizable to most US nephrologists. CONCLUSIONS Insights from a select group of US nephrologists who are early adopters of conservative care signal the need for a stronger cultural and health system commitment to building care models capable of supporting patients who choose to forgo dialysis.
Collapse
Affiliation(s)
- Susan P Y Wong
- Kidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA.
| | | | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | | | - Janelle S Taylor
- Department of Anthropology, University of Washington, Seattle, WA
| | - Ann M O'Hare
- Kidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA
| |
Collapse
|
12
|
Mc Causland FR, Claggett B, Sabbisetti VS, Jarolim P, Waikar SS. Hypertonic Mannitol for the Prevention of Intradialytic Hypotension: A Randomized Controlled Trial. Am J Kidney Dis 2019; 74:483-490. [PMID: 31040088 DOI: 10.1053/j.ajkd.2019.03.415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Intradialytic hypotension (IDH) is a common complication at the initiation of hemodialysis (HD) therapy, is associated with greater mortality, and may be related to relatively rapid shifts in plasma osmolality. This study sought to evaluate the effect of an intervention to minimize intradialytic changes in plasma osmolality on the occurrence of IDH. STUDY DESIGN Double-blind, single-center, randomized, controlled trial. SETTING & PARTICIPANTS Individuals requiring initiation of HD for acute or chronic kidney disease. INTERVENTION Mannitol, 0.25g/kg/h, versus a similar volume of 0.9% saline solution during the first 3 HD sessions. OUTCOMES The primary end point was average decline in systolic blood pressure (SBP). The secondary end point was the proportion of total sessions complicated by IDH (defined as a decrease ≥ 20mm Hg from the pre-HD SBP). Exploratory end points included biomarkers of cardiac and kidney injury. RESULTS 52 patients were randomly assigned and contributed to 156 study visits. There were no significant differences in average SBP decline between the mannitol and placebo groups (15±11 vs 19±16mm Hg; P = 0.3). The proportion of total sessions complicated by IDH was lower in the mannitol group compared to placebo (25% vs 43%), with a nominally lower risk for developing an episode of IDH (OR, 0.38; 95% CI, 0.14-1.00), though this finding was of borderline statistical significance (P = 0.05). There were no consistent differences in cardiac and kidney injury biomarker levels between treatment groups. LIMITATIONS Modest sample size and number of events. CONCLUSIONS In this pilot randomized controlled trial studying patients requiring initiation of HD, we found no difference in absolute SBP decline between those who received mannitol and those who received saline solution. However, there were fewer overall IDH events and a nominally lower risk for dialysis sessions being complicated by IDH in the mannitol group. A larger multicenter randomized controlled trial is warranted. FUNDING Government funding to an author (Dr Mc Causland is supported by National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK102511). TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT01520207.
Collapse
Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Brigham and Women's Hospital, Boston, MA.
| | - Brian Claggett
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Venkata S Sabbisetti
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Petr Jarolim
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Sushrut S Waikar
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
13
|
Chen YY, Chen L, Huang JW, Yang JY. Effects of Early Frequent Nephrology Care on Emergency Department Visits among Patients with End-stage Renal Disease. Int J Environ Res Public Health 2019; 16:E1158. [PMID: 30935119 PMCID: PMC6479768 DOI: 10.3390/ijerph16071158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 11/16/2022]
Abstract
In this retrospective cohort study, we examined the association between predialysis nephrology care status and emergency department (ED) events among patients with end-stage renal disease. Data pertaining to 76,702 patients who began dialysis treatment between 1999 and 2010 were obtained from the National Health Insurance Research Database of Taiwan (NHIRD). The patients were divided into three groups based on the timing of the first nephrology care visit prior to the initiation of maintenance dialysis, and the frequency of nephrologist visits (i.e., early referral/frequent consultation, early referral/infrequent consultation, late referral). At 1-year post-dialysis initiation, a large number of the patients had experienced at least one all-cause ED visit (58%), infection-related ED visit (17%), or potentially avoidable ED visit (7%). Cox proportional hazard models revealed that patients who received early frequent care faced an 8% lower risk of all-cause ED visit (HR: 0.92; 95% CI: 0.90⁻0.94), a 24% lower risk of infection-related ED visit (HR: 0.76; 95% CI: 0.73⁻0.79), and a 24% lower risk of avoidable ED visit (HR: 0.76; 95% CI: 0.71⁻0.81), compared with patients in the late referral group. With regard to the patients undergoing early infrequent consultations, the only marginally significant association was for infection-related ED visits. Recurrent event analysis revealed generally consistent results. Overall, these findings indicate that continuous nephrology care from early in the predialysis period could reduce the risk of ED utilization in the first year of dialysis treatment.
Collapse
Affiliation(s)
- Yun-Yi Chen
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei 100, Taiwan.
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan 350, Taiwan.
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Ju-Yeh Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei 100, Taiwan.
- Division of Nephrology, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan.
- Department of Quality Management Center, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan.
