Hospitalization during advancing chronic kidney disease

One Nation-One Dialysis: Breaking Barriers, Empowering Lives

The objective of India's One Nation One Dialysis (ONOD) program is to remove the barriers that end-stage kidney disease patients face in accessing consistent, quality dialysis services across the nation. A unified and standardized dialysis care approach is what ONOD aims to achieve at a national level. The objective of ONOD is to improve access to, affordability of, and quality in dialysis services for economically weaker segments of society and those living in remote areas of the country by providing dialysis services through public-private partnerships. The ONOD program places a lot of emphasis on the infrastructure development, funding support, skill development, regulatory reforms, and technological integration of dialysis services. By implementing ONOD, India can improve patient outcomes, close the supply-demand gaps for end-stage kidney disease kidney replacement therapy, and create a more balanced and sustainable kidney healthcare ecosystem.

Association between physical function and hospitalization among older patients with pre-dialysis chronic kidney disease after educational hospitalization: A single-center prospective cohort study

INTRODUCTION

This study aimed to investigate the factors associated with hospitalization in older patients with pre-dialysis CKD, including physical function.

METHODS

This single-center, prospective cohort study included 111 patients aged ≥65 years with stage 3-5 non-hemodialyzed CKD. Physical function was assessed using the short physical performance battery (SPPB), 10-m walk test, and grip strength test. Hospitalizations and reasons for readmission were tracked from discharge to the end of the follow-up period.

RESULTS

Kaplan-Meier analysis showed significant associations between rehospitalization and SPPB, 10-meter walk speed, and grip strength. The cutoff values predicting rehospitalization were 11 points for SPPB, 1.1 m/s for 10-meter walk speed, and 31 kg for grip strength. Multivariate Cox regression revealed that SPPB, hemoglobin, and estimated glomerular filtration rate (eGFR) were independently associated with rehospitalization risk.

CONCLUSIONS

SPPB may predict hospitalization in older pre-dialysis CKD patients, emphasizing the importance of screening and preventing physical function decline.

Interactive Computer-Adaptive Chronic Kidney Disease (I-C-CKD) Education for Hospitalized African American Patients: Protocol for a Randomized Controlled Trial

BACKGROUND

End-stage kidney disease (ESKD) or kidney failure is a condition where the kidneys lose the ability to function. African American individuals are 4 times as likely to develop ESKD compared to White American individuals. In addition, African American patients are less likely to have an optimal dialysis start and to choose renal replacement therapy modalities that align with their goals and values. Our prior work shows that culturally tailored, in-person education improves patient outcomes. This is the foundation for our innovative intervention using an African American virtual patient educator as an option for hospitalized patients with chronic kidney disease (CKD).

OBJECTIVE

The Interactive Computer-Adaptive Chronic Kidney Disease (I-C-CKD) study will determine whether the computerized adaptive education and usual hospital care impact the health literacy of African American patients with kidney disease. It will also assess how patients' lifestyle and commitment to health goals are impacted by the method of health literacy education.

METHODS

We will screen, recruit, and enroll hospitalized patients who self-identify as African American and have advanced CKD based on their estimated glomerular filtration rate. Eligible patients who verbally consented will be randomly assigned into either the computerized adaptive education intervention group or the control group (usual hospital care). Patients in the intervention group will receive a culturally tailored, adaptive education module. To analyze pretest, posttest, and follow-up survey results on patient CKD knowledge, ESKD treatment options, and health goals, we will use a paired, 2-tailed t test with a Bonferroni adjustment for multiple comparisons.

RESULTS

Recruitment for the I-C-CKD study began on May 2, 2023. We are currently recruiting and have enrolled 96 patients who completed both pretest and posttest surveys as of December 2024. This includes 50 patients in the control group and 46 patients in the intervention group. Data analysis has not occurred.

CONCLUSIONS

African American individuals often receive less patient education about self-care and treatment options for CKD. We hope this study provides a solution to increase hospitalized African American patients' knowledge of CKD and motivation for CKD self-care through computerized adaptive education, reduce disparities, and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06364358; https://clinicaltrials.gov/study/NCT06364358.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66846.

Hospitalization Causes and Epidemiological Characteristics Among Patients With End-Stage Renal Disease: A Six-Year Retrospective Study

BACKGROUND

Chronic kidney disease (CKD) leads to a high rate of complications requiring hospital admission for advanced management. Therefore, this study aims to analyze the main causes of hospitalization following the initiation of renal replacement therapy (RRT).

MATERIALS AND METHODS

This observational and descriptive study utilized a non-probabilistic quota sampling method, reviewing a total of 423 medical records from General Regional Hospital 1 of the Mexican Social Security Institute in Querétaro. The study evaluated the frequency and causality of hospitalizations during a retrospective period from 2018 to 2023.

RESULTS

There were 1,162 hospitalization events involving 423 patients; 71.63% of patients started RRT with peritoneal dialysis, while 26% began with hemodialysis. The leading cause of hospitalization was electrolyte imbalance (397; 34.17%), followed by peritonitis associated with peritoneal dialysis (351; 30.21%), change to hemodialysis (270; 23.24%), Tenckhoff catheter dysfunction (209; 17.99%), and fluid overload (205; 17.64%). The group with the highest number of events was renal-related complications, followed by infectious causes.

CONCLUSIONS

Hospitalizations in end-stage CKD patients often arise from the complex renal pathophysiology and complications related to acute and decompensated renal function. This condition refers to the kidneys' failure to maintain essential physiological functions despite ongoing treatment, leading to issues such as electrolyte imbalances, fluid overload, and uremic syndrome. To reduce morbidity and mortality, measures such as enhanced training in ambulatory dialysis, improved catheter care, and early infection detection are crucial. A comprehensive approach that addresses both acute issues and preventive strategies is essential for improving clinical outcomes and quality of life for these patients.

Care trajectory differences in women and men with end-stage renal disease after dialysis initiation

Few studies investigated sex-related differences in care consumption after dialysis initiation. Therefore, the aim of this study was to compare the care trajectory in the first year after dialysis start between men and women by taking into account the context of dialysis initiation. All patients who started dialysis in France in 2015 were included. Clinical data of patients and context of dialysis initiation were extracted from the Renal Epidemiology and Information Network (REIN) registry. Data on care consumption in the first year after dialysis start came from the French national health data system (SNDS): hospital stays <24h, hospital stays to prepare or maintain vascular access, hospital stays >24h for kidney problems and hospital stays >24h for other problems, and consultations with a general practitioner. Variables were compared between men and women with the χ2 test and Student's or Welch t-test and logistic regression models were used to identify the factors associated with care consumption after dialysis start. The analysis concerned 8,856 patients (36% of women). Men were less likely to have a hospital stays >24h for kidney problems than women (OR = 0.8, 95% CI = [0.7-0.9]) and less general practitioner consultations (OR = 0.8, 95% CI = [0.8-0.9]), in the year after dialysis initiation, after adjustment on patient's characteristics. Moreover, hospital stays for vascular access preparation or maintenance were longer in women than men (median duration: 2 days [0-2] vs. 1 day [0-2], p < 0.001). In conclusion, despite greater comorbidities in men, this study found few differences in post-dialysis care trajectory between men and women.

