Predicting mortality and uptake of renal replacement therapy in patients with stage 4 chronic kidney disease

Conway, Bryan; Webster, Angela C; Ramsay, George; Morgan, Neal; Neary, John; Whitworth, Caroline; Harty, John

doi:10.1093/ndt/gfn772

Cited by 72 publications

(77 citation statements)

References 20 publications

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“…However, results from these reports are not consistent. One cohort study from the United Kingdom showed that crude mortality and the percentage of ESRD at 5 years were 47.5% and 24.7%, respectively (43), which is consistent with the population-based study (13). On the other hand, a study from Canada indicated that 7% of patients died, and 25% started RRT during the first 2 years of follow-up (44), which is similar to our results.…”

Section: Discussionsupporting

confidence: 91%

Impact of Age and Overt Proteinuria on Outcomes of Stage 3 to 5 Chronic Kidney Disease in a Referred Cohort

Obi

Kimura

Nagasawa

et al. 2010

Clinical Journal of the American Society of Nephrology

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Results: The median age of subjects was 67.0 years, and median follow-up was 3.2 years. Overt proteinuria was present in 57.0% of subjects. For stage 3, 4, and 5 CKD, cumulative mortality and probability of ESRD at 3 years was 9.5 and 6.5%, 11.2 and 27.8%, and 16.5 and 79.1%, respectively. Using proportional-hazards regression models, age was a determinant for death, whereas overt proteinuria was strongly associated with ESRD. Among stage 3 CKD patients older than 65 years without overt proteinuria, the incidence of death before renal replacement therapy (RRT) was 2.8/100 patient-years and none had ESRD. In patients with advanced CKD and overt proteinuria, the incidence of ESRD was substantially higher than that of death before RRT.Conclusions: Stratification by age, proteinuria level, and CKD stage could predict the competing outcomes of death before RRT and ESRD among CKD patients.

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Section: Discussionsupporting

confidence: 91%

Impact of Age and Overt Proteinuria on Outcomes of Stage 3 to 5 Chronic Kidney Disease in a Referred Cohort

Obi

Kimura

Nagasawa

et al. 2010

Clinical Journal of the American Society of Nephrology

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“…[9][10][11][12][13][14][15][16] Current literature on ESRD outcomes in chronic kidney disease (CKD) is primarily predicated on a theory of a smooth continuous progressive loss of glomerular filtration rate (GFR) with several publications over the decades describing CKD progression to ESRD in terms of annual rates of GFR decline in mL/ min/1.73 m 2 /year or as mean annualized estimated glomerular filtration rate (eGFR) slopes. 4,[17][18][19] Furthermore, in the large renin-angiotensin-aldosterone system (RAAS) blockade reno-protection trials, the efficacy of reno-protective strategies has been adjudged on the basis of how much more or less the rate of doubling of serum creatinine or decline of GFR was impacted by different intervention strategies. 11,15,16 The question remains whether, in fact, we really understand the natural history of CKD with particular reference to progression to ESRD and/or death outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…11,15,16 The question remains whether, in fact, we really understand the natural history of CKD with particular reference to progression to ESRD and/or death outcomes. [19][20][21][22] The natural history of CKD, in general,…”

Section: Introductionmentioning

confidence: 99%

Syndrome of rapid-onset end-stage renal disease: a new unrecognized pattern of CKD progression to ESRD