- Lee-Ming Institute of Technology, New Taipei City 243, Taiwan.
| |
Collapse
|
14
|
Mc Causland FR, Claggett B, Burdmann EA, Chertow GM, Cooper ME, Eckardt KU, Ivanovich P, Levey AS, Lewis EF, McGill JB, McMurray JJV, Parfrey P, Parving HH, Remuzzi G, Singh AK, Solomon SD, Toto RD, Pfeffer MA. Treatment of Anemia With Darbepoetin Prior to Dialysis Initiation and Clinical Outcomes: Analyses From the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT). Am J Kidney Dis 2018; 73:309-315. [PMID: 30578152 DOI: 10.1053/j.ajkd.2018.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022]
Abstract
RATIONALE & OBJECTIVE Evidence from clinical trials to guide patient preparation for maintenance dialysis therapy is limited. Although anemia is associated with mortality and cardiovascular (CV) disease in individuals initiating maintenance dialysis therapy, it is not known if treatment of anemia before dialysis therapy initiation with erythropoiesis-stimulating agents alters outcomes. STUDY DESIGN Post hoc analysis of a randomized controlled trial. SETTING & PARTICIPANTS Participants with type 2 diabetes and chronic kidney disease who progressed to dialysis therapy (n=590) in the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT). EXPOSURE Randomized treatment assignment (darbepoetin vs placebo). OUTCOMES All-cause mortality, CV mortality, nonfatal myocardial infarction, heart failure, and stroke within the first 180 days of dialysis therapy initiation. ANALYTICAL APPROACH Proportional hazards regression. RESULTS Overall, 590 of 4,038 (14.6%) participants initiated dialysis therapy during the trial (n=298 and 292 in the darbepoetin and placebo groups, respectively). Corresponding hemoglobin levels were 11.3±1.6 and 9.5±1.5g/dL (P<0.001). Death from any cause occurred in 31 (10.4%) participants assigned to darbepoetin and 28 (9.6%) assigned to placebo (HR, 1.16; 95% CI, 0.69-1.93), while death from CV causes occurred in 15 (5.0%) and 13 (4.5%) participants, respectively (HR, 1.21; 95% CI, 0.58-1.93). There were no differences in risk for nonfatal myocardial infarction or heart failure. Stroke occurred in 8 (2.8%) participants assigned to darbepoetin and 1 (0.3%) assigned to placebo (HR, 8.6; 95% CI, 1.1-68.7). LIMITATIONS Post hoc analyses of a subgroup of study participants. CONCLUSIONS Despite initiating dialysis therapy with a higher hemoglobin level, prior treatment with darbepoetin was not associated with a reduction in mortality, myocardial infarction, or heart failure in the first 180 days, but a higher frequency of stroke was observed. In the absence of more definitive data, this may inform decisions regarding the use of erythropoiesis-stimulating agents to treat mild to moderate anemia in patients with type 2 diabetes and chronic kidney disease nearing dialysis therapy initiation.
Collapse
Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Brian Claggett
- Harvard Medical School, Boston, MA; Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Emmanuel A Burdmann
- Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mark E Cooper
- Monash University Central Clinical School, Melbourne, VIC, Australia
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Eldrin F Lewis
- Harvard Medical School, Boston, MA; Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Janet B McGill
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Patrick Parfrey
- Health Sciences Centre, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Hans-Henrik Parving
- Department of Medical Endocrinology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri; Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Ajay K Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Scott D Solomon
- Harvard Medical School, Boston, MA; Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Robert D Toto
- Renal Division, University of Texas Southwestern, Dallas, TX
| | - Marc A Pfeffer
- Harvard Medical School, Boston, MA; Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
15
|
Owaki A, Inaguma D, Aoyama I, Inaba S, Koide S, Ito E, Takahashi K, Hayashi H, Hasegawa M, Yuzawa Y. Serum phosphate level at initiation of dialysis is associated with all-cause mortality: a multicenter prospective cohort study. Ren Fail 2018; 40:475-482. [PMID: 30153079 PMCID: PMC6116670 DOI: 10.1080/0886022x.2018.1499530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction: As glomerular filtration rate (GFR) decreases, serum phosphate level increases. Previous reports indicated that serum phosphate level was associated with mortality in patients on dialysis. However, few reports have examined the association using dialysis initiation as the baseline period. Methods: This was a multicenter prospective cohort analysis including 1492 patients. Patients were classified into four quartiles based on the serum phosphate level at dialysis initiation, with Q1 being the lowest and Q4 the highest. All-cause mortality after dialysis initiation was compared using the log-rank test. The propensity score represented the probability of being assigned to group Q1 or Q2–4. All-cause mortality was compared in propensity score-matched patients by using the log-rank test for Kaplan–Meier curves. All-cause mortality of Q1 was compared with that for Q2–4 using multivariate Cox proportional hazard regression analysis. All-cause mortality was also determined among stratified groups with or without use of phosphate binders. Results: Significant differences in cumulative survival rates were observed between the four groups (p < .001). After propensity score-matching, mortality was significantly higher in the Q1 group than the Q2-4 group (p = .046). All-cause mortality was significantly higher in the Q1 group after adjustment for history of CAD (hazard ratio [HR] = 0.76, 95% confidence interval [CI]: 0.58 − 1.00, p = .048). However, there was no significant difference between the two groups after adjustment for estimated GFR. Conclusion: The serum phosphate level at the time of dialysis initiation was associated with all-cause mortality. However, the serum phosphate level was dependent on the renal function.
Collapse
Affiliation(s)
- Akiko Owaki
- a Tosei General Hospital , Seto , Aichi , Japan.,b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group
| | - Daijo Inaguma
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Isao Aoyama
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,d Japan Community Health Care Organization Chukyo Hospital , Nagoya , Aichi , Japan
| | | | - Shigehisa Koide
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Eri Ito
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Kazuo Takahashi
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Hiroki Hayashi
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Midori Hasegawa
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Yukio Yuzawa
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | | |
Collapse
|
16
|
Javaid MM, Khan BA, Yeo XEE, Teo BW, Subramanian S. Sustained Increase in Peritoneal Dialysis Prevalence through a Structured PD Initiation Service. ARCH ESP UROL 2018; 38:374-376. [PMID: 30185478 DOI: 10.3747/pdi.2017.00261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A structured peritoneal dialysis (PD) initiation service provided by a dedicated team of nephrologists, interventionists, and PD nurses, taking patients through the stages of predialysis education and monitoring, dialysis catheter insertion, dialysis initiation, and follow-up in the immediate post-dialysis initiation period, can go a long way in expanding PD prevalence. The authors noticed a rapid expansion of their PD program following the introduction of such a service, and they share their experience in this article. A multidisciplinary team providing 1-stop coordinated care may help in alleviating the differences in patient selection criteria, minimize delays in PD catheter insertions, ensure timely initiation of dialysis, reduce the need to start dialysis urgently, actively identify and sort any teething issues, enhance patients' confidence, and reduce technique failures.