Antibiotic availability for outpatient treatment of acute peritonitis in chronic peritoneal dialysis patients: A case series

BACKGROUND

Peritoneal dialysis (PD) is a commonly used form of renal replacement therapy for patients that have reached end-stage renal disease. Acute bacterial peritonitis (ABP) in chronic PD patients results in pain, increased costs, injury to the peritoneal membrane, and PD modality failure. Optimal antibiotic treatment of acute bacterial peritonitis (ABP) in chronic PD patients should be intraperitoneal, outpatient-based, appropriate, prompt, and uninterrupted. We investigated the frequency of and predisposition to suboptimal antibiotic courses for ABP in our chronic PD patients.

METHODS

Twenty-four charts of patients with ABP were reviewed, to test the null hypothesis that all ABP patients received antibiotics optimally.

RESULTS

After 12 patient exclusions (hospitalization), 9 suboptimal antibiotic events were detected in 6 of the remaining 12 patients, disproving the null hypothesis (p < 0.02). Most suboptimal antibiotics courses (7 of 9) resulted from delays and/or gaps in therapy or antibiotics prescribed outside of community standard. Suboptimal antibiotic events occurred on nights and weekends rather than during the workweek (p < 0.02) and in the emergency room rather than the PD clinic (p < 0.02).

CONCLUSIONS

Suboptimal ABP antibiotic therapy occurs commonly and is influenced by time and location of presentation and lack of knowledge by patients and physicians. Prevention of suboptimal antibiotic courses in the treatment of ABP in chronic PD patients includes education of patients and providers and allowing emergency rooms and PD clinics to dispense antibiotics for home use.

Causes of Hospitalization among End-Stage Kidney Disease Cohort before and after Hemodialysis

Patients with end-stage kidney disease (ESKD) have a greater risk of comorbidities, including diabetes and anemia, and have higher hospital admission rates than patients with other diseases. The cause of hospital admissions is associated with ESKD prognosis. This retrospective cohort study involved patients with ESKD who received hemodialysis and investigated whether the cause of hospital admission changed before versus after they started hemodialysis. This study recruited 592 patients with ESKD who received hemodialysis at any period between January 2005 and November 2017 and had been assigned the International Classification of Diseases Ninth Revision Clinical Modification (ICD-9-CM) code for ESKD. The patients' demographic data and hospitalization status one year before and two years after they received hemodialysis were analyzed. A McNemar test was conducted to analyze the diagnostic changes from before to after hemodialysis in patients with ESKD. The study's sample of patients with ESKD comprised more women (51.86%) than men and had an average age of 67.15 years. The numbers of patients admitted to the hospital for the following conditions all decreased significantly after they received hemodialysis: type 2 (non-insulin-dependent and adult-onset) diabetes; native atherosclerosis; urinary tract infection; gastric ulcer without mention of hemorrhage, perforation, or obstruction; pneumonia; reflux esophagitis; duodenal ulcer without mention of hemorrhage, perforation, or obstruction; and bacteremia. Most patients exhibited one or more of the following comorbidities: diabetes (n = 407, 68.75%), hypertension (n = 491, 82.94%), congestive heart failure (n = 161, 27.20%), ischemic heart disease (n = 125, 21.11%), cerebrovascular accident (n = 93, 15.71%), and gout (n = 96, 16.22%). An analysis of variance (ANOVA) indicated that changes in the ICD-9-CM codes for native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were associated with age. Patients who developed pneumonia before or after they received hemodialysis tended to be older (range: 69-70 years old). This study investigated the causes of hospital admission among patients with ESKD one year before and two years after they received hemodialysis. This study's results revealed hypertension to be the most common comorbidity. Regarding the cause of admission, pneumonia was more prevalent in older than in younger patients. Moreover, changes in the ICD-9-CM codes of native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were significantly correlated with age. Therefore, when administering comprehensive nursing care and treatment for ESKD, clinicians should not only focus on comorbidities but also consider factors (e.g., age) that can affect patient prognosis.

Cost of End-of-Life Inpatient Encounters in Patients with Chronic Kidney Disease in the United States: A Report from the DISCOVER CKD Retrospective Cohort

INTRODUCTION

Real-world data reporting healthcare resource utilisation and costs associated with end-of-life care for patients with chronic kidney disease (CKD) are limited. We examined length of hospitalisation and costs associated with end-of-life inpatient encounters using retrospective data from DISCOVER CKD.

METHODS

Data on inpatient encounters for patients with CKD aged ≥ 18 years between January 2016 and March 2020 were extracted from the US Premier Hospital Database. Encounters ending in death were identified and grouped by reason for the encounter, using the International Classification of Diseases, Tenth Revision, and by their insurance coverage. Encounters were evaluated overall and stratified according to cardiovascular (CV), kidney failure and infection-related reasons, and by their coverage by commercial, Medicaid, Medicare or other insurers. Length of hospitalisation and total costs were calculated for encounters.

RESULTS

Among 237,734 encounters ending in death, the mean [standard deviation (SD)] age was 74.2 (12.4) years, and 45.3% of patients were female. In total, 25,118, 4210 and 76,307 encounters were classified as relating to CV reasons, kidney failure and infection, respectively. Among all encounters, the mean (SD) length of hospitalisation ranged from 9.1 (11.2) (Medicare) to 12.8 (18.4) (Medicaid) days. Across insurers, encounters related to kidney failure were associated with the longest hospitalisations compared with CV and infection [mean range (days): 10.7-15.9 vs. 7.5-10.5 and 8.7-12.7, respectively]. The median [interquartile range (IQR)] total cost of any inpatient encounter was $17,057 ($8040-35,873). Kidney failure-related encounters had higher costs compared with CV and infection [median (IQR), $18,469 ($8673-38,315) vs. $17,503 ($7766-39,693) and $16,403 ($7762-34,910), respectively]. Medicaid-covered encounters had the highest costs of all insurers [median (IQR), $16,189 ($7725-33,443)].

CONCLUSIONS

Among patients with CKD, end-of-life encounters were most frequently related to infection. Encounters relating to kidney failure incurred the highest costs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04034992.

