pre-ESRD Nephrology Care Research Articles

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs

The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain. Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known. To compare initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs the Department of Veterans Affairs (VA). Retrospective cohort study of patients from the US Medicare and VA health care systems evaluated 11 215 veterans aged 67 years or older with incident kidney failure between January 1, 2008, and December 31, 2011. Data analysis was performed March 15, 2016, through September 20, 2017. Pre-ESRD nephrology care in Medicare vs VA health care systems. Dialysis treatment and death within 2 years. Of the 11 215 patients included in the study, 11 085 (98.8%) were men; mean (SD) age was 79.1 (6.9) years. Within 2 years of incident kidney failure, 7071 (63.0%) of the patients started dialysis and 5280 (47.1%) died. Patients who received pre-ESRD nephrology care in Medicare were more likely to undergo dialysis compared with patients who received pre-ESRD nephrology care in VA (82% vs 53%; adjusted risk difference, 28 percentage points; 95% CI, 26-30 percentage points). Differences in dialysis initiation between Medicare and VA were more pronounced among patients aged 80 years or older and patients with dementia or metastatic cancer, and less pronounced among patients with paralysis (P < .05 for interaction). Two-year mortality was higher for patients who received pre-ESRD care in Medicare compared with VA (53% vs 44%; adjusted risk difference, 5 percentage points; 95% CI, 3-7 percentage points). The findings were similar in a propensity-matched analysis. Veterans who receive pre-ESRD nephrology care in Medicare receive dialysis more often yet are also more likely to die within 2 years compared with those in VA. The VA's integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a concomitant increase in mortality.

Pre-ESRD Care and Mortality in Incident ESRD Patients With Multiple Myeloma.

The relationship between mortality and pre-ESRD (end-stage renal disease) nephrology care in incident ESRD patients with multiple myeloma (MM) as the primary cause of renal failure has not been examined. Among 439,206 incident US hemodialysis patients with MM as the primary cause of ESRD (June 1, 2005 to May 31, 2009) identified using the US Renal Data System, adjusted odds ratios (OR) for reported pre-ESRD nephrology care for ESRD due to MM (n=4561) versus other causes (n=434,645) were calculated. The association of pre-ESRD nephrology care with subsequent mortality in MM-ESRD patients was examined. MM-ESRD patients were less likely to have any predialysis nephrology care in the year before initiation of dialysis (34.8% vs. 58.5%; OR=0.38; 95% confidence interval [CI], 0.34-0.43) compared with patients with ESRD due to other causes. MM-ESRD patients compared with others were more likely to have catheters on first dialysis (91.8% vs. 75.6%; OR=4.15; 95% CI, 3.54-4.86). Incident MM-ESRD patients receiving predialysis care for ≥6 months had significantly lower 1-year mortality (hazard ratio 0.89; 95% CI, 0.82-0.97 and 0.88; 95% CI, 0.80-0.96, respectively), relative to those without this care. A catheter for dialysis access was associated with a 1.6-fold increase in 1-year mortality in incident MM-ESRD (hazard ratio 1.55; 95% CI, 1.32-1.83). MM-ESRD patients were less likely to have predialysis nephrology care and more likely to use catheters on first dialysis. However, predialysis care is independently associated with lower mortality in MM-ESRD patients. Predialysis care should be prioritized in MM patients approaching ESRD.

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System

Background: Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period. Methods: In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables. Results: MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access. Conclusions: MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.

Does wealth make health? Cherchez la renal replacement therapy.

In this issue of CKJ, McQuarrie et al. have explored the relationship between socioeconomic status and outcomes among Scottish patients with a renal biopsy diagnosis of primary glomerulonephritis. Patients in the lower socioeconomic category had a twofold higher risk of death. No significant differences were observed on progression to end-stage renal disease (ESRD) requiring renal replacement therapy (RRT), suggesting that overall medical management was appropriate for all socioeconomic categories. The findings are significant since they come from an ethnically homogeneous population with free access to healthcare; they also relate to a specific aetiology of chronic kidney disease (CKD) expected to be less dependent on unhealthy lifestyles than other more frequent aetiologies that dominate studies of CKD in general, such as diabetic or hypertensive nephropathy. A closer look at the data suggests that living in a high socioeconomic area is associated with lower mortality, rather than the other way round. Furthermore, the differences in mortality were most pronounced during the RRT stage of CKD, providing clues for further research. In this regard, Wilmink et al. and Nee et al. point to access to pre-ESRD nephrology care and to the best kidney transplantation options as modifiable factors to be studied in the realm of T3 translational research to improve CKD patient outcomes.

