Predialysis Nephrology Research Articles

Predialysis Nephrology Care and Costs in Elderly Patients Initiating Dialysis

Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization. We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1-3 nephrology visits), moderate- (4-6 visits), and high-intensity (>6 visits) nephrology care during this time period. There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤ 3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001). Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.

Early nephrology care provided by the nephrologist alone is not sufficient to mitigate the social and psychological aspects of chronic kidney disease

OBJECTIVE:Patients with chronic kidney disease who receive early nephrology care have a better prognosis with maintenance dialysis. We aimed to determine whether early referral to a nephrologist can also improve the psychological burden of having chronic kidney disease.SUBJECTS AND METHODS:Thirty‐nine patients with chronic kidney disease that required hemodialysis were studied: 19 had a ≥ 6-month history of nephrology care (Group1), and 20 had never received any prior nephrology care (Group2). All patients participated in a semi‐structured interview that addressed their perceived knowledge and psychological aspects related to CKD and hemodialysis. Demographic and laboratory data as well as socioeconomic status were evaluated.RESULTS:In both groups, most of the patients were of low socioeconomic status. Group 1 had significantly better laboratory parameters (p<0.05). The patients' answers to the questions showed no differences between the groups: 63% of Group 1 and 55% of Group 2 reported that they had no prior knowledge about dialysis; 58% and 40%, respectively, reported that they “don't completely understand what the doctor says”; and 74% and 85%, respectively, believed that their “kidneys would work again”.CONCLUSION:Pre‐dialysis nephrology care improves the clinical conditions of the patients with chronic kidney disease but is insufficient for minimizing other aspects of having chronic kidney disease.

The D&amp;T report

The D&amp;T report

Arteriovenous Fistulas among Incident Hemodialysis Patients in Department of Defense and Veterans Affairs Facilities

A higher proportion of patients initiate hemodialysis (HD) with an arteriovenous fistula (AVF) in countries with universal health care systems compared with the United States. Because federally sponsored national health care organizations in the United States, such as the Department of Veterans Affairs (DVA) and the Department of Defense (DoD), are similar to a universal health care model, we studied AVF use within these organizations. We used the US Renal Data System database to perform a cross-sectional analysis of patients who initiated HD between 2005 and 2006. Patients who received predialysis nephrology care had 10-fold greater odds of initiating dialysis with an AVF (adjusted odds ratio [aOR] 10.3; 95% confidence interval [CI] 9.6 to 11.1). DVA/DoD insurance also independently associated with initiating HD with an AVF (aOR 1.4; 95% CI 1.2 to 1.5). Fewer patients initiated HD at a DoD facility, but these patients were also approximately twice as likely to use an AVF (aOR 2.3; 95% CI 1.2 to 4.6). In conclusion, patients in DVA/DoD systems are significantly more likely to use an AVF at initiation of HD than patients with other insurance types, including Medicare. Further study of these federal systems may identify practices that could improve processes of care across health care systems to increase the number of patients who initiate HD with an AVF.

Lessons from Geographic Variations in Predialysis Nephrology Care

Inadequate access to nephrology subspecialists among patients with advanced chronic kidney disease (CKD) is one of the major public health problems of our discipline. Depending on its definition and the specific geographic and health care setting, between 20 and 66% of patients reaching ESRD do not see a nephrologist in a timely manner to receive adequate management of their progressive kidney failure or the long-term complications of advancing CKD. These patients are also robbed of their ability to receive appropriate education to make informed choices about their preferred treatment modality and to prepare optimally for the treatment option they choose. Thus, it has been shown in numerous countries and health care systems that delayed nephrologic care for patients with advanced CKD is associated with inadequate quality of care during transition from CKD to ESRD and with inferior outcomes on renal replacement therapy (RRT). Patients who have CKD and experience inadequately late nephrologic care are less likely to initiate RRT using peritoneal dialysis,1 and, when they do, their chances for a technique failure increase.2 When they start RRT using hemodialysis, patients seen inadequately late by a nephrologist are more likely to require temporary or tunneled central venous catheterization and are less likely to use a more preferable peripheral access, particularly arteriovenous fistulas, for initiation of dialysis thereafter.3, …

Chronic kidney disease: appropriateness of therapeutic management and associated factors in the AVENIR study

