A Novel Approach to Developing a Discordance Index for Older Adults With Chronic Kidney Disease

Abstract

Background Older adults with chronic kidney disease (CKD)-discordant conditions (comorbid conditions with treatment recommendations that potentially complicate CKD management) have greater risk of hospitalization and death. Our goal was to develop a CKD-Discordance Index using electronic health records to improve recognition of discordance. Methods This retrospective cohort included Kaiser Permanente Southern California patients aged ≥65 years with incident CKD (N=30,932). To guide inclusion of conditions in the Index and weight each condition, we first developed a prediction model for 1-year hospitalization risk using Cox regression. Points were assigned proportional to regression coefficients derived from the model. Next, the CKD-Discordance Index was calculated as an individual’s total points divided by the maximum possible discordance points. The association between CKD-Discordance Index and hospitalizations, ED visits, and mortality was accessed using multivariable adjusted Cox regression. Results Overall, mean (SD) age was 77.9 (7.6), 55% were female, 59.3% were white, and 32% (n=9,869) had ≥1 hospitalization during 1 year of follow-up. The CKD-Discordance Index included the following: heart failure, gastroesophageal reflux disease/peptic ulcer disease, osteoarthritis, dementia, depression, cancer, chronic obstructive pulmonary disease/asthma, and having ≥4 prescribers. Compared to those with a CKD-Discordance Index of 0, adjusted hazard ratios (95% CI) for hospitalization were 1.39 (1.27-1.51) and 1.81 (1.64-2.01) for those with a CKD-Discordance Index of 0.001-0.24 and ≥0.25, respectively (Ptrend<0.001). A graded pattern of risk was seen for ED visits and all-cause mortality. Conclusion A data-driven approach identified CKD-discordant indicators for a CKD-Discordance Index. Higher CKD-Discordance Index was associated with healthcare utilization and mortality.

Geriatric Syndromes and Health-Related Quality of Life in Older Adults with Chronic Kidney Disease

“… 40 For example, in a study of 436 Dutch individuals with CKD, over 80% reported weakness and one third had pain. 41 Although multiple medical conditions, often referred to as multimorbidity, has received much attention, 42 including in persons with CKD, 43 – 45 the presence of multiple geriatric syndromes in older adults has been relatively limited. Using cross-sectional Health and Retirement Study data, Cigolle et al found that older adults with multiple geriatric syndromes were more likely to have difficulties with activities of daily living.…”

Reserve and resilience in CKD: concept introduction and baseline results from the Physical REsilience Prediction in Advanced REnal Disease (PREPARED) study

“…While prior studies have shown that older adults with advanced CKD are at risk for functional decline, less is known about what contributes to their functional loss. One possibility is that older adults with advanced CKD commonly experience health stressors, including illnesses or injuries that require an acute care encounter such as an emergency department (ED) visit or hospitalization, and these events result in functional impairment [ 7 – 9 ]. One’s capacity to respond before a health stressor and the trajectory of functional recovery afterwards are described by the emerging geriatric concepts of reserve and resilience, respectively [ 10 , 11 ].…”

A Mobile App to Support Self-management of Chronic Kidney Disease: Development Study

“…In addition, CKD is usually accompanied by multiple comorbidities including type 2 diabetes, hypertension, and obesity [1,3], and individualized therapies to manage each comorbidity may not be concordant, which may frustrate the patient. Moreover, patients with CKD who receive discordant treatment recommendations owing to conditions that potentially complicate CKD management-for example, health failure or cancer-or because of having multiple medication prescribers have higher risk of health care usage and mortality [4].…”