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

Kalantar-Zadeh, Kamyar; Kövesdy, Csaba P.; Streja, Elani; Rhee, Connie M.; Soohoo, Melissa; Chen, Joline L.T.; Molnár, Miklós; Obi, Yoshitsugu; Gillen, Daniel L.; Nguyen, Danh V.; Norris, Keith C.; Sim, John J.; Jacobsen, S.J.

doi:10.1093/ndt/gfw357

Cited by 75 publications

(64 citation statements)

References 72 publications

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“…Kidney disease patients transitioning to dialysis-dependent CKD have a particularly high mortality risk within the first 6 months after the initiation of dialysis treatment compared to prevalent HD patients or renal transplant recipients [18, 31, 32]. Therefore, specialized pre-ESRD patient care, which focuses on factors that are commonly associated with adverse clinical events may improve post-ESRD outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…The analytical cohort was derived from the United States Renal Data System (USRDS) Special Study Center Transition of Care in CKD, which aimed to investigate incident ESRD US veterans who transitioned to ESRD between October 1, 2007 and March 30, 2014 [18-23]. Of the original population of 85,505 veterans derived from USRDS records, we excluded patients without data on follow-up ( n = 1,958) and with missing date of birth ( n = 3).…”

Section: Methodsmentioning

confidence: 99%

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Association of Pre-End-Stage Renal Disease Hemoglobin with Early Dialysis Outcomes

et al. 2018

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Background: Incident hemodialysis patients have a high mortality risk within the first months after dialysis initiation. Pre-end-stage renal disease (ESRD) factors like anemia management may impact early post-ESRD outcomes. Therefore, we evaluated the impact of pre-ESRD hemoglobin (Hgb) and pre-ESRD Hgb slope on post-ESRD mortality and hospitalization outcomes. Methods: The study included 31,472 veterans transitioning to ESRD. Using Cox and negative binomial regression models, we evaluated the association of pre-ESRD Hgb and Hgb slope with 12-month post-ESRD all-cause and cardiovascular mortality and hospitalization rates using 4 levels of hierarchical multivariable adjustment, including erythropoietin use and kidney decline in slope models. Results: The cohort was 2% female, 30% African-American, and on average 68 ± 11 years old. Compared to Hgb 10–< 11 g/dL, both low (< 10 g/dL) and high (≥12 g/dL) levels were associated with higher all-cause mortality after full adjustment (HR 1.25 [95% CI 1.15–1.35] and 1.09 [95% CI 1.02–1.18], respectively). Similarly, Hgb exhibited a U-shaped association with CV mortality, while only lower Hgb was associated with a higher hospitalization rate. Neither an annual pre-ESRD decline in Hgb nor increase was associated with higher post-ESRD mortality risk after adjustment for kidney decline. However, we observed a modest J-shaped association between pre-ESRD Hgb slope and post-ESRD hospitalization rate. Conclusions: Lower and higher pre-ESRD Hgb levels are associated with a higher risk of early post-ESRD mortality, while there was no association between the pre-ESRD slope and mortality. An increase in pre-ESRD Hgb slope was associated with higher risk of post-ESRD hospitalization. Additional studies aimed at anemia management prior to ESRD transition are warranted.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Association of Pre-End-Stage Renal Disease Hemoglobin with Early Dialysis Outcomes

et al. 2018

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“…The Transition of Care in CKD (TC‐CKD) study is a historical cohort of US veterans with incident ESRD . We included 64,930 veterans derived from the United States Renal Data System (USRDS) who transitioned to dialysis treatment from April 1, 2009, through March 30, 2014.…”

Section: Methodsmentioning

confidence: 99%

Association of Pre-ESRD Serum Calcium With Post-ESRD Mortality Among Incident ESRD Patients: A Cohort Study