The nephrology literature contains little information about the global patterns of medication used in the management of patients with chronic kidney disease (CKD). This study aims to evaluate the appropriateness of nephrological therapeutic management of CKD patients compared with current guidelines and to investigate associations between patient characteristics and the quality of therapeutic management. All adult CKD patients who were starting dialysis in Lorraine (France) between 1 January 2005 and 31 December 2006 and who had been referred to a nephrologist no less than 1 month previously were enrolled. Demographic, clinical, biological and therapeutic data were collected retrospectively from medical records covering the period from the first nephrology consultation to initiation of dialysis. Outcomes of interest were the appropriateness of the therapeutic management of five aspects of CKD: hypertension/proteinuria, anaemia, bone disease, metabolic acidosis and dyslipidemia. Therapeutic care was given a global rating (high, moderate or poor), depending on the number of aspects being managed appropriately. Relationships between the global rating and demographic and clinical characteristics of patients were explored. During predialysis nephrology follow-up, 93.1% of the 420 patients enrolled were receiving antihypertensive therapy; 67.1% were taking a renin-angiotensin system inhibitor. Other prescriptions included: erythropoiesis-stimulating agents (67.4%), iron (48.3%), phosphate binders (38.1%), vitamin D (21.1%), bicarbonates (15.5%) and statins (36.2%). Hypertension/proteinuria was managed appropriately in 72.4% of cases, anaemia in 56.2%, bone disease in 16.7%, metabolic acidosis in 60.2% and dyslipidemia in 61.4%. The global quality of care was high in 22.1% of cases, moderate in 65.7% and poor in 12.2%. After adjustment, the more nephrology consultations a patient had before dialysis, the higher the quality of his or her care. The quality of therapeutic care delivered to CKD patients in nephrology setting was suboptimal when assessed in terms of adherence to guidelines.

Características clínicas y analíticas de los pacientes con insuficiencia renal crónica en tratamiento con hemodiálisis en España. Proyecto ENOD (Estudio Nacional de Optimización de Diálisis)

Chronic kidney disease represents an important burden for public health systems. More than 40,000 patients suffer from chronic kidney disease in Spain, with enormous pharmacologic and health service costs. The loss of renal function requires replacement therapy, among which hemodialysis is the most frequently used while patients wait for a renal transplant.Nevertheless, patient survival in hemodialysis is markedly lower than that in the general population with the same characteristics. Especially noticeable is the high rate of cardiovascular mortality, which becomes even more important if we take into account that a substantial number of patients entering dialysis programs are previously diabetic or hypertensive, thus exponentially increasing their cardiovascular risk. There are several dialyzers, treatments, and different dialysis techniques that seem to decrease this high cardiovascular risk, together with the beneficial effects of predialysis nephrology care.The aim of this cross-sectional study was to evaluate the main cardiovascular risk factors by analyzing the characteristics of prevalent dialysis patients throughout Spain from different categories of centers. Special emphasis is placed on the presence of diabetes, previous heart disease, anemia, hypertension, and mineral-metabolism disorders to propose future potential targets to improve quality of life and decrease morbidity and mortality among this patient population.Our results demonstrate the importance of early diagnosis of diabetic nephropathy and heart disease, control of hypertension, adequate dialysis, and the prevention of secondary hyperparathyroidism. New commercially available drugs may play an important role in the near future.

Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies

The need to educate patients in order to enable them to participate in making appropriate choices for all therapeutic options in end stage renal disease would seem obvious yet there are many barriers to providing such information. We measured 'perceived knowledge' of the therapeutic options for end stage renal disease in a cohort of patients with chronic kidney disease in established treatment programs. A self administered questionnaire was given to 676 patients with stage 3-5 chronic kidney disease as part of the CRIOS study designed to identify trends in practice patterns and outcomes over a 4 year period. The median patient age was 66, about three-fourths were Caucasian and almost half were diabetic. When patients were asked to rate their level of knowledge, about one-third reported limited or no understanding of their chronic kidney disease and no awareness regarding their treatment options. A significant and substantial number of patients indicated they had no familiarity with transplant, hemodialysis, and continuous ambulatory or automated peritoneal dialysis. Perceived knowledge improved with the progression of kidney disease and frequency of nephrology visits; however, only about half of patients with 4 or more nephrology appointments in the prior year reported knowing of hemodialysis, continuous ambulatory peritoneal dialysis or transplant. Age, gender and disease had no impact on levels of patient knowledge, but African-Americans reported having significantly less understanding than Asians or Caucasians. These findings suggest that the lack of perception concerning the treatment options chronic kidney and end stage renal disease reflects, in part, problems with the education of patients by nephrologists and not a lack of referral of these patients to nephrologists for care. The discrepancy of perceived knowledge between African-Americans and other races needs special attention.

Early Initiation of Dialysis and Late Implantation of Catheters Adversely Affect Outcomes of Patients on Chronic Peritoneal Dialysis

Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD). Retrospective cohort. 275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (> or =6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) > or =5 or <5 mL/minute/1.73 m(2)]. All-cause mortality and hospitalization. During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization. Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.

Predialysis Nephrologist Care and Access to Kidney Transplantation in the United States

Predialysis nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a nephrologist >3 months prior to dialysis and one-third <or=3 months prior to dialysis (early vs. late nephrologist care; ENC vs. LNC). Overall, 515 patients were added to the KT wait-list and 406 underwent KT during follow-up (2.3 years). In multivariate analyses, ENC was associated with a 41% (95%CI: 15-72%) greater rate of being wait-listed compared to LNC and a 54% (95%CI: 22-96%) greater rate of KT. Similar associations existed with number of predialysis nephrology visits. Earlier and more frequent predialysis nephrologist care were associated with greater access to the KT wait-list as well as a higher rate of KT, indicating that LNC may augment existing inequalities that impair access to KT.