Group-Based Exercise in CKD Stage 3b to 4: A Randomized Clinical Trial

Rationale & Objective

We aimed to test interventions to improve physical activity in persons with advanced chronic kidney disease not yet receiving dialysis.

Study Design

Randomized controlled trial with parallel-group design.

Setting & Participants

We embedded a pragmatic referral to exercise programming in high-volume kidney clinics servicing diverse populations in San Jose, CA, and Atlanta, GA. We recruited 56 participants with estimated glomerular filtration rates < 45 mL/min/1.73 m².

Interventions

We randomly assigned participants to a mobile health (mHealth) group—wearable activity trackers and fitness professional counseling, or an Exercise is Medicine intervention framework (EIM) group—mHealth components plus twice-weekly small-group directed exercise sessions customized to persons with kidney disease. We performed assessments at baseline, 8 weeks at the end of active intervention, and 16 weeks after passive follow-up and used multilevel mixed models to assess between-group differences.

Outcomes

Activity tracker total daily step count.

Results

Of 56 participants, 86% belonged to a racial/ethnic minority group; randomly assigned groups were well balanced on baseline step count. In intention-to-treat analyses, the EIM and mHealth groups both experienced declines in daily step counts, but there was an attenuated reduction in light intensity physical activity (standard error 0.2 [5.8] vs −8.5 [5.4] min/d; P = 0.08) in the EIM compared with the mHealth group at 8 weeks. In as-treated analyses, total daily step count, distance covered, and light and moderate-vigorous activity minutes per day improved in the EIM group and declined in the mHealth group at 8 weeks (standard error +335 [506] vs −884 [340] steps per day; P = 0.05; P < 0.05 for secondary measures), but group differences faded at 16 weeks. There were no differences in quality-of-life and mental health measures during the study.

Limitations

Small sample size, limited duration of study, assessment of intermediate outcomes (steps per day).

Conclusions

A clinic-integrated referral to small-group exercise sessions is feasible, safe, and moderately effective in improving physical activity in an underserved population with high comorbid conditions.

Funding

Normon S Coplon Applied Pragmatic Clinical Research program.

Trial Registration

NCT03311763

Costs associated with the administration of erythropoiesis-stimulating agents for the treatment of anemia in patients with non-dialysis-dependent chronic kidney disease: a US societal perspective

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are commonly used to treat anemia due to chronic kidney disease (CKD). In addition to drug acquisition costs, the administration of ESAs can include direct and indirect costs due to the needle-based route of administration (eg, time spent by health care staff administering therapy, and patients' and caregivers' time spent receiving or assisting with therapy). However, a comprehensive assessment of the costs associated with the administration of ESAs is lacking. OBJECTIVE: To estimate the excess costs associated with the needle-based administration of ESAs for the treatment of anemia due to non-dialysis-dependent (NDD) CKD in the United States in 2019 from a societal perspective. METHODS: Excess costs associated with ESA administration were estimated as the sum of annual costs that could be avoided with the introduction of an oral treatment with comparable safety and efficacy to ESAs. Cost components included direct health care costs, transportation costs, and work productivity loss costs from the perspective of both patients and caregivers (as applicable). Costs were estimated based on scientific publications, governmental agencies, and the results of a recent survey of US patients and caregivers of patients with anemia and CKD. The setting of the administration (ie, at home vs in clinic), frequency of administration, and insurance type were considered. RESULTS: At the societal level, annual excess costs associated with ESA administration were estimated at $2.5 billion in the United States in 2019, based on an estimated 462,005 patients with anemia and NDD-CKD treated with ESAs. Overall, 94.4% ($2.4 billion) of these costs were incurred from in-clinic ESA administration. When stratifying costs by insurance type, Medicare-insured patients accounted for 79.4% ($2.0 billion) of total annual excess costs. The largest contributor to total annual excess costs was direct health care costs ($1.4 billion, 54.9%), followed by patient work productivity loss costs ($846 million, 33.9%), caregiver work productivity loss costs ($197 million, 7.9%), and transportation costs ($81 million, 3.3%). Total annual excess costs of in-clinic administration ranged from $2,572 per patient receiving monthly administration to $20,948 per patient receiving thrice-weekly administration, while the total annual excess costs of at-home administration ranged from $1,123 per patient receiving monthly administration to $2,109 per patient receiving thrice-weekly administration. At the ESA administration level (ie, for each ESA administration), total excess costs were estimated at $128 per in-clinic ESA administration and $7 per at-home ESA administration, excluding monitoring costs. CONCLUSIONS: The needle-based administration of ESAs in patients with NDD-CKD is associated with a substantial economic burden. The introduction of an oral treatment has the potential to result in important cost savings from a societal perspective. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development & Commercialization, Inc., and Akebia Therapeutics, Inc. The study sponsors participated in the study design, data collection, analysis, interpretation of the data, writing of the report, and in the decision to submit the manuscript for publication. Gauthier-Loiselle, Cloutier, Serra, Bungay, and Guérin are employees of Analysis Group, Inc., a consulting firm that received funding from Otsuka Pharmaceutical Development & Commercialization, Inc., for the conduct of this study. Michalopoulos was an employee of Otsuka Pharmaceutical Development & Commercialization, Inc., at the time the study was conducted. Szabo is an employee of Akebia Therapeutics, Inc.

Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist

OBJECTIVES

Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs).

METHODS

A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling.

KEY FINDINGS

In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001).

CONCLUSIONS

Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

Impact of Chronic Kidney Disease on Revascularization and Outcomes in Patients with ST-Elevation Myocardial Infarction

Chronic kidney disease (CKD) in patients with ST-elevation myocardial infarction (STEMI) is associated with worse outcomes. We assessed the impact of CKD on guideline directed coronary revascularization and outcomes among STEMI patients. The Nationwide Inpatient Sample dataset from 2012-2014 was used to identify patients with STEMI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were categorized as non-CKD, CKD without dialysis, and CKD with dialysis (CKD-HD). Outcomes were revascularization, death and acute renal failure requiring dialysis (ARFD). A total of 534,845 were included (88.9% non-CKD; 9.6% CKD without dialysis, and 1.5% CKD-HD). PCI was performed in 77.4% non-CKD, 56.2% CKD without dialysis, and 48% CKD-HD patients (p < 0.0001). In-hospital mortality and ARFD were significantly higher in CKD patients (16.5% and 40.6%) compared with non-CKD patients (7.12% and 7.17%) (p < 0.0001). In-hospital mortality was significantly lower in patients treated revascularization compared with patients treated medically (non-CKD: adjusted odds ratio (aOR) 0.280, p < 0.0001; CKD without dialysis: aOR 0.39, p < 0.0001; CKD-HD: aOR 0.48, p < 0.0001). CKD was associated with higher length of hospital stay and cost (5.86 ± 13.97, 7.57 ± 26.06 and 3.99 ± 11.09 days; p < 0.0001; $25,696 ± $63,024, $35,666 ± $104,940 and $23,264 ± $49,712; p < 0.0001 in non-CKD, CKD without dialysis and CKD-HD patients respectively). In conclusion, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. Coronary revascularization for STEMI in CKD patients was associated with lower mortality compared to medical management. The presence of CKD in patients with STEMI is associated with higher mortality and ARFD, prolonged hospital stay and higher hospital cost.