Collapse
Affiliation(s)
- Muhammad Masoom Javaid
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Mildura Base Hospital, Victoria, Australia
| | - Behram Ali Khan
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Xi Er Emily Yeo
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore
| | - Boon Wee Teo
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Srinivas Subramanian
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
17
|
Rhee CM, Kovesdy CP, You AS, Sim JJ, Soohoo M, Streja E, Molnar MZ, Amin AN, Abbott K, Nguyen DV, Kalantar-Zadeh K. Hypoglycemia-Related Hospitalizations and Mortality Among Patients With Diabetes Transitioning to Dialysis. Am J Kidney Dis 2018; 72:701-710. [PMID: 30037725 DOI: 10.1053/j.ajkd.2018.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/27/2018] [Indexed: 12/17/2022]
Abstract
RATIONALE & OBJECTIVE Diabetic patients with declining kidney function are at heightened risk for hypoglycemia. We sought to determine whether hypoglycemia-related hospitalizations in the interval before dialysis therapy initiation are associated with post-end-stage renal disease (ESRD) mortality among incident patients with ESRD with diabetes. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS US veterans from the national Veterans Affairs database with diabetes and chronic kidney disease transitioning to dialysis therapy from October 2007 to September 2011. EXPOSURE Hypoglycemia-related hospitalizations during the pre-ESRD period and antidiabetic medication regimens. OUTCOME The outcome of post-ESRD all-cause mortality was evaluated relative to pre-ESRD hypoglycemia. The outcome of pre-ESRD hypoglycemia-related hospitalization was evaluated relative to antidiabetic medication regimens. ANALYTIC APPROACH We examined whether the occurrence and frequency of pre-ESRD hypoglycemia-related hospitalizations are associated with post-ESRD mortality using Cox regression models adjusted for case-mix covariates. In a subcohort of patients prescribed 0 to 2 oral antidiabetic drugs and/or insulin, we examined the 12 most commonly prescribed antidiabetic medication regimens and risk for pre-ESRD hypoglycemia-related hospitalization using logistic regression models adjusted for case-mix covariates. RESULTS Among 30,156 patients who met eligibility criteria, the occurrence of pre-ESRD hypoglycemia-related hospitalization(s) was associated with higher post-ESRD mortality risk: adjusted HR (aHR), 1.25; 95% CI, 1.17-1.34 (reference group: no hypoglycemia hospitalization). Increasing frequency of hypoglycemia-related hospitalizations was independently associated with incrementally higher mortality risk: aHRs of 1.21 (95% CI, 1.12-1.30), 1.47 (95% CI, 1.19-1.82), and 2.07 (95% CI, 1.46-2.95) for 1, 2, and 3 or more hypoglycemia-related hospitalizations, respectively (reference group: no hypoglycemia hospitalization). Compared with patients who were prescribed neither oral antidiabetic drugs nor insulin, medication regimens that included sulfonylureas and/or insulin were associated with higher risk for hypoglycemia. LIMITATIONS Residual confounding cannot be excluded. CONCLUSIONS Among incident patients with ESRD with diabetes, a dose-dependent relationship between frequency of pre-ESRD hypoglycemia-related hospitalizations and post-ESRD mortality was observed. Further study of diabetic management strategies that prevent hypoglycemia as patients with chronic kidney disease transition to ESRD are warranted.
Collapse
Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA.
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - John J Sim
- Kaiser Permanente of Southern California, Los Angeles, CA
| | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Kevin Abbott
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| |
Collapse
|
18
|
Lee T, Qian J, Thamer M, Allon M. Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter. Am J Kidney Dis 2018; 72:509-518. [PMID: 29784614 DOI: 10.1053/j.ajkd.2018.03.023] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/13/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. STUDY DESIGN Retrospective cohort study using national administrative data. SETTINGS & PARTCIPANTS Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n=7,433) or AVG (n=2,025) within the ensuing 6 months. PREDICTOR Arteriovenous access subtype, AVF or AVG. OUTCOMES Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access. ANALYTICAL APPROACH Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access. RESULTS Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P<0.001). LIMITATIONS Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period. CONCLUSIONS In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).
Collapse
Affiliation(s)
- Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL; Veterans Affairs Medical Center, Birmingham, AL.