Second vascular access after failure of the first fistula in the elderly .

In patients with failure of an initial arteriovenous fistula (AVF), a subsequent vascular access is needed before hemodialysis (HD) initiation. To assess the optimal access strategy after a failed AVF, we linked data from the US Renal Data System with Medicare claims data identifying 21,436 patients ≥67 years old who started HD between January 1, 2005, and December 31, 2008, with an AVF placed as their first predialysis access. Of the 10,568 subjects whose AVF failed, 1,796 patients had an AVF placed as a second access predialysis (AVF2 group) and 399 patients had an arteriovenous graft placed as a second access predialysis (AVG2 group). Second access success was defined as HD initiation for the first HD session using this access avoiding need for a catheter. The mean age for AVF2 and AVG2 groups was 75.9±6.0 and 75.9±5.9 years with a significantly greater percentage of men and whites in the AVF2 group and women and blacks in the AVG2 group. Overall, 53% of AVF2 group initiated dialysis using AVF2, and 66% of AVG2 group started dialysis using AVG2 (p<0.001). The following variables were found to be associated with AVF2 failure: female gender, peripheral vascular disease (PVD), interventional procedures, and the absence of pre-ESRD nephrology care. AVG2 failure was associated with white race, lower body mass index (BMI), and the absence of pre-ESRD (end-stage renal disease) nephrology care. Since the success rate to avoid the use of a catheter was significantly higher in the AVG2 group than in the AVF2 group, an AVG may be a preferable choice of second access in certain patients, especially in females, blacks and those with PVD. .

Impact of poverty and race on pre-end-stage renal disease care among dialysis patients in the United States.

BackgroundAccess to nephrology care prior to end-stage renal disease (ESRD) is significantly associated with lower rates of morbidity and mortality. We assessed the association of area-level and individual-level indicators of poverty and race/ethnicity on pre-ESRD care provided by nephrologists.MethodsIn this retrospective cohort study using the US Renal Data System database, we identified 739 537 patients initiated on maintenance dialysis from 1 January 2007 through 31 December 2012. We assessed the Medicare–Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data obtained from the 2010 US census. We conducted multivariable logistic regression of pre-ESRD nephrology care as the outcome variable.ResultsAmong patients in the lowest area-level MHI quintile, 61.28% received pre-ESRD nephrology care versus 67.68% among those in higher quintiles (P < 0.001). Similarly, the proportions of dual-eligible and nondual-eligible patients who had pre-ESRD nephrology care were 61.49 and 69.84%, respectively (P < 0.001). Patients in the lowest area-level MHI quintile were associated with significantly lower likelihood of pre-ESRD nephrology care (adjusted odds ratio [aOR] 0.86 [95% confidence interval (CI) 0.85–0.87]) compared with those in higher quintiles. Both African American (AA) and Hispanic patients were significantly less likely to have received pre-ESRD nephrology care [aOR 0.85 (95% CI 0.84–0.86) and aOR 0.72 (95% CI 0.71–0.74), respectively].ConclusionsIndividual- and area-level measures of poverty, AA race and Hispanic ethnicity were independently associated with a lower likelihood of pre-ESRD nephrology care. Efforts to improve pre-ESRD nephrology care may require focusing on the poor and minority groups.

Why minorities live longer on dialysis: an in-depth examination of the Danish nephrology registry.

