Predialysis Cardiovascular Disease Medication Adherence and Mortality After Transition to Dialysis

Abstract

Background Medication non-adherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of pre-dialysis medication adherence among patients with advanced chronic kidney disease with mortality following their transition to dialysis. Study Design Observational study. Setting & Participants 32,348 US veterans who transitioned to dialysis during 2007–2011. Predictors Adherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the pre-dialysis year. Outcomes Post-dialysis initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders. Results The mean age of the cohort was 72±11 (SD) years, among whom 96% were male, 74% were white, 23% were African American, and 69% were diabetic. During median follow-up of 23 (IQR, 9–36) months, 18,608 patients died. Among patients with PDC >80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278–288]/1000 patient-years [PY]); among patients with PDC >60%–80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285–304]/1000 PY); among patients with PDC ≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271–313]/1000 PY). Compared to patients with PDC >80%, adjusted HR for post-dialysis initiation all-cause mortality for patients with PDC >60%–80% was 1.12 (95% CI, 1.08–1.16) and for patients with PDC ≤60% was 1.21 (95% CI, 1.11–1.30). In addition, compared to patients showing medication persistence, adjusted HR risk for post-dialysis initiation all-cause mortality for patients with non-persistence was 1.11 (95% CI, 1.05–1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses. Limitations Large number of missing values; the results may not be generalizable to women or the general US population. Conclusions Pre-dialysis cardiovascular medication non-adherence is an independent risk factor for post-dialysis mortality among advanced chronic kidney disease patients transitioning to dialysis. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis initiation.

Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease

“…A recent example is the linkage of the US Veterans Health Administration (VHA) database with the entire US national dialysis database, also known as the United States Renal Data System (USRDS) [27][28][29]. This innovative linkage has enabled researchers and care providers for the first time to examine the first two categories of transitions (from non-dialysis CKD to de novo RRT, see Table 1) including the impact of pre-ESRD conditions during the prelude period (see below) on early ESRD outcomes [27][28][29]. Transition categories 3 and 4 (inter-modality transitions) can also be examined via these data linkages during the first several months of dialysis therapy, where the impact of pre-dialysis conditions on dialysis outcomes is still likely substantial.…”

“…+3 months since dialysis initiation. This systemic definition of prelude has enabled a more efficient and commensurate analysis of pre-ESRD conditions and their impact on outcomes during RRT, as we have recently reported [27,28]. The concept of prelude has particularly facilitated the study of ESRD transition decisions, including timing and modality selection, associated with the best outcomes.…”

Pre-End-Stage Renal Disease Hemoglobin Variability Predicts Post-End-Stage Renal Disease Mortality in Patients Transitioning to Dialysis

“…We analyzed longitudinal data from the Transition of Care in CKD (TC-CKD) study, a retrospective cohort study examining US veterans with incident ESRD transitioning to dialysis from October 1, 2007 through September 30, 2011 [18–20]. A total of 52,172 US veterans were identified from the US Renal Data System (USRDS) [21] as a source population.…”

“…The start of the follow-up period was the date of dialysis initiation, and patients were followed up until death or other censoring events including kidney transplantation, loss of follow-up, or the last date of available follow-up (December 27, 2012 and October 6, 2011 for all-cause and cause-specific mortality, respectively) [18–20]. All-cause mortality data, censoring events, and associated dates were obtained from VA and USRDS data sources [21].…”

Evolution of Cardiovascular Disease During the Transition to End-Stage Renal Disease

“…48 The authors reported that 76% of patients had over 80% adherence to CVD medications prior to initiating dialysis. Patients with high CVD medication adherence were older, more likely to be white and married, and were more likely to initiate dialysis with an arteriovenous fistula.…”