| | - Joyce Qian
- Medical Technology and Practice Patterns Institute, Bethesda, MD
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, MD
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL
| |
Collapse
|
19
|
Bansal N, Roy J, Chen HY, Deo R, Dobre M, Fischer MJ, Foster E, Go AS, He J, Keane MG, Kusek JW, Mohler E, Navaneethan SD, Rahman M, Hsu CY. Evolution of Echocardiographic Measures of Cardiac Disease From CKD to ESRD and Risk of All-Cause Mortality: Findings From the CRIC Study. Am J Kidney Dis 2018; 72:390-399. [PMID: 29784617 DOI: 10.1053/j.ajkd.2018.02.363] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 02/24/2018] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Abnormal cardiac structure and function are common in chronic kidney disease (CKD) and end-stage renal disease (ESRD) and linked with mortality and heart failure. We examined changes in echocardiographic measures during the transition from CKD to ESRD and their associations with post-ESRD mortality. STUDY DESIGN Prospective study. SETTING & PARTICIPANTS We studied 417 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) who had research echocardiograms during CKD and ESRD. PREDICTOR We measured change in left ventricular mass index, left ventricular ejection fraction (LVEF), diastolic relaxation (normal, mildly abnormal, and moderately/severely abnormal), left ventricular end-systolic (LVESV), end-diastolic (LVEDV) volume, and left atrial volume from CKD to ESRD. OUTCOMES All-cause mortality after dialysis therapy initiation. ANALYTICAL APPROACH Cox proportional hazard models were used to test the association of change in each echocardiographic measure with postdialysis mortality. RESULTS Over a mean of 2.9 years between pre- and postdialysis echocardiograms, there was worsening of mean LVEF (52.5% to 48.6%; P<0.001) and LVESV (18.6 to 20.2mL/m2.7; P<0.001). During this time, there was improvement in left ventricular mass index (60.4 to 58.4g/m2.7; P=0.005) and diastolic relaxation (11.11% to 4.94% with moderately/severely abnormal; P=0.02). Changes in left atrial volume (4.09 to 4.15mL/m2; P=0.08) or LVEDV (38.6 to 38.4mL/m2.7; P=0.8) were not significant. Worsening from CKD to ESRD of LVEF (adjusted HR for every 1% decline in LVEF, 1.03; 95% CI, 1.00-1.06) and LVESV (adjusted HR for every 1mL/m2.7 increase, 1.04; 95% CI, 1.02-1.07) were independently associated with greater risk for postdialysis mortality. LIMITATIONS Some missing or technically inadequate echocardiograms. CONCLUSIONS In a longitudinal study of patients with CKD who subsequently initiated dialysis therapy, LVEF and LVESV worsened and were significantly associated with greater risk for postdialysis mortality. There may be opportunities for intervention during this transition period to improve outcomes.
Collapse
Affiliation(s)
| | - Jason Roy
- University of Pennsylvania, Philadelphia, PA
| | | | - Rajat Deo
- University of Pennsylvania, Philadelphia, PA
| | - Mirela Dobre
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Michael J Fischer
- Center of Innovation for Complex Chronic Healthcare, Edward Hines VA Hospital and Jesse Brown VAMC And University of Illinois at Chicago, Chicago, IL
| | - Elyse Foster
- University of California, San Francisco, San Francisco, CA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland; University of California, San Francisco, San Francisco, CA
| | - Jiang He
- Tulane University, New Orleans, LA
| | | | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | | | - Mahboob Rahman
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Chi-Yuan Hsu
- Division of Research, Kaiser Permanente Northern California, Oakland; University of California, San Francisco, San Francisco, CA
| | | |
Collapse
|
20
|
Ku E, Kopple JD, Johansen KL, McCulloch CE, Go AS, Xie D, Lin F, Hamm LL, He J, Kusek JW, Navaneethan SD, Ricardo AC, Rincon-Choles H, Smogorzewski M, Hsu CY. Longitudinal Weight Change During CKD Progression and Its Association With Subsequent Mortality. Am J Kidney Dis 2017; 71:657-665. [PMID: 29217305 DOI: 10.1053/j.ajkd.2017.09.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/12/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Few studies have investigated the changes in weight that may occur over time among adults with the progression of chronic kidney disease (CKD). Whether such weight changes are independently associated with death after the onset of end-stage renal disease has also not been rigorously examined. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS We studied 3,933 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study, a longitudinal cohort of patients with CKD. We also performed similar analyses among 1,067 participants of the African American Study of Kidney Disease and Hypertension (AASK). PREDICTORS Estimated glomerular filtration rate (eGFR) and weight change during CKD. OUTCOME Weight and all-cause mortality after dialysis therapy initiation. RESULTS During a median follow-up of 5.7 years in CRIC, weight change was not linear. Weight was stable until cystatin C-based eGFR (eGFRcys) decreased to <35mL/min/1.73m2; thereafter, weight declined at a mean rate of 1.45 kg (95% CI, 1.19-1.70) for every 10 mL/min/1.73m2 decline in eGFRcys. Among the 770 CRIC participants who began hemodialysis or peritoneal dialysis therapy during follow-up, a >5% annualized weight loss after eGFR decreased to <35mL/min/1.73m2 was associated with a 54% higher risk for death after dialysis therapy initiation (95% CI, 1.17-2.03) compared with those with more stable weight (annualized weight changes within 5% of baseline) in adjusted analysis. Similar findings were observed in the AASK. LIMITATIONS Inclusion of research participants only; inability to distinguish intentional versus unintentional weight loss. CONCLUSIONS Significant weight loss began relatively early during the course of CKD and was associated with a substantially higher risk for death after dialysis therapy initiation. Further studies are needed to determine whether interventions to optimize weight and nutritional status before the initiation of dialysis therapy will improve outcomes after end-stage renal disease.
Collapse
Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
| | - Joel D Kopple
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, and University of California, Los Angeles Schools of Medicine and Public Health, Los Angeles, CA
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - L Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - John W Kusek
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | | | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Hernan Rincon-Choles
- Glickman Urological and Kidney Institute, Department of Nephrology, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | |
Collapse
|
21
|
Affiliation(s)
- Gavril Hercz
- Division of Nephrology, Humber River Hospital, Canadian Psychoanalytic Society, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Ravel VA, Soohoo M, Rhee CM, Streja E, Sim JJ, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality. Am J Kidney Dis 2017; 70:207-217. [PMID: 28291617 PMCID: PMC5526740 DOI: 10.1053/j.ajkd.2016.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/19/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. PREDICTOR Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160mmHg in 10-mmHg increments) and 5 (<60 to ≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures. OUTCOMES & MEASUREMENTS Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. RESULTS Mean predialysis SBP and DBP were 141.2±16.1 (SD) and 73.7±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. LIMITATIONS Results cannot be inferred to show causality and may not be generalizable to women or the general US population. CONCLUSIONS Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.