NDT Advance Access published January 6, 2016 Nephrol Dial Transplant (2016) 0: 1–4 doi: 10.1093/ndt/gfv419 In Focus Why minorities live longer on dialysis: an in-depth examination of the Danish nephrology registry Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA and 2 David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA Correspondence and offprints requests to: Connie M. Rhee; E-mail: crhee1@uci.edu Epidemiological data have consistently shown that various ra- cial and ethnic minorities, including black, Hispanic, Indo- Asian and Arab-Israeli populations, have a disproportionately higher prevalence of end-stage renal disease (ESRD) compared with those of white European ancestry [1–3]. Among minorities with ESRD, numerous disparities have been observed, including less access to pre-ESRD nephrology care, poorer achievement of dialysis performance measures (e.g. hemoglobin and parathyroid hormone levels) and lower kidney transplantation rates [4–6]. Despite these inequities, population-based studies show that racial/ethnic minorities receiving dialysis have a paradoxical survival advantage compared with their white counterparts [1, 2, 5, 7–9]. While these racial/ethnic differences in ESRD survival have been well documented in US and Canadian-based popula- tions, there have been few studies of European dialysis patients, and these have largely been restricted to populations in the UK and The Netherlands (Table 1) [3, 10–14]. Further examination of dialysis populations from other countries of the European Union are warranted, given their (i) disparate racial/ethnic com- positions, (ii) lower comorbidity burden and mortality rates, (iii) differential age distributions and (iv) distinct health care delivery systems across different European Union nations. In this issue of Nephrology Dialysis Transplantation, van den Beukel et al. [14] conducted one of the largest European-based studies of race, ethnicity and survival among incident dialysis patients to date using the Danish National Registry, which has comprehensive capture of all Danish ESRD patients from 1990 onward. The investigators granularly examined the sur- vival of various immigrant racial/ethnic populations and found that all immigrant subgroups had lower mortality risk compared with native Danes in crude and adjusted analyses. Linkage of patient-level data to Statistics Denmark, a Danish governmental organization under the Ministry for Economic © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. and Interior Affairs, also permitted examination of the associ- ation between the duration of residence and death risk among immigrants, which demonstrated that in Western immigrants, the survival benefit attenuated over time but remained robust among those of non-Western origin [14, 15]. Access to the Danish Nephrology Registry allows for in- depth examination of the entire Danish incident dialysis population, from whom inferences can be drawn without sub- stantial selection or survivor bias. For example, the study’s low proportion of immigrant dialysis patients (∼9%) was similar to that of the broader Danish population (∼7%), and was largely comprised of patients of Western, Arab, South and Southeast Asian and sub-Saharan African origin [14, 15]. The predominantly white population, in conjunction with the relatively low burden of diabetes as the primary cause of ESRD (23%), may account for Denmark’s decline in ESRD over the past decade [incidence rates of treated ESRD patients as of 2000 and 2013 were 132 and 117 per million, respectively, according to longitudinal international data from the United States Renal Data System (USRDS)] [1]. Another notable ob- servation was the similar age-adjusted rates of kidney trans- plantation among immigrant subgroups and native Danes, which stands in contrast to other Western nations, where black and Hispanic dialysis patients are less likely to undergo transplantation [1, 5]. Given their equivalent transplant rates, it is unlikely that the diminution of healthier native Danish dialysis patients due to kidney transplantation is an explana- tory factor for lower mortality risk among immigrants; in addition, competing risk methods used to address differential transplantation rates across race/ethnicity demonstrated a robust immigrant survival advantage. Direct study of the Danish dialysis population also pro- vides a unique opportunity to dissect potential mechanisms Downloaded from http://ndt.oxfordjournals.org/ at University of California, Los Angeles on January 7, 2016 Connie M. Rhee 1 , Kamyar Kalantar-Zadeh 1 and Keith C. Norris 2

Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA.

BackgroundLonger nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes.MethodsWe investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010.ResultsOverall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57–0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R2 = 0.47; P < 0.001).ConclusionsThis study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.

Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis.

To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region. National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region. Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care. LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.

Indicators of Increased Access to Quality Care Among End Stage Renal Disease Patients Preemptively Referred for Transplantation.

Background: Little is known about whether preemptive referral [referral for kidney transplant (KTx) evaluation prior to initiating dialysis] is associated with indicators of access to quality care among End Stage Renal Disease (ESRD) patients. Methods: KTx center-level data for 4,825 patients with no previous transplant who had been on dialysis and were referred for KTx evaluation from 2005-2010 were linked with United States Renal Data System baseline and follow-up data through September 2011. Chi-square tests were used to examine the association between preemptive referral and indicators of increased access to quality care [private insurance, pre-ESRD nephrology care, erythropoietin use, normal hemoglobin (≥10.0 g/dl) and albumin levels (≥3.5 g/dl)] at the time of ESRD start. Results: Of the 4,825 referred patients, 845 (17.5%) had been referred prior to initiating dialysis. Preemptively referred patients were significantly more likely than patients referred after dialysis start to have private insurance (vs. Medicare or Medicaid), pre-ESRD nephrology care, erythropoietin use, and normal hemoglobin and albumin levels (Table).Table: Indicators of Quality Care in Preemptively Referred vs. Non-Preemptively Referred PatientsConclusions: Preemptive referral for KTx evaluation is associated with indicators of increased access to quality care, which may explain improved outcomes for patients with preemptive referral compared to those referred after dialysis start.

Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). Several factors associated with AVF placement have been identified (e.g., age, sex, race, comorbidities). We hypothesized that geographic location of patient residence might be associated with the probability of AVF placement as the initial access. We used the data from the United States Renal Data System (USRDS) database (2005-2008) linked to Medicare claims (2003-2008). Logistic regression was used to estimate specific characteristics of population associated with the AVF as first access placed or attempted for HD initiation. Our primary variable of interest was the geographic location, and the multivariate model was adjusted for age, sex, race, body mass index, primary cause of end-stage renal disease (ESRD), duration of pre-ESRD nephrology care, comorbidities, employment status, substance abuse, and income. Geographic location was determined using the data collected by the RUCA project and divided population into metropolitan, micropolitan, and rural categories. Patients (n = 111,953) identified from the USRDS database with linked Medicare claims were examined. Rates of fistula placement in the metropolitan, micropolitan, and rural population were 18.5%, 22.4%, and 21.6%, respectively. In comparison, patients who received catheter as the first access were 81.5%, 77.6% and 78.4%, respectively. The odds ratio of AVF placement as a first HD access in the rural and metropolitan population compared with the micropolitan population were 0.96 (0.90-1.03; P = 0.26) and 0.80 (0.76-0.84; P < 0.001), respectively. Our results indicate the presence of geographic disparities in AVF placement with decreased rates of AVF as the first access created in the metropolitan (but not rural) populations compared with the micropolitan communities.

Provider and Care Characteristics Associated with Timing of Dialysis Initiation

There is a trend in the United States to maintenance dialysis initiation at higher levels of estimated GFR. This study aimed to determine whether provider characteristics and pre-ESRD nephrology care and vascular access are independently associated with higher estimated GFR at initiation. This retrospective cohort study used US Renal Data System data for patients who initiated dialysis in 2006 (n=83,621) and American Medical Association Physician Master File data for provider characteristics. Patient characteristics and estimated GFR were defined, and providers at dialysis initiation were identified. Earlier dialysis initiation was defined as initiation at estimated GFR>10 ml/min per 1.73 m(2). Nephrologist density per 100 ESRD patients was calculated by Health Service Area in 2006. Associations between provider characteristics and estimated GFR were determined using logistic regression and linear regression models, accounting for provider clustering. Of the cohort, 47.8% of patients initiated dialysis at estimated GFR>10 ml/min per 1.73 m(2), and 16.2% of patients initiated dialysis at estimated GFR≥15 ml/min per 1.73 m(2). Predialysis nephrologist care for 0-12 months was associated with greater odds of earlier initiation compared with no care. Patients initiating with an arteriovenous fistula or graft were more likely to initiate earlier than patients initiating with a catheter. Provider sex was not associated with timing of dialysis initiation as measured by estimated GFR. Care by providers who graduated from nondomestic medical schools was associated with greater odds of earlier initiation. Greater provider experience was associated with lower likelihood of earlier initiation. This study supports the hypothesis that provider factors are associated with timing of dialysis initiation in the United States.

Factors predicting failure of AV “fistula first” policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre-dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥ 67 years old who had an AVF as their initial vascular access placed pre-dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty-eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre-HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00-1.02), female gender (OR 1.69; 95% CI 1.55-1.83), black race (OR 1.41; 95% CI 1.26-1.58), history of diabetes (OR 1.22; 95% CI 1.06-1.39), cardiac failure (OR 1.26; 95% CI 1.15-1.37), and shorter duration of pre-end-stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre-ESRD nephrology follow up of more than 12 months; 95% CI 1.07-1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre-ESRD nephrology care with predialysis AVF failure.

Racial and Ethnic Differences in Pediatric Access to Preemptive Kidney Transplantation in the United States

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57–1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.

English

BACKGROUND: Mortality risk among haemodialysis (HD) patients may be highest soon after initiation of HD. Studies from different geographical areas have been published regarding the predictors of early mortality among incident haemodialysis patients. With this background we started our study to asses early mortality causes among incident haemodialysis patients in our institute in Central India so that group of patients with risk factors can be educated and can be intervened early. MATERIALS & METHODS: 215 patients eligible for the evaluation of mortality in the first 120 days of dialysis were reviewed for their clinical and biochemical data. Univariate statistical tests using chi-square for binary variables and t-test for continuous variables were performed. RESULTS: The overall incident mortality within 120 days was 39 (18.1%) patients of which cardiovascular causes accounted for 51% of all the causes. Early mortality rate was not significantly increased in the comparison of gender groups but increased in patients with diabetes mellitus (29.4% vs.14.6%), those with reduced dialysis frequency (27.9% vs. 11.6%), the presence of low serum albumin (34.2% vs. 9.3%), the presence of a central venous catheter (26.7% vs. 10.1%) and the lack of Pre-ESRD nephrology care (23.6% vs. 11.6%) and in old age. The low serum albumin below 35 g/l was the strongest predictor of early mortality, the survival rates in patients with serum albumin less than 35 g/l and those with serum albumin equal to or greater than 35 g/l were 65.8% and 90.7%, respectively (p< 0.001). CONCLUSION: T he present study suggest that the important predictors of early mortality in the first 120 days of starting HD include the presence of diabetes mellitus, decreased frequency of dialysis sessions, the presence of low serum albumin, the presence of a central venous catheter, presence of urinary tract infection and the lack of Pre- ESRD nephrology care. These results also support the importance of arterio-venous fistula placement in the predialysis period with avoidance of temporary or permanent catheter placement and adequate predialysis nephrology care with a nephrologist at least 1 month before HD.

