Pre-Dialysis Visits to a Nephrology Department and Major Cardiovascular Events in Patients Undergoing Dialysis

Abstract

Background and ObjectivesPre-dialysis care by a nephrology out-patient department (OPD) may affect the outcomes of patients who ultimately undergo maintenance dialysis. This study examined the effect of pre-dialysis care by a nephrology OPD on the incidence of one-year major cardiovascular events after initiation of dialysis.Design, Setting Participants, & MeasurementsThe study consisted of Taiwanese patients with chronic kidney disease (CKD) who commenced dialysis from 2006 to 2008. The number of nephrology OPD visits during the critical care period (within 6 months of initiation of dialysis) and the early care period (6–36 months before initiation of dialysis) were analyzed. The primary outcome measure was one-year major cardiovascular events.ResultsA total of 1191 CKD patients who initiated dialysis from 2006 to 2008 were included. Binary logistic regression showed that patients with ≧3 visits during the critical care period and those with ≧11 visits during the early care period had fewer composite major cardiovascular events than those with 0 visits. Patients with early referral are less likely to experience composite major cardiovascular events than those with late referral, with aOR 0.574 (95% CI = 0.43–0.77, P<0.001). Patients with both ≧3 visits during critical care period and ≧11 visits during early care period were less likely to experience composite major cardiovascular events (aOR = 0.25, 95% CI = 0.16–0.39, P < 0.001).ConclusionsPatients with adequate pre-dialysis nephrology OPD visits, not just early referral, may had fewer one-year composite major cardiovascular events after initiation of dialysis. This information may be important to medical care providers and public health policy makers in their efforts to improve the well-being of CKD patients.

Early referral to nephrological care improves long-term survival and hospitalization after dialysis initiation, independent of optimal dialysis start – a call for harmonization of reimbursement policies

“…Nephrological monitoring of CKD patients is recommended by clinical guidelines starting at CKD stage 3b [ 25 ] or later [ 23 ]. Besides improved survival, numerous additional advantages have been described, such as better cardiovascular morbidity [ 32 ] and, in line with the findings of the current study, better control of anemia and nutritional status [ 7 , 33 ] and a higher frequency of dialysis initiation via an AVF [ 34 ]. While a causative analysis of specific aspects of predialysis nephrological care on improved long-term morbidity and mortality after dialysis initiation is beyond the scope of this article, these findings may be indicative of the underlying mechanisms.…”

Dialysis decision-making process by Chinese American patients at an urban, academic medical center: a retrospective chart review

“…Based on the observations about time to dialysis, eGFR value, and access at dialysis initiation, our chart review suggests that Chinese American patients at Tufts Medical Center received care equivalent to other participants. Literature suggests that patients with more pre-dialysis visits had better peritoneal dialysis-related outcomes, fewer cardiovascular events and lower mortality [ 40 , 41 ].…”

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease

“…Only a few studies have reported on the prevalence of nephrology care among patients with CKD. [23,24,25] Huang et al [23] reported that 77.1% of patients who initiated dialysis from 2006 to 2008 had at least 1 nephrology-related visit during the previous 3 years. However, nephrology visit rates are usually quite low among patients with an eGFR of <60 mL/min/1.73 m 2 .…”