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

Abstract

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.

Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study

“…Existing studies provided conflicting results, ranging from a small survival benefit 29 to no association. 30,31 Heterogeneous findings may be due to differences in participant characteristics (e.g., veterans or younger participants) [29][30][31] or definitions of chronic kidney disease (e.g., varying eGFR thresholds and numbers of eGFR measurements). All existing studies used a "look-back" approach to assess the presence or absence of nephrology care (e.g., any previous contact with a nephrologist, 31 1 visit in the past year, 30 or using a 1-year landmark period).…”

“…All existing studies used a "look-back" approach to assess the presence or absence of nephrology care (e.g., any previous contact with a nephrologist, 31 1 visit in the past year, 30 or using a 1-year landmark period). 29 None addressed time-varying confounding. In our population-based, longitudinal design, we applied recommended definitions for stage 4 chronic kidney disease, 1 including alternative methods, 25 based on laboratory data captured from blood tests done within a defined geographical area.…”

Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

“…Using data that included veterans receiving care in 2010, Fung et al noted that 38% of study population with advanced CKD (eGFR#30 ml/min per 1.73 m 2 ) were followed by a nephrologist before reaching ESKD, and receipt of nephrology care was associated with lower mortality (6). Using more recent data, in those with diabetes and eGFR 15-29 ml/min per 1.73 m 2 , 38% of patients were seen by a VA nephrologist.…”

“…Previous studies have also reported that over one third of veterans who initiated chronic dialysis (between January 2000 and December 2001) were not receiving appropriate predialysis nephrology care (5). On the other hand, recent reports indicate that the receipt of predialysis nephrology care was associated with lower mortality among veterans (6). Several programs have been implemented to improve the quality of care delivered to the VA CKD population (7,8).…”

Racial Disparities in Nephrology Consultation and Disease Progression among Veterans with CKD: An Observational Cohort Study

“…Our analysis focused on the key process-of-care measure of nephrology consultation. 41 Prior studies that examined dialysis patient cohorts have reported that nephrology care before ESRD is associated with lower morbidity and mortality. 14,15,35,42,43 Nephrology consultation may benefit these patients through more timely placement of an arteriovenous fistula or graft instead of a dialysis catheter before dialysis initiation, as well as better control of BP, anemia, or metabolic parameters such as calcium, phosphorous, and parathyroid hormone concentrations.…”