Obi

Park

Soohoo

et al. 2018

Journal of Bone and Mineral Research

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Albumin-corrected serum calcium (cSCa) decline at late stages of chronic kidney disease and rise after dialysis initiation. Although hypercalcemia is associated with higher mortality in end-stage renal disease (ESRD), there are scarce data on the impact of pre-ESRD cSCa on post-ESRD mortality. Therefore, we used a large national cohort of 21,826 US veterans who transitioned to dialysis in all US Department of Veterans Affairs health care facilities over 2009 to 2014 to examine the associations with all-cause and cause-specific post-ESRD mortality of (1) cSCa concentrations averaged over the last 6 months and (2) its rate of decline during the last 12 months before dialysis initiation. Mean concentrations and median rate of decline of cSCa were 9.3 ± 0.7 mg/dL and -0.15 (interquartile range -0.39 to 0.07) mg/dL/year, respectively. A total of 9596 patients died during the follow-up period (mean 1.9 years; total 41,541 patient-years) with an incidence rate of 23.1 per 100 patient-years. There was an independent linear association between higher cSCa with higher mortality (p < 0.001). The mortality risk associated with cSCa ≥9.0 mg/dL was attenuated among active vitamin D users (p < 0.001). Patients with faster decline in cSCa showed lower mortality irrespective of baseline cSCa concentrations. These cSCa-mortality associations were stronger for noncardiovascular versus cardiovascular death. In conclusion, lower pre-ESRD cSCa and faster decline in cSCa were consistently and linearly associated with better post-ESRD survival among US veterans, especially for noncardiovascular death. Further studies are needed to determine if correcting hypocalcemia is beneficial or harmful and which intervention is preferred when indicated among patients transitioning to ESRD. © 2018 American Society for Bone and Mineral Research.

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“…We conducted a cohort study with longitudinal data from the Transition of Care in CKD (TC-CKD) study (22–25), a retrospective cohort study specifically examining U.S. veterans with advanced CKD who newly transitioned to treatment with dialysis. Our source population consisted of 52,172 patients from the national VA database who transitioned to treatment with dialysis over the period from 1 October 2007 to 30 September 2011 (1).…”

Section: Methodsmentioning

confidence: 99%

“…Our primary cohort was designated as the “Overall HbA 1c Cohort,” which was intended to capture all patients with diabetes, using a history of HbA 1c measurement as a sensitive proxy. The Overall HbA 1c Cohort included patients who did not have missing censoring event dates, were ≥18 years of age, and underwent one or more HbA 1c measurements up to 1 year preceding dialysis initiation (“prelude period”) (22). Because HbA 1c levels may have been measured in patients without diabetes (prediabetic patients), we also designated a “Restricted HbA 1c Cohort” using more specific criteria, including ICD-9 codes for diabetes, prior to dialysis initiation and/or cause of ESRD due to diabetes, that may potentially misclassify (i.e., under-capture) patients with diabetes (Supplementary Fig.…”

Section: Methodsmentioning

confidence: 99%

Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes

et al. 2017

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OBJECTIVEAlthough early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain. We hypothesized that glycemic status, defined by hemoglobin A1c (HbA1c) and random glucose levels, in the pre–end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD.RESEARCH DESIGN AND METHODSAmong 17,819 U.S. veterans with diabetic CKD transitioning to dialysis from October 2007 to September 2011, we examined the association of mean HbA1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survival models. Secondary analyses examined cardiovascular mortality using competing risks methods.RESULTSHbA1c levels ≥8% (≥64 mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6% to <7% [42–53 mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07–1.32] and 1.48 (1.31–1.67) for HbA1c 8% to <9% [64–75 mmol/mol] and ≥9% [≥75 mmol/mol], respectively). Random glucose levels ≥200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20–1.49]). Cumulative incidence curves showed that incrementally higher mean HbA1c and random glucose levels were associated with increasingly higher cardiovascular mortality.CONCLUSIONSIn patients with diabetes and CKD transitioning to dialysis, higher mean HbA1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.

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

Cited by 75 publications

References 72 publications

Association of Pre-End-Stage Renal Disease Hemoglobin with Early Dialysis Outcomes

Association of Pre-End-Stage Renal Disease Hemoglobin with Early Dialysis Outcomes

Association of Pre-ESRD Serum Calcium With Post-ESRD Mortality Among Incident ESRD Patients: A Cohort Study

Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes

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