Review of pre end-stage renal disease care in the western region in Saudi Arabia

Background: The risk factors for chronic kidney disease (CKD) are increasing in the Saudi population. Consequently, the incidence and prevalence of end-stage renal disease (ESRD) have increased substantially in Saudi Arabia over the past three decades. This study was conducted to review pre-ESRD care and investigate the primary causes of ESRD among haemodialysis patients in the western region in Saudi Arabia. Methods: A pilot cross-sectional study was conducted in Al-Noor Kidney Centre and Jeddah Kidney Centre in the western region of Saudi Arabia. Participants were patients with ESRD on regular haemodialysis during 2011. Main outcome measures were pre-ESRD care including: reason of referral to nephrology care, source of referral to nephrology care, duration of pre-ESRD care, and vascular access at the first dialysis; and primary causes of ESRD. Results: Preliminary indicators of pre-ESRD care showed that: endocrine, nutritional and metabolic diseases, and immunity disorders were the principal reason for patient referral in 50.6% (95% CIs, 45.1_56.1) of patients; 50.6% (95% CIs, 45.6_55.6) of the patient referrals arrived from the emergency department; a large proportion of haemodialysis patients were not receiving pre-ESRD nephrology care, 47.6% (95% CIs, 41.7_53.5); the predominant vascular access point for haemodialysis was initially a catheter 88.3% (95% CIs, 84.5_91.3). The dominant causes of ESRD were hypertensive nephropathy, 55.8% (95% CIs, 50.8_60.7) and diabetic nephropathy, 24.6% (95% CIs, 20.4_29.1). Conclusions: Pre-ESRD nephrology care needs to be improved in Saudi Arabia. Potential strategies could involve: regular screening of high risk people, encouraging communication between healthcare practitioners, and education on the need to refer patients with CKD to nephrology care in earlier disease stages; and increasing patients’ awareness about their health conditions and potential consequences of their kidney disease.

Treatment Center and Geographic Variability in Pre-ESRD Care Associate with Increased Mortality

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of > 30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of > or = 6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.

Predictors of Early Mortality among Incident US Hemodialysis Patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Mortality risk among hemodialysis (HD) patients may be highest soon after initiation of HD. A period of elevated mortality risk was identified among US incident HD patients, and which patient characteristics predict death during this period and throughout the first year was examined using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996 through 2004). A retrospective cohort study design was used to identify mortality risk factors. All patient information was collected at enrollment. Life-table analyses and discrete logistic regression were used to identify a period of elevated mortality risk. Cox regression was used to estimate adjusted hazard ratios (HR) measuring associations between patient characteristics and mortality and to examine whether these associations changed during the first year of HD. Among 4802 incident patients, risk for death was elevated during the first 120 d compared with 121 to 365 d (27.5 versus 21.9 deaths per 100 person-years; P = 0.002). Cause-specific mortality rates were higher in the first 120 d than in the subsequent 121 to 365 d for nearly all causes, with the greatest difference being for cardiovascular-related deaths. In addition, 20% of all deaths in the first 120 d occurred subsequent to withdrawal from dialysis. Most covariates were found to have consistent effects during the first year of HD: Older age, catheter vascular access, albumin <3.5, phosphorus <3.5, cancer, and congestive heart failure all were associated with elevated mortality. Pre-ESRD nephrology care was associated with a significantly lower risk for death before 120 d (HR 0.65; 95% confidence interval 0.51 to 0.83) but not in the subsequent 121- to 365-d period (HR 1.03; 95% confidence interval 0.83 to 1.27). This care was related to approximately 50% lower rates of both cardiac deaths and withdrawal from dialysis during the first 120 d. Mortality risk was highest in the first 120 d after HD initiation. Inadequate predialysis nephrology care was strongly associated with mortality during this period, highlighting the potential benefits of contact with a nephrologist at least 1 mo before HD initiation.