Collapse
Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa; Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - 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
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN.
| |
Collapse
|
23
|
Rivara MB, Chen CH, Nair A, Cobb D, Himmelfarb J, Mehrotra R. Indication for Dialysis Initiation and Mortality in Patients With Chronic Kidney Failure: A Retrospective Cohort Study. Am J Kidney Dis 2017; 69:41-50. [PMID: 27637132 DOI: 10.1053/j.ajkd.2016.06.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/29/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Initiation of maintenance dialysis therapy for patients with chronic kidney failure is a period of high risk for adverse patient outcomes. Whether indications for dialysis therapy initiation are associated with mortality in this population is unknown. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 461 patients who initiated dialysis therapy (hemodialysis, 437; peritoneal dialysis, 24) from January 1, 2004, through December 31, 2012, and were treated in facilities operated by a single dialysis organization. Follow-up for the primary outcome was through December 31, 2013. PREDICTOR Clinically documented primary indication for dialysis therapy initiation, as categorized into 4 groups: laboratory evidence of kidney function decline (reference category), uremic symptoms, volume overload or hypertension, and other/unknown. OUTCOMES All-cause mortality. RESULTS During a median follow-up of 2.4 years, 183 (40%) patients died. Crude mortality rates were 10.0 (95% CI, 6.8-14.7), 12.7 (95% CI, 10.2-15.7), 21.7 (95% CI, 16.4-28.6), and 12.2 (95% CI, 6.8-14.7) deaths/100 patient-years among patients initiating dialysis therapy primarily for laboratory evidence of kidney function decline, uremic symptoms, volume overload or hypertension, and other/unknown reason, respectively. Following adjustment for demographic variables, coexisting illnesses, and estimated glomerular filtration rate, initiation of dialysis therapy for uremic symptoms, volume overload or hypertension, or other/unknown reasons was associated with 1.12 (95% CI, 0.72-1.77), 1.69 (95% CI, 1.02-2.80), and 1.28 (95% CI, 0.73-2.26) times higher risk, respectively, for subsequent mortality compared to initiation for laboratory evidence of kidney function decline. LIMITATIONS Possibility of residual confounding by unmeasured variables; reliance on clinical documentation to ascertain exposure. CONCLUSIONS Patients initiating dialysis therapy due to volume overload may have increased risk for mortality compared with patients initiating dialysis due to laboratory evidence of kidney function decline. Further studies are needed to identify and test interventions that might reduce this risk.
Collapse
Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA.
| | - Chang Huei Chen
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Anupama Nair
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | | | - Jonathan Himmelfarb
- Kidney Research Institute, Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Rajnish Mehrotra
- Kidney Research Institute, Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
24
|
Abstract
The United States Renal Data System (USRDS) registry of end-stage renal disease has often been used to study the timing of dialysis initiation, measured by estimated glomerular filtration rate (eGFR) at dialysis initiation. We conducted an observational study and examined how well variables in the USRDS database explain the trends and variation in eGFR at dialysis initiation.We identified 971,481 patients who initiated dialysis between 1995 and 2012 in the USRDS registry.The mean eGFR at dialysis initiation monotonically rose from 7.7 in 1995 to 11.1 in 2009, and then leveled off to 10.9 mL/min/1.73 m in 2012. The trend of rising, then leveling off was similar across all subgroups studied. Substantial variation in eGFR at dialysis initiation was observed, with standard deviation of 4.38 (95% CI: 2.0-18.4). A total of 11.4% of the total variation occurred across physicians and 88.6% within physicians. Adjustment for measured factors only modestly decreased the total variation. Of the total variance, 10.7% was explained by measured patient-level variables and 1.2% by measured physician and other factors, while 9.2% of physician-level variation and 78.9% of patient-level variation remained unexplained. The extent of variation explained by measured variables was similar over the entire study period.The finding that the majority of variation in eGFR at dialysis initiation is unexplained by measured variables casts doubt on how well eGFR serves as a measure for "timing" of dialysis initiation, and it indicates the need to collect more focused data to gain understanding of factors that affect timing of dialysis initiation in the US.
Collapse
Affiliation(s)
- Yun Li
- Arbor Research Collaborative for Health
- University of Michigan, Ann Arbor, MI, USA
| | - Yan Jin
- Arbor Research Collaborative for Health
| | | | | | | | | | - Bruce M. Robinson
- Arbor Research Collaborative for Health
- University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
25
|
Inaguma D, Koide S, Takahashi K, Hayashi H, Hasegawa M, Yuzawa Y. Association between resting heart rate just before starting the first dialysis session and mortality: A multicentre prospective cohort study. Nephrology (Carlton) 2017; 23:461-468. [PMID: 28332737 DOI: 10.1111/nep.13048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/10/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
Abstract
AIM Some observational studies of the general population showed that resting heart rate was associated with mortality. However, the relationship was unclear in dialysis patients. METHODS The study was a multicentre prospective cohort analysis including 1102 patients. Patients were classified into four groups based on resting heart rate just before starting the first dialysis session: <60/min; 60-79/min; 80-100/min; and ≥101/min. All-cause mortality, cardiovascular (CV) related mortality, and incidences of CV events after dialysis initiation were compared using the log-rank test. All-cause mortality rates for patients with heart rates <60, 60-79, and ≥101/min were compared to those for patients with heart rates 80-100/min, using multivariate Cox proportional hazard regression analysis. Moreover, we compared the outcomes among patients without use of β-blocker or heart failure symptom at the first dialysis session. RESULTS Significant differences were observed in the all-cause mortality rates among the four groups (P = 0.007). Multivariate analysis revealed that all-cause mortality was significantly higher in patients with heart rate ≥ 101/min than in patients with heart rate 80-100/min (hazard ratio [HR] = 2.30, 95% confidence interval [CI]: 1.25-4.23). Subgroup analysis showed that among patients without use of b-blocker or heart failure symptom, all-cause mortality rates for those with heart rates ≥101/min were significantly higher than in patients with heart rate 80-100/min (HR = 2.98, 95% CI: 1.51-5.88, HR = 3.65, 95% CI: 1.59-8.36, respectively). CONCLUSION The resting heart rate just before starting the first dialysis session was associated with all-cause mortality after dialysis initiation.