Predialysis Nephrology Care Improves Dialysis Outcomes

“Knowing is not enough; we must apply. Willing is not enough; we must do.“ — Goethe Bradbury and associates utilized the Dialysis Outcomes and Practice Patterns Study (DOPPS) database to identify predictors of early mortality among recent US incident hemodialysis patients (1). This editorial addresses the implications of those findings within the context of numerous other observations supporting that notion. This is not a new or contentious position (2). Perhaps a randomized controlled trial might settle the question of the efficacy of predialysis care, but surely we understand that rationale and have wiser ways to use limited resources. Maybe we are asking the wrong question. Why has progress toward implementing predialysis care been so slow, ineffective, inefficient, and inadequate? The first of the two subtitles of this editorial suggests a cynical “Now what?” We’ve had a pretty clear picture for more than two decades as to what we need to do, but we have failed to implement what we know to be the best practices and to provide the direction as to how to do it. This lack of success is not restricted to the US. Perhaps our systems are so broken and incentives so misaligned that, for all practical purposes, well-demonstrated benefits of predialysis nephrology care are lost. Or, ever the optimist, are there some potential solutions? We have been attempting to fix this problem for more than 20 years with minimal success. We could continue to take small, ineffective steps, and see no real progress until those of us reading this editorial are long retired. Alternatively, we can attempt bold initiatives that use the available evidence and our experiences to do what needs to be done. The alternative subtitle to this editorial is “Chapter Two,” implying a new start; let’s move on. Let’s figure out a way to …

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.

Does predialysis nephrology care influence patient survival after initiation of dialysis?

Early nephrology referral of patients with chronic kidney disease (CKD) has been suggested to reduce mortality after initiation of dialysis. This retrospective cohort study of incident dialysis patients between 1995 and 1998 was performed to address the association between frequency of nephrology care during the 24 months before initiation of dialysis and first-year mortality after initiation of dialysis. Patient data were obtained from the Centers for Medicare & Medicaid Services. Patients who started dialysis between 1995 and 1998, and were Medicare-eligible for at least 24 months before initiation of dialysis, were included. One or more nephrology visits during a month was considered a month of nephrology care (MNC). Of the total 109,321 patients, only 50% had received nephrology care during the 24 months before initiation of dialysis. Overall, first-year mortality after initiation of dialysis was 36%. Cardiac disease was the major cause of mortality (46%). After adjusting for comorbidity, higher mortality was associated with increasing age (HR, 1.04 per year increase; 95% CI, 1.03 to 1.04) and more frequent visits to generalists (HR, 1.009 per visit increase; 95% CI, 1.003 to 1.014) and specialists (HR, 1.012 per visit increase; 95% CI, 1.011 to 1.013). Compared to patients with >/=3 MNC in the six months before initiation of dialysis, higher mortality was observed among those with no MNC during the 24 months before initiation of dialysis (HR, 1.51; 95% CI, 1.45 to 1.58), no MNC during the six months before initiation of dialysis (HR, 1.28; 95% CI, 1.20 to 1.36), and one or two MNC during the six months before initiation of dialysis (HR, 1.23; 95% CI, 1.18 to 1.29). Nephrology care before dialysis is important, and consistency of care in the immediate six months before dialysis is a predictor of mortality. Consistent nephrology care may be more important than previously thought, particularly because the frequency and severity of CKD complications increase as patients approach dialysis.

Associations with predialysis vascular access management

Background: The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines encourage increasing the proportion of arteriovenous fistulae among incident hemodialysis patients. Achieving optimal outcomes requires predialysis out-patient follow-up by a nephrologist, predialysis placement of a vascular access, and adequate maturation of the vascular access. Methods: We assessed the effect of clinical factors on predialysis vascular access management in all incident hemodialysis patients at a single institution during a 2-year period. Results: Of 157 patients initiating dialysis therapy from January 1, 2001, to December 31, 2002, a total of 73.2% had predialysis follow-up by a nephrologist, 46.5% had predialysis vascular access surgery, and 35.0% initiated their first dialysis session with a permanent access. Among patients using a permanent access on their first dialysis session, 67.3% used a fistula. Patients with diabetes were more likely than those without diabetes to have predialysis nephrology follow-up (81.5% versus 61.5%; P = 0.005), undergo predialysis vascular access surgery (56.5% versus 32.3%; P = 0.003), and initiate their first dialysis session with a fistula or graft (43.5% versus 23.1%; P = 0.008). Duration of predialysis nephrology follow-up was similar between patients with and without diabetes (median, 412 versus 300 days; P = 0.27). Patient age, sex, and race were not predictive of predialysis access management. Conclusion: Despite attempts to follow the K/DOQI guidelines, 65% of incident hemodialysis patients initiated their first dialysis treatment with a catheter. Patients with diabetes were significantly more likely to have predialysis follow-up by a nephrologist and thus more likely to initiate their first dialysis session with a permanent access. Emphasis on early referral of patients with chronic kidney disease without diabetes to nephrologists may increase fistula use among incident hemodialysis patients.