Onuigbo¹

2010

Renal Failure

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By most estimates, we have an increasing worldwide end-stage renal disease (ESRD) epidemic. This is despite at least two decades of intensified reno-protection strategies, including attempts at optimal hypertension management, optimization of diabetic control, smoking cessation efforts, and the extensive application of renin-angiotensin-aldosterone system (RAAS) blockade in both diabetic and nondiabetic chronic nephropathies. The current consensus is that chronic kidney disease (CKD) progression to ESRD is a continuous, progressive, and predictable loss of estimated glomerular filtration rate (eGFR) in CKD patients, inexorably leading to ESRD. Our recent experience in a Mayo Health System Hypertension Clinic, as well as new reports associating ESRD development in CKD patients with episodes of acute kidney injury (AKI), led us to hypothesize that CKD to ESRD progression may not be that predictable, after all. Among a 100 high-risk CKD patient cohort that we have followed up prospectively since 2002, we demonstrated that in 15 of 17 (88%) patients who progressed to ESRD, progression from CKD to ESRD was unpredictable, nonlinear, abrupt, and rapid, and this followed AKI secondary to medical and surgical events. We have coined a new term, the syndrome of rapid-onset end-stage renal disease (SORO-ESRD), to represent this unrecognized syndrome. Larger studies are warranted to confirm our single-center findings. If confirmed to represent a significant proportion of the ESRD population, at least here in the United States, this finding will demand major paradigm shifts in the current concepts of reno-protection and "A-V Fistula first" programs.

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“…For example, in elderly patients with reduced but stable kidney function, a low eGFR (30 to 60 ml/min per 1.73 m 2 ) may be an indicator of age-related comorbidity rather than vascular pathology, the latter being responsive to treatment with angiotensin-receptor blockers if caused by proteinuria. 21,22 Depending on their cardiovascular risk profile and level of proteinuria, elderly patients with stable kidney function could be monitored in primary care, [23][24][25] whereas those with RKFD are more likely to benefit from specialist referral because they are at greater risk for adverse outcomes. 4 -6 However, future research must assess the effect and cost-effectiveness of different follow-up strategies.…”

Section: Discussionmentioning

confidence: 99%

Dipstick Proteinuria as a Screening Strategy to Identify Rapid Renal Decline

Clark

Macnab²,

Sontrop³

et al. 2011

Journal of the American Society of Nephrology

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Rapid kidney function decline (RKFD) predicts cardiovascular morbidity and mortality, but serial assessment of estimated GFR (eGFR) is not cost-effective for the general population. Here, we evaluated the predictive value of albuminuria and three thresholds of dipstick proteinuria to identify RKFD in 2,574 participants in a community-based prospective cohort study with a median of 7 years follow-up. Median change in eGFR was Ϫ0.78 ml/min per 1.73 m 2 per year; with 8.5% experiencing RKFD, defined as a Ͼ5% annual eGFR decline from baseline. Of those with RKFD, 65% advanced to a new CKD stage compared with 19% of those without RKFD. Dipstick protein Ն1 g/L was a stronger predictor of RKFD than albuminuria. Overall, 2.5% screened positive for dipstick protein Ն1 g/L at baseline; one of every 2.6 patients would have RKFD if all were followed with serial eGFR measurement. Overall, the screening strategy correctly identified progression status for 90.8% of patients, mislabeled 1.5% as RKFD, and missed 7.7% with eventual RKFD. Among those with risk factors (cardiovascular disease, age Ͼ60, diabetes, or hypertension), the probability of identifying RKFD from serial eGFR measurements increased from 13 to 44% after incorporating dipstick protein (Ն1g/L threshold). In summary, inexpensive screening with urine dipstick should allow primary care physicians to follow fewer patients with serial eGFR assessment but still identify those with rapid decline of kidney function.

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Predicting mortality and uptake of renal replacement therapy in patients with stage 4 chronic kidney disease

Abstract: Most patients with stage 4 CKD, in particular the elderly, die without commencing RRT. Patients at low risk of progression can be identified and discharged safely to primary care with an active management plan.

Cited by 72 publications

References 20 publications

Impact of Age and Overt Proteinuria on Outcomes of Stage 3 to 5 Chronic Kidney Disease in a Referred Cohort

Impact of Age and Overt Proteinuria on Outcomes of Stage 3 to 5 Chronic Kidney Disease in a Referred Cohort

Syndrome of rapid-onset end-stage renal disease: a new unrecognized pattern of CKD progression to ESRD

Dipstick Proteinuria as a Screening Strategy to Identify Rapid Renal Decline

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