Collapse
Affiliation(s)
- Daijo Inaguma
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan.,The Aichi Cohort Study of Prognosis in Patients Newly Initiated Into Dialysis (AICOPP) Group
| | - Shigehisa Koide
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan.,The Aichi Cohort Study of Prognosis in Patients Newly Initiated Into Dialysis (AICOPP) Group
| | - Kazuo Takahashi
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hiroki Hayashi
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Midori Hasegawa
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yukio Yuzawa
- Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | | |
Collapse
|
26
|
Plantinga LC, Patzer RE, Franch HA, Bowling CB. Serious Fall Injuries Before and After Initiation of Hemodialysis Among Older ESRD Patients in the United States: A Retrospective Cohort Study. Am J Kidney Dis 2017; 70:76-83. [PMID: 28139394 DOI: 10.1053/j.ajkd.2016.11.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/27/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Because initiation of dialysis therapy often occurs in the setting of acute illness and may signal worsening health and functional decline, we examined whether rates of serious fall injuries among older hemodialysis patients differ before and after dialysis therapy initiation. STUDY DESIGN Retrospective cohort study of claims data from the 2 years spanning dialysis therapy initiation among patients initiating dialysis therapy in 2010 to 2012. SETTING & PARTICIPANTS Claims from 81,653 Medicare end-stage renal disease beneficiaries aged 67 to 100 years. PREDICTOR Post- versus pre-dialysis therapy initiation periods, defined as on or after versus before dialysis therapy initiation. OUTCOMES Serious fall injuries were defined using diagnostic codes for falls in combination with fractures, brain injuries, or joint dislocation. Incidence rate ratios (overall and stratified) for post- versus pre-dialysis therapy initiation periods were estimated using generalized estimating equation models with a negative binomial link. RESULTS Overall, 12,757 serious fall injuries occurred in the pre- and post-dialysis therapy initiation periods. Annual rates of serious fall injuries were 64.4 (95% CI, 62.7-66.2) and 107.8 (95% CI, 105.4-110.3) per 1,000 patient-years, respectively, in the pre- and post-dialysis therapy initiation periods (incidence rate ratio, 1.62; 95% CI, 1.56-1.67). Relative rates of serious fall injuries in the post- vs pre-dialysis initiation periods were of greater magnitude among patients who were younger (<75 years), had pre-end-stage renal disease nephrology care, had albumin levels > 3g/dL, were able to walk and transfer, did not need assistance with activities of daily living, and were not institutionalized compared with relative rates among their counterparts. LIMITATIONS Potential misclassification due to the use of claims data and survival bias among those initiating hemodialysis therapy. CONCLUSIONS Among older Medicare beneficiaries receiving hemodialysis, serious fall injuries are common, the post-dialysis initiation period is a high-risk time for falls, and dialysis therapy initiation may be an important time to screen for fall risk factors and implement multifactorial fall prevention strategies.
Collapse
Affiliation(s)
- Laura C Plantinga
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA.
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University, Atlanta, GA
| | - Harold A Franch
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - C Barrett Bowling
- Birmingham/Atlanta VA Geriatrics Research, Education, and Clinical Center, Decatur; Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA
| |
Collapse
|
27
|
Wick JP, Turin TC, Faris PD, MacRae JM, Weaver RG, Tonelli M, Manns BJ, Hemmelgarn BR. A Clinical Risk Prediction Tool for 6-Month Mortality After Dialysis Initiation Among Older Adults. Am J Kidney Dis 2016; 69:568-575. [PMID: 27856091 DOI: 10.1053/j.ajkd.2016.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 08/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Information on an individual's risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. STUDY DESIGN Prediction model using retrospective administrative and clinical data. SETTING & PARTICIPANTS We linked administrative and clinical data to define a cohort of 2,199 older adults (age ≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March 2012. CANDIDATE PREDICTORS Demographics, laboratory data, comorbid conditions, and measures of health system use. OUTCOMES All-cause mortality within 6 months of dialysis therapy initiation. ANALYTICAL APPROACH Predicted mortality by logistic regression with 10-fold cross-validation. RESULTS 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9mL/min/1.73m2 (1 point) or ≥15mL/min/1.73m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic = 0.72) and calibration (Hosmer-Lemeshow χ2=10.36; P=0.2) were reasonable. As examples, a score < 5 equated to <25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. LIMITATIONS The tool has not been externally validated; thus, generalizability cannot be assessed. CONCLUSIONS We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.