Temporal evolution of C-reactive protein levels and its association with the incident hospitalization risk among individuals with stage 3-4 chronic kidney disease

BACKGROUND

Elevated C-reactive protein (CRP) levels as an inflammatory marker have been associated with poor outcomes in patients with chronic kidney disease (CKD). However, its single assessment may not reflect clinical significance before an adverse clinical endpoint. We studied the CRP level trajectories, which may be related with the intensity of the inflammatory process, and its association with time-to-first hospitalization in CKD.

METHODS

A cohort of 739 patients with stage 3-4 CKD were retrospectively observed for seven years. The time-to-event outcome was all-cause hospitalization. Clinical and laboratory features were measured at baseline. Longitudinal changes in naturally logged CRP levels were modeled using the Joint Longitudinal-Survival model adjusted with baseline covariates.

RESULTS

Logged CRP changes were evaluated with a median measurement (interquartile range) of 4 (2, 7), during a median (interquartile range) follow-up of 2.3 (1.2, 3.9) years. The estimated mean increase in logged CRP was 0.35 mg/L per year. 299 (40.5%) patients reached the endpoint, and increase in logged CRP with time was associated with increased risk of hospitalization (HR 1.96; 95% CI 1.05-3.66; p = 0.034), but baseline logged CRP did not have a significant effect on the time-to-first hospitalization (HR 0.98; 95% CI 0.85-1.13; p = 0.736).

CONCLUSION

All-cause hospitalization was associated significantly with CRP trajectories. Temporal evolutions of these repeatedly measured biomarkers might predict clinical outcomes in patients with CKD and may be useful for individual risk profiling. Furthermore, early management may provide an opportunity to better patient survival.

Hospitalization Trajectories and Risks of ESKD and Death in Individuals With CKD

INTRODUCTION

Management of chronic kidney disease (CKD) entails high medical complexity and often results in high hospitalization burden. There are limited data on the associations of longitudinal hospital utilization patterns with adverse clinical outcomes in individuals with CKD.

METHODS

We derived cumulative all-cause hospitalization trajectory groups using latent class trajectory analysis in 3012 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study who were alive and did not reach end-stage kidney disease (ESKD) within 4 years of study entry. Cox proportional hazards models tested the associations between hospitalization trajectory groups and risks of ESKD and death prior to the onset of ESKD (ESKD-censored death).

RESULTS

Within 4 years of study entry, there were 5658 hospitalizations among 3012 participants. We identified 3 distinct subgroups of individuals with CKD based on cumulative all-cause hospitalization trajectories over 4 years: low-utilizer (n = 1066), intermediate-utilizer (n = 1802), and high-utilizer (n = 144). High-utilizers represented a patient population of lower socioeconomic status who had a greater prevalence of comorbid conditions and lower kidney function compared with intermediate- and low-utilizers. After the 4-year ascertainment period to form the trajectory subgroups, there were 544 ESKD events and 437 ESKD-censored deaths during a median follow-up time of 5.1 years. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.49-fold (95% confidence interval [CI] 1.22-1.84) and 1.75-fold (95% CI 1.20-2.56) higher risk of ESKD in adjusted analyses, respectively. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.48-fold (95% CI 1.17-1.87) and 2.58-fold (95% CI 1.74-3.83) higher risk of ESKD-censored death in adjusted analyses, respectively.

CONCLUSIONS

Trajectories of cumulative all-cause hospitalization identify subgroups of individuals with CKD who are at high risk of ESKD and death.

Baseline characteristics and outcomes of end-stage renal disease patients after in-hospital sudden cardiac arrest: a national perspective

PURPOSE

End-stage renal disease (ESRD) is a well-recognized risk factor for the development of sudden cardiac arrest (SCA). There is limited data on baseline characteristics and outcomes after an in-hospital SCA event in ESRD patients.

METHODS

For the purpose of this study, data were obtained from the National Inpatient Sample from January 2007 to December 2017. In-hospital SCA was identified using the International Classification of Disease, 9th Revision, Clinical Modification and International Classification of Disease, 10th Revision, Clinical Modification codes of 99.60, 99.63, and 5A12012. ESRD patients were subsequently identified using codes of 585.6 and N18.6. Baseline characteristics and outcomes were compared among ESRD and non-ESRD patients in crude and propensity score (PS)-matched cohorts. Predictors of mortality in ESRD patients after an in-hospital SCA event were analyzed using a multivariate logistic regression model.

RESULTS

A total of 1,412,985 patients sustained in-hospital SCA during our study period. ESRD patients with in-hospital SCA were younger and had a higher burden of key co-morbidities. Mortality was similar in ESRD and non-ESRD patients in PS-matched cohort (70.4% vs. 70.7%, p = 0.45) with an overall downward trend over our study years. Advanced age, Black race, and key co-morbidities independently predicted increased mortality while prior implantable defibrillator was associated with decreased mortality in ESRD patients after an in-hospital SCA event.

CONCLUSIONS

In the context of in-hospital SCA, mortality is similar in ESRD and non-ESRD patients in adjusted analysis. Adequate risk factor modification could further mitigate the risk of in-hospital SCA among ESRD patients.

Hospitalizations among adults with chronic kidney disease in the United States: A cohort study

BACKGROUND

Adults with chronic kidney disease (CKD) are hospitalized more frequently than those without CKD, but the magnitude of this excess morbidity and the factors associated with hospitalizations are not well known.

