Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis

Fischer, Michael J.; Stroupe, Kevin T.; Kaufman, James S.; O’Hare, Ann M.; Browning, Margaret M.; Sohn, Min-Woong; Huo, Zhiping; Hynes, Denise M.

doi:10.1186/s12882-016-0324-5

Cited by 34 publications

(28 citation statements)

References 41 publications

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“…This suggests that the observed association between inpatient transition and mortality was in large part due to underlying patient characteristics and/or lack of proper pre-transition care, and not caused by the hospitalization per se. Receiving more intensive pre-dialysis Nephrology care has been associated with more favorable outcomes, [19] as has initiation of hemodialysis using an arteriovenous fistula (compared to an arteriovenous graft, and especially to a central venous catheter) as initial vascular access. [20–22] In addition to these well-described benefits of proper pre-transition Nephrology care, our findings suggest that they may extend to lowering the proportion of patients needing inpatient hemodialysis transition.…”

Section: Discussionmentioning

confidence: 99%

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Arif¹,

Sumida

Molnár³

et al. 2017

Nephron

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Background: Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. Methods: We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. Results: A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. Conclusions: Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.

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Section: Discussionmentioning

confidence: 99%

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Arif¹,

Sumida

Molnár³

et al. 2017

Nephron

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“…It is plausible that clinical and process-of-care factors prior to ESRD may continue to play a role in determining survival after chronic hemodialysis ensues. For instance, it is known that pre-ESRD nephrology care is associated with better survival and prospects for transplantation after incident dialysis [11, 12]. We believe the findings from our study are significant and clinically relevant and can guide health care providers to recognize patients with history of pre-ESRD AKI events.…”

Section: Discussionmentioning

confidence: 74%

Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

et al. 2018

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Background: Acute kidney injury (AKI) is associated with increased morbidity and mortality. Mortality in end-stage renal disease (ESRD) patients is highest during the first year of dialysis. The impact of pre-ESRD AKI events on long-term outcomes in incident ESRD patients remains unknown. Methods: We evaluated a retrospective cohort of 47,341 incident hemodialysis patients from the United States Renal Data System with linked Medicare data for at least 2 years prior to hemodialysis initiation. We examined the impact of pre-ESRD AKI events in the 2-year pre-ESRD period on the type of vascular access used at hemodialysis initiation (central venous catheter (CVC) versus arteriovenous access), and 1-year all-cause mortality after initiating hemodialysis. Results: The mean age was 72 ± 11 years. Of the study cohort, 18% initiated hemodialysis with arteriovenous access, and 54% of patients had at least one pre-ESRD AKI event. One-year, all-cause mortality was 32%. Compared to 75% for patients without a pre-ESRD AKI event, 89% of patients with a pre-ESRD AKI event initiated hemodialysis with CVC than arteriovenous access (p < 0.001). A pre-ESRD AKI event was associated with lower adjusted odds of starting hemodialysis with an arteriovenous access (OR 0.47; 95% CI 0.44–0.50, p < 0.001), and higher adjusted odds of 1-year mortality (OR 1.36; 95% CI 1.30–1.42, p < 0.001). Conclusion: An AKI event prior to initiating hemodialysis independently increases the risk of CVC use and predicts 1-year mortality. Improving processes of care after AKI events may improve dialysis outcomes in patients who progress to ESRD.

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“…31 Among a cohort of older veterans who initiated dialysis, Fischer et al found that those who had a higher number of predialysis visits had lower 2-year mortality after dialysis initiation. 11 Conversely, Winkelmayer et al found no substantial improvement in one-year survival among older adults initiating dialysis during 1996-2006, despite an 18.5% increase in earlier nephrology referrals. 5 …”

Section: Discussionmentioning

confidence: 96%

“…4,5 However, there is conflicting evidence regarding benefits of such care, in part because the risk for progression to ESRD varies widely among patients with a low eGFR. 6,7 Whereas some studies suggest that earlier referral to nephrology (patients having seen a nephrologist six to twelve months prior to initiation of dialysis) is associated with lower mortality after initiation of dialysis 8-11 ; other studies have not. 5,12 …”

mentioning

confidence: 99%

Receipt of Nephrology Care and Clinical Outcomes Among Veterans With Advanced CKD

Fung

Chang

Chertow

et al. 2017

American Journal of Kidney Diseases

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Background Clinical practice guidelines recommend referral to nephrology once estimated glomerular filtration rate (eGFR) falls below 30 ml/min/1.73 m2; however, evidence for benefits of nephrology care are mixed. Study Design Observational cohort using landmark analysis. Settings & Participants A national cohort of veterans with advanced CKD, defined by an outpatient eGFR ≤30 ml/min/1.73m2 for January 1, 2010 through December 31, 2010 and a prior eGFR <60 ml/min/1.73m2, using administrative and laboratory data from the Department of Veterans Affairs and the US Renal Data System. Predictor Receipt and frequency of outpatient nephrology care over 12 months. Outcomes Survival and progression to ESRD (receipt of dialysis or kidney transplantation) were the primary outcomes. In addition, control of associated clinical parameters over 12 months were intermediate outcomes. Results Of 39,669 patients included in the cohort, 14,983 (37.8%) received nephrology care. Older age, heart failure, dementia, depression, and rapidly declining kidney function were independently associated with the absence of nephrology care. Over a mean follow up of 2.9 years, 14,719 (37.1%) patients died and 4,310 (10.9%) progressed to ESRD. In models adjusting for demographics, comorbidities, and trajectory of kidney function, nephrology care was associated with a lower risk of death (HR, 0.88; 95% CI, 0.85-0.91), but a higher risk of ESRD (HR, 1.48; 95% CI, 1.38-1.58). Among patients with clinical parameters outside of guideline recommendations at cohort entry, a significantly higher adjusted proportion of patients who received nephrology care had improvement in control of hemoglobin, potassium, albumin, calcium and phosphorus compared to those who did not receive nephrology care. Limitations May not be generalizable to non-veterans. Conclusions Among patients with advanced CKD, nephrology care was associated with lower mortality, but was not associated with a lower risk for progression to ESRD.

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Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis

Cited by 34 publications

References 41 publications

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

Receipt of Nephrology Care and Clinical Outcomes Among Veterans With Advanced CKD

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