Collapse
Affiliation(s)
- James P Wick
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Tanvir C Turin
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Peter D Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jennifer M MacRae
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Braden J Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| |
Collapse
|
28
|
Obi Y, Streja E, Rhee CM, Ravel V, Amin AN, Cupisti A, Chen J, Mathew AT, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study. Am J Kidney Dis 2016; 68:256-265. [PMID: 26867814 PMCID: PMC4969165 DOI: 10.1053/j.ajkd.2016.01.008] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/04/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF. STUDY DESIGN A longitudinal cohort. SETTING & PARTICIPANTS 23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year. PREDICTOR Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time. OUTCOMES Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year. RESULTS Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d. LIMITATIONS Potential selection bias and wide CIs. CONCLUSIONS Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.
Collapse
Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Vanessa Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine, Orange, CA
| | - Adamasco Cupisti
- Division of Nephrology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Yangpu, Shanghai, China
| | - Anna T Mathew
- Hofstra North Shore-LIJ School of Medicine, Division of Kidney Diseases and Hypertension, North Shore-LIJ Health System, Great Neck, NY
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA; Fielding School of Public Health at UCLA, Los Angeles, CA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.
| |
Collapse
|
29
|
Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ. Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis 2016; 66:823-36. [PMID: 26498415 DOI: 10.1053/j.ajkd.2014.11.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND In 2006, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) published clinical practice guidelines for hemodialysis adequacy. Recent studies evaluating hemodialysis adequacy as determined by initiation timing, frequency, duration, and membrane type and prompted an update to the guideline. STUDY DESIGN Systematic review and evidence synthesis. SETTING & POPULATION Patients with advanced chronic kidney disease receiving hemodialysis. SELECTION CRITERIA FOR STUDIES We screened publications from 2000 to March 2014, systematic reviews, and references and consulted the NKF-KDOQI Hemodialysis Adequacy Work Group members. We included randomized or controlled clinical trials in patients undergoing long-term hemodialysis if they reported outcomes of interest. INTERVENTIONS Early versus late dialysis therapy initiation; more frequent (>3 times a week) or longer duration (>4.5 hours) compared to conventional hemodialysis; low- versus high-flux dialyzer membranes. OUTCOMES All-cause and cardiovascular mortality, myocardial infarction, stroke, hospitalizations, quality of life, depression or cognitive function scores, blood pressure, number of antihypertensive medications, left ventricular mass, interdialytic weight gain, and harms or complications related to vascular access or the process of dialysis. RESULTS We included 32 articles reporting on 19 trials. Moderate-quality evidence indicated that earlier dialysis therapy initiation (at estimated creatinine clearance [eClcr] of 10-14mL/min) did not reduce mortality compared to later initiation (eClcr of 5-7mL/min). More than thrice-weekly hemodialysis and extended-length hemodialysis during a short follow-up did not improve clinical outcomes compared to conventional hemodialysis and resulted in a greater number of vascular access procedures (very low-quality evidence). Hemodialysis using high-flux membranes did not reduce all-cause mortality, but reduced cardiovascular mortality compared to hemodialysis using low-flux membranes (moderate-quality evidence). LIMITATIONS Few studies were adequately powered to evaluate mortality. Heterogeneity of study designs and interventions precluded pooling data for most outcomes. CONCLUSIONS Limited data indicate that earlier dialysis therapy initiation and more frequent and longer hemodialysis did not improve clinical outcomes compared to conventional hemodialysis.
Collapse
Affiliation(s)
- Yelena Slinin
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN.
| | - Nancy Greer
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Areef Ishani
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Carin Olson
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Indulis Rutks
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Timothy J Wilt
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN
| |
Collapse
|
30
|
Thamer M, Kaufman JS, Zhang Y, Zhang Q, Cotter DJ, Bang H. Predicting Early Death Among Elderly Dialysis Patients: Development and Validation of a Risk Score to Assist Shared Decision Making for Dialysis Initiation. Am J Kidney Dis 2015; 66:1024-32. [PMID: 26123861 PMCID: PMC4658211 DOI: 10.1053/j.ajkd.2015.05.014] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/05/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND A shared decision-making tool could help elderly patients with advanced chronic kidney disease decide about initiating dialysis therapy. Because mortality may be high in the first few months after initiating dialysis therapy, incorporating early mortality predictors in such a tool would be important for an informed decision. Our objective is to derive and validate a predictive risk score for early mortality after initiating dialysis therapy. STUDY DESIGN Retrospective observational cohort, with development and validation cohorts. SETTING & PARTICIPANTS US Renal Data System and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) patients with end-stage renal disease with a previous 2-year Medicare history who initiated dialysis therapy from January 1, 2009, to December 31, 2010. CANDIDATE PREDICTORS Demographics, predialysis care, laboratory data, functional limitations, and medical history. OUTCOMES All-cause mortality in the first 3 and 6 months. ANALYTICAL APPROACH Predicted mortality by logistic regression. RESULTS The simple risk score (total score, 0-9) included age (0-3 points), low albumin level, assistance with daily living, nursing home residence, cancer, heart failure, and hospitalization (1 point each), and showed area under the receiver operating characteristic curve (AUROC)=0.69 in the validation sample. A comprehensive risk score with additional predictors was also developed (with AUROC=0.72, high concordance between predicted vs observed risk). Mortality probabilities were estimated from these models, with the median score of 3 indicating 12% risk in 3 months and 20% in 6 months, and the highest scores (≥8) indicating 39% risk in 3 months and 55% in 6 months. LIMITATIONS Patients who did not choose dialysis therapy and did not have a 2-year Medicare history were excluded. CONCLUSIONS Routinely available information can be used by patients with chronic kidney disease, families, and their nephrologists to estimate the risk of early mortality after dialysis therapy initiation, which may facilitate informed decision making regarding treatment options.