METHODS AND FINDINGS

Data from 3,939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study between 2003 and 2008 at 7 clinical centers in the United States were used to estimate primary causes of hospitalizations, hospitalization rates, and baseline participant factors associated with all-cause, cardiovascular, and non-cardiovascular hospitalizations during a median follow up of 9.6 years. Multivariable-adjusted Poisson regression was used to identify factors associated with hospitalization rates, including demographics, blood pressure, estimated glomerular filtration rate (eGFR), and proteinuria. Hospitalization rates in CRIC were compared with rates in the Nationwide Inpatient Sample (NIS) from 2012. Of the 3,939 CRIC participants, 45.1% were female, and 41.9% identified as non-Hispanic black, with a mean age of 57.7 years, and the mean eGFR is 44.9 ml/min/1.73m2. CRIC participants had an unadjusted overall hospitalization rate of 35.0 per 100 person-years (PY) [95% CI: 34.3 to 35.6] and 11.1 per 100 PY [95% CI: 10.8 to 11.5] for cardiovascular-related causes. All-cause, non-cardiovascular, and cardiovascular hospitalizations were associated with older age (≥65 versus 45 to 64 years), more proteinuria (≥150 to <500 versus <150 mg/g), higher systolic blood pressure (≥140 versus 120 to <130 mmHg), diabetes (versus no diabetes), and lower eGFR (<60 versus ≥60 ml/min/1.73m2). Non-Hispanic black (versus non-Hispanic white) race/ethnicity was associated with higher risk for cardiovascular hospitalization [rate ratio (RR) 1.25, 95% CI: 1.16 to 1.35, p-value < 0.001], while risk among females was lower [RR 0.89, 95% CI: 0.83 to 0.96, p-value = 0.002]. Rates of cardiovascular hospitalizations were higher among those with ≥500 mg/g of proteinuria irrespective of eGFR. The most common causes of hospitalization were related to cardiovascular (31.8%), genitourinary (8.7%), digestive (8.3%), endocrine, nutritional or metabolic (8.3%), and respiratory (6.7%) causes. Hospitalization rates were higher in CRIC than the NIS, except for non-cardiovascular hospitalizations among individuals aged >65 years. Limitations of the study include possible misclassification by diagnostic codes, residual confounding, and potential bias from healthy volunteer effect due to its observational nature.

CONCLUSIONS

In this study, we observed that adults with CKD had a higher hospitalization rate than the general population that is hospitalized, and even moderate reductions in kidney function were associated with elevated rates of hospitalization. Causes of hospitalization were predominantly related to cardiovascular disease, but other causes contributed, particularly, genitourinary, digestive, and endocrine, nutritional, and metabolic illnesses. High levels of proteinuria were observed to have the largest association with hospitalizations across a wide range of kidney function levels.

Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study

Patients with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.

Analysis of 2897 hospitalization events for patients with chronic kidney disease: results from CKD-JAC study

BACKGROUND

Chronic kidney disease is a known risk factor for end-stage renal and cardiovascular diseases. However, data are limited on the causes of hospitalization in patients with chronic kidney disease of maintenance period. This study aimed to aggregate hospitalization data of CKD patients and to determine the high-risk population. In addition, we compared CKD population to general population.

METHODS

We conducted a post hoc analysis of the chronic kidney disease-Japan cohort study, a multicenter prospective cohort study of 2966 patients with chronic kidney disease with a median 3.9 years of follow-up. We examined the hospitalization reasons and analyzed the risk factors.

RESULTS

We found 2897 all-cause hospitalization events (252.3 events/1000 person-years), a hospitalization incidence 17.1-fold higher than that in an age- and sex-matched cohort from the general Japanese population. Kidney, eye and adnexa, and heart-related hospital admissions were the most common. All-cause hospitalization increased with chronic kidney disease stage and with the presence of diabetes. Patients with diabetes at enrollment had 345.7 hospitalization events/1000 person-years, which is considerably higher than 196.8 events/1000 person-years for those without diabetes. Survival analysis, using hospitalization as an event, showed earlier all-cause hospitalization with the progression of chronic kidney disease stage and diabetes. Cardiovascular disease hospitalizations were more strongly influenced by diabetes than chronic kidney disease stage.

CONCLUSIONS

Patients with chronic kidney disease and diabetes are highly vulnerable to hospitalization for a variety of diseases. These descriptive data can be valuable in predicting the prognosis of patients with chronic kidney disease.

Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients

BACKGROUND

Patients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown.

METHODS

We evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation.

RESULTS

Mean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), infection related hospitalization (OR, 1.51; CI, 1.45-1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83-1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19-1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization.

CONCLUSION

Pre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.

Patient Experience with Primary Care Physician and Risk for Hospitalization in Hispanics with CKD

BACKGROUND AND OBJECTIVES

In the general population, the quality of the patient experience with their primary care physician may influence health outcomes but this has not been evaluated in CKD. This is relevant for the growing Hispanic CKD population, which potentially faces challenges to the quality of the patient experience related to language or cultural factors. We evaluated the association between the patient experience with their primary care physician and outcomes in Hispanics with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This prospective observational study included 252 English- and Spanish-speaking Hispanics with entry eGFR of 20-70 ml/min per 1.73 m2, enrolled in the Hispanic Chronic Renal Insufficiency Cohort study between 2005 and 2008. Patient experience with their primary care physician was assessed by the Ambulatory Care Experiences Survey subscales: communication quality, whole-person orientation, health promotion, interpersonal treatment, and trust. Poisson and proportional hazards models were used to assess the association between the patient experience and outcomes, which included hospitalization, ESKD, and all-cause death.

RESULTS

Participants had a mean age of 56 years, 38% were women, 80% were primary Spanish speakers, and had a mean eGFR of 38 ml/min per 1.73 m2. Over 4.8 years (median) follow-up, there were 619 hospitalizations, 103 ESKD events, and 56 deaths. As compared with higher subscale scores, lower scores on four of the five subscales were associated with a higher adjusted rate ratio (RR) for all-cause hospitalization (communication quality: RR, 1.54; 95% confidence interval [95% CI], 1.25 to 1.90; health promotion: RR, 1.31; 95% CI, 1.05 to 1.62; interpersonal treatment: RR, 1.50; 95% CI, 1.22 to 1.85; and trust: RR, 1.57; 95% CI, 1.27 to 1.93). There was no significant association of subscales with incident ESKD or all-cause death.

CONCLUSIONS

Lower perceived quality of the patient experience with their primary care physician was associated with a higher risk of hospitalization.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

Inequality in Care and Differences in Outcome Following Stroke in People With ESRD

Introduction

Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality.

Methods

This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses.

Results

A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84).

Conclusion

Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.

Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5

Background

Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent.

Methods

The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable.

Results

Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable.

Conclusions

Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.

Hospital Readmission among New Dialysis Patients Associated with Young Age and Poor Functional Status

BACKGROUND/AIMS

Over one-third of hospital discharges among dialysis patients are followed by 30-day readmission. The first year after dialysis start is a high-risk time frame. We examined the rate, causes, timing, and predictors of 30-day readmissions among adult, incident dialysis patients.

METHODS

Hospital readmissions were assessed from the 91st day to the 15th month after the initiation of dialysis using a Mayo Clinic registry linkage to United States Renal Data System claims during the period January 2001-December 2010.

