Background A shared decision-making tool could help elderly advanced chronic kidney disease (CKD) patients decide about initiating dialysis. Since mortality may be high in the first few months after initiating dialysis, 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. Study Design Retrospective observational cohort, with development and validation cohorts. Setting & Participants US Renal Data System (USRDS) and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) end-stage renal disease (ESRD) patients with previous 2-year Medicare history who initiated dialysis January 1, 2009–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 via logistic regression. Results The simple risk score (total score, 0–9) included age (0–3 points); low albumin, 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: 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 and who did not have 2 year Medicare history were excluded. Conclusions Routinely available information can be used by CKD patients, families and their nephrologists to estimate risk of early mortality after dialysis initiation, which may facilitate informed decision-making regarding treatment options.

Background Corticosteroids are the mainstay for treatment of systemic lupus erythematosus (SLE). The potential role of corticosteroid use on the pathogenesis of permanent organ damage requires appropriate adjustment for confounding by disease activity. We estimate the effect of corticosteroids (prednisone dose) on permanent organ damage among persons with SLE. Methods We identified 525 incident SLE patients in the Hopkins Lupus Cohort. At each visit, clinical activity indices, laboratory data, and treatment were recorded. The study population was followed from the month after the first visit until June 29 2006, irreversible organ damage, death, loss to follow-up, or receipt of pulse methylprednisolone therapy. We estimated the effect of cumulative average dose of prednisone on organ damage using a marginal structural model to adjust for time-dependent confounding by indication due to SLE disease activity. Findings Compared with non prednisone use, the hazard ratio (95% confidence interval) of organ damage for prednisone was 1.16 (0.59, 2.20) for cumulative average doses >0–180 mg/month, 1.50 (0.67, 3.39) for >180–360 mg/month, 1.64 (0.67, 4.06) for >360–540 mg/month, and 2.51 (1.02, 6.19) for >540 mg/month. In contrast, standard Cox regression models estimated higher hazard ratios at all dose levels. Interpretation Our results suggest that low doses of prednisone do not result in a substantially increased risk of irreversible organ damage.

Epoetin dose requirement is an independent predictor of total mortality in hemodialysis patients after adjustment for hematocrit. Poor responders who continue to have low hematocrit values despite the administration of high epoetin doses may not necessarily benefit from more epoetin, but perhaps should be considered for other adjunctive therapies. In contrast to conventional wisdom, this study suggests that epoetin dosing requirements could provide important prognostic information beyond that predicted by hematocrit alone.

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