Collapse
Affiliation(s)
- Mae Thamer
- Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD 20816
| | - James S. Kaufman
- VA NY Harbor Healthcare System and New York University School of Medicine, 423 East 23 St, New York, NY 10010
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD 20816
| | - Qian Zhang
- Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD 20816
| | - Dennis J. Cotter
- Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD 20816
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California at Davis, One Shields Ave, Med-Sci 1C, Davis, CA 95616
| |
Collapse
|
31
|
Yu MK, O'Hare AM, Batten A, Sulc CA, Neely EL, Liu CF, Hebert PL. Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs. Clin J Am Soc Nephrol 2015. [PMID: 26206891 DOI: 10.2215/cjn.12731214] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2). RESULTS The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001). CONCLUSIONS Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.
Collapse
Affiliation(s)
- Margaret K Yu
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington
| | - Ann M O'Hare
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington
| | - Adam Batten
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Christine A Sulc
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Emily L Neely
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Chuan-Fen Liu
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and
| | - Paul L Hebert
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and
| |
Collapse
|
32
|
O'Hare AM, Wong SP, Yu MK, Wynar B, Perkins M, Liu CF, Lemon JM, Hebert PL. Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation. J Am Soc Nephrol 2015; 26:1975-81. [PMID: 25700539 DOI: 10.1681/asn.2013050531] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/23/2014] [Indexed: 11/03/2022] Open
Abstract
Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.
Collapse
Affiliation(s)
- Ann M O'Hare
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and Group Health Research Institute, Seattle, Washington
| | - Susan P Wong
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and
| | - Margaret K Yu
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Departments of Medicine and
| | - Bruce Wynar
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Mark Perkins
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Chuan-Fen Liu
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Health Services, University of Washington, Seattle, Washington; and
| | - Jaclyn M Lemon
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Paul L Hebert
- Department of Veterans Affairs Health Services Research and Development Center of Excellence, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Health Services, University of Washington, Seattle, Washington; and
| |
Collapse
|
33
|
Pisoni RL, Zepel L, Port FK, Robinson BM. Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons. Am J Kidney Dis 2015; 65:905-15. [PMID: 25662834 DOI: 10.1053/j.ajkd.2014.12.014] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 12/11/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice. STUDY DESIGN Prospective observational cohort study of vascular access. SETTING & PARTICIPANTS Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N=3,442; US patients) and 19 other nations (N=8,478). PREDICTORS Country, patient demographics, time period. OUTCOMES Vascular access use, pre-end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors. RESULTS In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having ≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported. LIMITATIONS Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population. CONCLUSIONS AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.
Collapse
Affiliation(s)
| | - Lindsay Zepel
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| |
Collapse
|
34
|
Crews DC, Scialla JJ, Boulware LE, Navaneethan SD, Nally JV, Liu X, Arrigain S, Schold JD, Ephraim PL, Jolly SE, Sozio SM, Michels WM, Miskulin DC, Tangri N, Shafi T, Wu AW, Bandeen-Roche K. Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD. Am J Kidney Dis 2014; 63:806-15. [PMID: 24508475 DOI: 10.1053/j.ajkd.2013.12.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 12/27/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Previous observational studies examining outcomes associated with the timing of dialysis therapy initiation in the United States have often been limited by lead time and survivor bias. STUDY DESIGN Retrospective cohort study comparing the effectiveness of early versus later (conventional) dialysis therapy initiation in advanced chronic kidney disease (CKD). The analysis used inverse probability weighting to account for an individual's contribution to different exposure groups over time in a pooled logistic regression model. Patients contributed risk to both exposure categories (early and later initiation) until there was a clear treatment strategy (ie, dialysis therapy was initiated early or estimated glomerular filtration rate [eGFR] decreased to <10mL/min/1.73m(2)). SETTING & PARTICIPANTS Patients with CKD who had at least one face-to-face outpatient encounter with a Cleveland Clinic health care provider as of January 1, 2005, and at least 3 eGFRs in the range of 20-30mL/min/1.73m(2) measured at least 180 days apart. PREDICTORS Timing of dialysis therapy initiation as determined using model-based interpolation of eGFR trajectories over time. Timing was defined as early (interpolated eGFR at dialysis therapy initiation≥10mL/min/1.73m(2)) or later (eGFR < 10mL/min/1.73m(2)) and was time-varying. OUTCOMES Death from any cause occurring from the time that eGFR was equal to 20mL/min/1.73m(2) through September 15, 2009. RESULTS The study population consisted of 652 patients meeting inclusion criteria. Most (71.3%) of the study population did not initiate dialysis therapy during follow-up. Patients who did not initiate dialysis therapy (n=465) were older, more likely to be white, and had more favorable laboratory profiles than those who started dialysis therapy. Overall, 146 initiated dialysis early and 80 had eGFRs decrease to <10mL/min/1.73m(2). Many participants (n=426) were censored prior to attaining a clear treatment strategy and were considered undeclared. There was no statistically significant survival difference for the early compared with later initiation strategy (OR, 0.85; 95% CI, 0.65-1.11). LIMITATIONS Interpolated eGFR, moderate sample size, and likely unmeasured confounders. CONCLUSIONS In patients with advanced CKD, timing of dialysis therapy initiation was not associated with mortality when accounting for lead time bias and survivor bias.
Collapse
Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Julia J Scialla
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - L Ebony Boulware
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sankar D Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Joseph V Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Xiaobo Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Patti L Ephraim
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Stacey E Jolly
- Department of General Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Stephen M Sozio
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Wieneke M Michels
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Dana C Miskulin
- Division of Nephrology, Tufts University School of Medicine, Boston, MA
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Albert W Wu
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health, Policy, and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | |
Collapse
|