RESULTS

Among 1,727 patients with ≥1 hospitalization, 532 (31%) had ≥1, and 261 (15%) had ≥2 readmissions. Readmission rate was 1.1% per person-day post-discharge, and the highest rates (2.5% per person-day) occurred ≤5 days after index admission. The overall cumulative readmission rate was 33.8% at day 30. Common readmission diagnoses included cardiac issues (22%), vascular disorders (19%), and infection (13%). Similar-cause readmissions to index hospitalization were more common during days 0-14 post-discharge than days 15-30 (37.5 vs. 22.9%; p = 0.004). Younger age at dialysis initiation, inability to transfer/ambulate, serum creatinine ≤5.3 mg/dL, higher number of previous hospitalizations, and longer duration on dialysis were associated with higher readmission rates in multivariable analyses. Patients aged 18-39 were few (8.3%) but comprised 17.7% of "high-readmission" users such that a 30-year-old patient had an 87% chance of being readmitted within 30 days of any hospital discharge, whereas an 80-year-old patient had a 25% chance.

CONCLUSIONS

Overall, 30-day readmissions are common within the first year of dialysis start. The first 10-day period after discharge, young patients, and those with poor functional status represent key areas for targeted interventions to reduce readmissions.

Trends in the Management of Patients With Kidney Failure in Alberta, Canada (2004-2013)

BACKGROUND

Based on clinical practice guidelines, specific quality indicators are examined to assess the performance of a health care system for patients with end-stage renal disease (ESRD). We examined trends in the proportion of patients with ESRD referred late to nephrology, timing of dialysis initiation in those with chronic kidney disease, and proportion of patients with ESRD treated with pre-emptive kidney transplantation or peritoneal dialysis (PD). Design:: This was a retrospective cohort study. Setting:: The study was conducted in Alberta, Canada. Patients:: Alberta residents aged 18 years or older with incident ESRD requiring renal replacement therapy between 2004 and 2013 were included. Measurements:: Descriptive statistics, and log binomial and linear regression models were used for analysis. Methods:: We determined the proportion of patients with ESRD who did not see a nephrologist within 90 days prior to starting dialysis (late referrals) and those who were receiving PD 90 days after dialysis initiation. Among those who had been seen by a nephrologist for at least 90 days, we also assessed the proportion who initiated dialysis with estimated glomerular filtration rate (eGFR) higher than or equal to 10.5 mL/min/1.73 m2, and underwent a pre-emptive transplant. Results:: Our cohort included 5343 patients (mean age 61.8 years, 61.2% male). Over a 10-year period, there was a decrease in the proportion of late referrals (26.4% to 21.1%, P = .001). We also noted a decrease in the proportion of dialysis initiation with eGFR higher than or equal to 10.5 mL/min/1.73 m2 (21.2% to 14.7%, P < .001), with a significant increase in the proportion of patients initiating dialysis as an inpatient (38.8% to 45.2%, P = .001). There was a non-significant decrease in both the proportion of patients treated with a pre-emptive transplant and PD at 90 days over the 10-year period. Limitations:: The use of administrative data restricted the availability of clinical data regarding underlying circumstances of each quality indicator, including patient symptoms, indications for dialysis initiation, and PD eligibility.

CONCLUSIONS

We noted improvement in late referrals and early dialysis initiation over time. However, we also noted low and stable use of pre-emptive kidney transplantation and PD at 90 days, which warrants further exploration. These findings support the need for quality improvement initiatives designed to address these gaps in care and improve outcomes for patients with kidney failure.

Effects of health service geographic accessibility in patients with treated end stage kidney disease: Cohort study 2000-2010

AIM

Patients in rural areas experience poor access to health services. There are limited data on patterns of health service utilization in rural patients treated with renal replacement therapy (RRT).

METHODS

All prevalent patients over the age of 18 and resident in New South Wales who were receiving RRT on 01/07/2000 and incident patients who started RRT between 01/07/2000 up until 31/07/2010 were included in the study. The Accessibility Remoteness Index of Australia was used to measure rurality and to categorize participant postcode of residence at the time of their first use of a New South Wales healthcare facility after the start of RRT. We assessed (1) rates of hospitalization, (2) rates of inter-hospital transfer (IHT), (3) length of hospital stay (LOS) and (4) survival. Day-only and dialysis admissions were excluded. Negative binomial regression was used to calculate incidence rate ratios (IRR) for hospitalizations, IHT and LOS. Cox proportional hazards was used to calculate hazard ratios (HR) for survival.

RESULTS

Of the 10 505 patients included in the analysis, 1527 (15%) were rural residents while 8978 (85%) resided in urban areas. Median follow up time from start of RRT/study to end of study/death was 4.2 years (IQR 2.0 to 8.2). After allowing for differences in baseline characteristics, rural residence increased the rates of hospitalization by 8% (IRR 1.08: 95% CI 1.01-1.15; P = 0.02), rates of IHT by 176% (IRR 2.76: 95% CI 2.44-3.13; P < 0.001) and the hazard of death by 14% (HR 1.14 95% CI: 1.05-1.24; P = 0.003) LOS was similar (Median 4.0; P = 0.07).

CONCLUSIONS

Rural residents receiving RRT have higher hospitalization rates, markedly higher rates of IHT and higher long-term mortality compared with their urban counterparts.

Health economic evaluation of paricalcitol(®) versus cinacalcet + calcitriol (oral) in Italy. [corrected]

BACKGROUND AND OBJECTIVE

Chronic kidney disease (CKD) is a highly morbid disorder. The most severe form of CKD is end-stage renal disease (ESRD), in which the patient requires some form of renal replacement therapy to survive. The increasing incidence, prevalence, and costs of ESRD are major national healthcare concerns. The objective of this study was to determine the cost effectiveness of two innovative therapies, paricalcitol versus cinacalcet + calcitriol (oral) in patients with CKD stage 5 (CKD 5) in the healthcare setting in Italy in 2013.

METHODS

A Markov process model was developed employing data sources from the published literature, paricalcitol clinical trials, official Italian price/tariff lists, and national population statistics. The analysis is based on a comparison of treatment with paricalcitol versus cinacalcet + calcitriol (oral) in CKD 5. The perspective of the study was that of the payer [Italian National Health Service (INHS)]. The primary efficacy outcomes in the paricalcitol and cinacalcet + calcitriol (oral) clinical trials (reduction of secondary hyperparathyroidism, complications, and mortality) were extrapolated to effectiveness outcomes: number of life-years gained (LYG) and number of quality-adjusted life-years (QALYs). Clinical and economic outcomes were discounted at 3 %.

