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

Abstract

Background: Multidisciplinary care is recommended for patients with advanced chronic kidney disease (CKD). A formalized, risk-based approach to CKD management is being adopted in some jurisdictions. In Ontario, Canada, the eligibility criteria for multidisciplinary CKD care funding were revised between 2016 and 2018 to a 2 year risk of kidney replacement therapy (KRT) greater than 10% calculated by the 4-variable Kidney Failure Risk Equation (KFRE). Implementation of the risk-based approach has led to the discharge of prevalent CKD patients. Objective: The primary objective of this study was to determine the frequency of occurrence of death and KRT initiation in patients discharged from CKD clinic. Design: Retrospective cohort study Setting: Single center multidisciplinary CKD clinic in Ontario, Canada Patients: Four hundred and twenty five patients seen at least once in 2013 at the multidisciplinary CKD clinic Measurements: Outcomes included discharge status, death, re-referral and KRT initiation. Reasons for discharge were recorded. Methods: Outcomes were extracted from available electronic medical records and the provincial death registry between the patient’s initial clinic visit in 2013 and January 1, 2020. KFRE-2 scores were calculated using the 4-variable KFRE equation. The hazard rates of death and KRT after discharge due to stable eGFR/low KFRE were compared to patients who remained in the clinic. Results: Of the 425 CKD patients, 69 (16%) and 19 (4%) were discharged to primary care and general nephrology, respectively. Of those discharged, 7 (8%) were re-referred to nephrology or CKD clinic, while only 2 (2%) discharged patients required subsequent KRT. The hazard of mortality was reduced after discharge from the clinic due to stable eGFR/low KFRE (adjusted HR = 0.45 [95% CI, 0.25-0.78, P = .005]). Limitations: Single center, observational retrospective study design and unknown kidney function over time post discharge for most patients Conclusions: Discharge of low risk patients from multidisciplinary CKD clinic appears feasible and safe, with fewer than 1 in 40 discharged patients subsequently initiated on KRT over the following 7 years.

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

“…KFRE risk-based thresholds have been proposed as a method to guide several aspects of nephrology care. 5 , 6 , 7 , 8 , 9 , 10 Several studies have predicted that using KFRE scores as a criterion for nephrology referral will result in a reduction in unnecessary referrals, and an increase in earlier referrals for patients at high risk of progression to kidney failure. 5 , 20 , 21 , 22 In one care setting in Canada, KFRE scores dictate the urgency of nephrology referral.…”

“…Prognostication is calibrated by region, 4 and can be further refined by incorporating additional data (serum phosphorus, albumin, bicarbonate, and calcium) into the 8-variable KFRE. 3 KFRE scores have been proposed as a method to institute risk-based thresholds for referrals to nephrology care 5 , 6 or multidisciplinary nephrology clinics, 7 , 8 and to guide KRT planning. 9 Some guidelines suggest referral to nephrology care when 5-year KFRE scores are >5%, and referral for dialysis access and/or transplantation when 2-year KFRE scores are >20% to 40%.…”

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

“…Our results are in line with a recent Canadian study finding a lower occurrence of mortality and KRT for patients discharged from multidisciplinary care. 28 Clinical decision support such as the KFRE can be a useful adjunctive tool for clinical decision-making; however, in certain cases, clinical judgment should be considered. The utility of the nephrologists' ability to override the recommendation of the KFRE tool based on clinical judgment was a key factor in adopting a risk-based approach to CKD care.…”

“…Our results are in line with a recent Canadian study finding a lower occurrence of mortality and KRT for patients discharged from multidisciplinary care. 28 …”