RESULTS

The base-case analysis is based on a 5-year time horizon. From the INHS perspective, the use of paricalcitol leads to a cost saving of €1,853 and an increase in LYG (0.136) and a gain in QALYs (0.089). Consequently, the use of paricalcitol is dominant over the use of combination cinacalcet + calcitriol (oral paricalcitol leads to cost savings and a higher effectiveness). Sensitivity analyses confirmed the robustness of the model.

CONCLUSION

The results showed that the favorable clinical benefit of paricalcitol results in positive health economic benefits. This study suggests that the use of paricalcitol in patients with ESRD may be cost effective from the perspective of the INHS.

Rate of Kidney Function Decline and Risk of Hospitalizations in Stage 3A CKD

BACKGROUND AND OBJECTIVES

Risk of hospitalizations is increased in patients with CKD. We sought to examine the association between rate of kidney function decline and risk of hospitalization in a cohort of patients with early CKD.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

We built a cohort of 247,888 United States veterans who had at least one eGFR measurement between October 1999 and September 2003 and an additional eGFR between October 2003 and September 2004. We selected patients whose initial eGFR was between 45 and 59 ml/min per 1.73 m2. Rate of eGFR change (in milliliters per minute per 1.73 m2 per year) was categorized as no decline (>0), mild (0 to -1, and served as the referent group), moderate (-1 to -5), or severe (>-5) eGFR decline. We built survival models to examine the association between the rate of kidney function decline and the risk of hospitalization and readmission and linear regression to estimate length of hospital stay.

RESULTS

Over a median observation of 9 years (interquartile range, 5.28-9.00), patients with moderate and severe eGFR decline exhibited a higher risk of hospitalizations (hazard ratio [HR], 1.22; 95% confidence interval [95% CI], 1.19 to 1.26; and HR, 1.33; 95% CI, 1.28 to 1.39, respectively). Among patients with moderate and severe eGFR decline, the association between the rate of decline and the risk of hospitalizations was more pronounced with an increased number of hospitalizations (P<0.01). Patients with moderate and severe eGFR decline had a higher risk of readmission (HR, 1.19; 95% CI, 1.13 to 1.26; and HR, 1.53; 95% CI, 1.43 to 1.63, respectively). Among patients with severe eGFR decline, the association between the rate of kidney function decline and the risk of readmission was stronger with an increased number of readmissions (P<0.01). Patients with moderate and severe eGFR decline experienced an additional length of stay of 1.40 (95% CI, 0.88 to 1.92) and 5.00 days per year (95% CI, 4.34 to 5.66), respectively.

CONCLUSIONS

The rate of kidney function decline is associated with a higher risk of hospitalizations, readmissions, and prolonged length of hospital stay.

Multidisciplinary care improves clinical outcome and reduces medical costs for pre-end-stage renal disease in Taiwan

Aim

Multidisciplinary care (MDC) for patients with chronic kidney disease (CKD) may help to optimize disease care and improve clinical outcomes. Our study aimed to evaluate the effectiveness of pre-end-stage renal disease (ESRD) patients under MDC and usual care in Taiwan.

Method

In this 3-year retrospective observational study, we recruited 822 ESRD subjects, aged 18 years and older, initiating maintenance dialysis more than 3 months from five cooperating hospitals. The MDC (n = 391) group was cared for by a nephrologists-based team and the usual care group (n = 431) was cared for by sub-specialists or nephrologists alone more than 90 days before dialysis initiation. Patient characteristics, dialysis modality, hospital utilization, hospitalization at dialysis initiation, mortality and medical cost were evaluated. Medical costs were further divided into in-hospital, emergency services and outpatient visits.

Results

The MDC group had a better prevalence in peritoneal dialysis (PD) selection, less temporary catheter use, a lower hospitalization rate at dialysis initiation and 15% reduction in the risk of hospitalization (P < 0.05). After adjusting for gender, age and Charlson Comorbidity Index score, there were lower in-hospital and higher outpatient costs in the MDC group during 3 months before dialysis initiation (P < 0.05). In contrast, medical costs (NT$ 146 038 vs 79 022) and hospitalization days (22.4 vs 15.5 days) at dialysis initiation were higher in the usual care group. Estimated medical costs during 3 months before dialysis till dialysis initiation, the MDC group yielded a reduction of NT$ 59 251 for each patient (P < 0.001). Patient mortality was not significantly different.

Conclusion

Multidisciplinary care intervention for pre-ESRD patients could not only significantly improve the quality of disease care and clinical outcome, but also reduce medical costs.

Management of Restless Legs Syndrome/Willis-Ekbom Disease in Hospitalized and Perioperative Patients

Restless legs syndrome (RLS) is a sensorimotor disorder that can cause significant discomfort, impaired quality of life, poor mood, and disturbed sleep. Because the disorder is chronic and associated with multiple comorbidities, RLS can be seen in an inpatient or perioperative setting. Certain characteristics of the hospitalized or surgical context can exacerbate or unmask RLS. Importantly, RLS and the associated discomfort and insomnia can prolong hospital stay and negatively impact outcomes. RLS medications should be continued during the hospital admission when possible. Avoidance of excessive phlebotomy and medications known to trigger RLS is helpful. Patients should increase activity when acceptable.

The association between intradialytic exercise and hospital usage among hemodialysis patients

Hemodialysis (HD) patients have high hospitalization rates. Benefits of intradialytic exercise have been proven in numerous studies yet exercise programs are still rarely used in the treatment of end-stage kidney disease (ESKD). Our objective was to determine if there was an association between a 6-month intradialytic bicycling program and hospitalization rates and length of stay (LOS) in ESKD patients. This was a retrospective cohort study that took place 6 months prior to and 6 months during an intradialtyic exercise program at an outpatient HD unit in Calgary, Alberta, Canada. Participants comprised 102 patients who had commenced HD <6 months (incident) or >6 months (prevalent) prior to starting exercise. The intervention comprised a 6-month intradialytic bicycling program. Main outcome measures were hospitalization rate, cause of hospitalization, and LOS. Patients were predominantly male (67.6%) aged 65.6 ± 13.5 years and median HD vintage 1 year (range: 0–12). Comorbidities included diabetes mellitus (50%) and cardiac disease (38.2%). The hospitalization incidence rate ratio (IRR) was 0.48 (0.23–0.98; P = 0.04) in incident and 0.89 (0.56–1.42; P = 0.64) in prevalent patients. The LOS decreased from 7.8 (95% confidence interval (CI): 7.3–8.4) to 3.1 (95% CI: 2.8–3.4) days and LOS IRR was 0.39 (0.35–0.45; P < 0.001). The main predictors of hospitalization were lower albumin levels (P = 0.007) and lack of intradialytic exercise program participation (P < 0.001). In conclusion, 6 months of intradialytic exercise was associated with decreased LOS in both incident and prevalent HD patients.

Risk factors for hospitalization among older, incident haemodialysis patients

AIMS

The number of elderly persons with end-stage renal disease is increasing with many requiring hospitalizations. This study examines the causes and predictors of hospitalization in older haemodialysis patients.

METHODS

We reviewed hospitalizations of older (≥65 years) incident chronic haemodialysis patients initiating therapy between 1 January 2007 and 31 December 2009 under the care of a single Midwestern United States dialysis provider.

RESULTS

Of 125 patients, the mean age was 76 ± 7 years and 72% were male. At first dialysis, 68% used a central venous catheter (CVC) and 51% were in the hospital. Mean follow-up was 1.8 ± 1.0 years. At least one hospitalization occurred in 89 (71%) patients and half of all patients were hospitalized once within the first 223 days. Total hospital admission rate was 1.48 per patient year with hospital days totalling 8.54 days per patient year. The three most common reasons for first admission were cardiac (33%), infection (18%) and gastrointestinal (12%). Predictors of future hospitalization included the first dialysis occurring in hospital (hazard ratios (HR) 2.1, 95% CI 1.4-3.3, P = 0.0005) and the use of a CVC at first haemodialysis (HR 2.6, CI 1.6-4.4, P < 0.0001).

CONCLUSION

Hospitalizations are common in older incident haemodialysis patients. Access preparation and overall burden of illness leading to the initial hospitalization appear to play a role. Identification of additional factors associated with hospitalization will allow for focused interventions to reduce hospitalization rates and increase the value of care.

High burden and unmet patient needs in chronic kidney disease

Chronic kidney disease (CKD) is a complex debilitating condition affecting more than 70 million people worldwide. With the increased prevalence in risk factors such as diabetes, hypertension, and cardiovascular disease in an aging population, CKD prevalence is also expected to increase. Increased awareness and understanding of the overall CKD burden by health care teams (patients, clinicians, and payers) is warranted so that overall care and treatment management may improve. This review of the burden of CKD summarizes available evidence of the clinical, humanistic, and economic burden of CKD and the current unmet need for new treatments and serves as a resource on the overall burden. Across countries, CKD prevalence varies considerably and is dependent upon patient characteristics. The prevalence of risk factors including diabetes, hypertension, cardiovascular disease, and congestive heart failure is noticeably higher in patients with lower estimated glomerular filtration rates (eGFRs) and results in highly complex CKD patient populations. As CKD severity worsens, there is a subsequent decline in patient health-related quality of life and an increased use of health care resources as well as burgeoning costs. With current treatment, nearly half of patients progress to unfavorable renal and cardiovascular outcomes. Although curative treatment that will arrest kidney deterioration is desired, innovative agents under investigation for CKD to slow kidney deterioration, such as atrasentan, bardoxolone methyl, and spherical carbon adsorbent, may offer patients healthier and more productive lives.

Effect of multidisciplinary pre-dialysis education in advanced chronic kidney disease: Propensity score matched cohort analysis

AIM

  The mortality and morbidity of end-stage renal failure patients remains high despite recent advances in pre-dialysis care. Previous studies suggesting a positive effect of pre-dialysis education were limited by unmatched comparisons between the recipients and non-recipients of education. The present study aimed to clarify the roles of the multidisciplinary pre-dialysis education (MPE) in chronic kidney disease patients.

METHODS

  We performed a retrospective single centre study, enrolling 1218 consecutive pre-dialysis chronic kidney disease patients, between July 2007 and Feb 2008 and followed them up to 30 months. By using propensity score matching, we matched 149 recipient- and non-recipient pairs from 1218 patients. The incidences of renal replacement therapy, mortality, cardiovascular event and infection were compared between recipients and non-recipients of MPE.

RESULTS

  Renal replacement therapy was initiated in 62 and 64 patients in the recipients and non-recipients, respectively (P > 0.05). The MPE reduced unplanned urgent dialysis (8.7% vs 24.2%, P < 0.001) and shortened hospital days (2.16 vs 5.05 days/patient per year). MPE recipients had a better metabolic status at the time of initiating renal replacement therapy. Although no significant survival advantage from MPE was exhibited, MPE recipients had lower incidence of cardiovascular events (adjusted hazard ratio, 0.24; 95% confidence interval (CI), 0.08 to 0.78; P = 0.017), and a tendency toward a lower infection rate (adjusted hazard ratio, 0.44; 95% CI, 0.17 to 1.11; P = 0.083).

CONCLUSION

  MPE was associated with better clinical outcomes in terms of urgent dialysis, cardiovascular events and infection.

Impact of elevated intact parathyroid hormone on mortality and renal disease progression in patients with chronic kidney disease stages 3 and 4

OBJECTIVE

To estimate the impact of elevated intact parathyroid hormone levels on time to death and renal replacement therapy in patients with chronic kidney disease stages 3 and 4.

METHODS

A retrospective cohort analysis from 01/1996 to 09/2007 was conducted in 11,092 patients with chronic kidney disease stages 3 and 4 patients using Cockroft-Gault and Modification of Diet in Renal Disease equations to estimate their glomerular filtration rates. Patients' highest parathyroid hormone levels were used to define the index date and cohort (followed for 1 year). Mortality and renal replacement therapy events were evaluated among cohorts at pre-defined parathyroid hormone levels.

RESULTS

As the intact parathyroid hormone levels increased, the mean age, number of females and estimated glomerular filtration rates decreased. Patients with an intact parathyroid hormone level<50 pg/mL were defined as the reference group. Similar results were found using the Modification of Diet in Renal Disease equation for calculating estimated glomerular filtration rate, which was possible in 48% of the patients where race could be identified. Combined mortality and renal replacement therapy adjusted hazard ratio using Cox regression for intact parathyroid hormone level 51-110 pg/mL was 1.12 (0.82-1.54), intact parathyroid hormone level 111-199 pg/mL was 2.42 (1.78-3.29), intact parathyroid hormone level 200-299 pg/mL was 3.01 (2.14-4.27), intact parathyroid hormone level 300-399 pg/mL was 3.12 (2.09-4.60), intact parathyroid hormone level 400-499 pg/mL was 3.91 (2.61-5.85) and intact parathyroid hormone level>500 pg/mL was 2.67 (1.84-3.84).

CONCLUSION

Intact parathyroid hormone levels>50 pg/mL in patients with chronic kidney disease stages 3 and 4 are associated with an escalating combined risk of death or RRT.

DNA hypermethylation and inflammatory markers in incident Japanese dialysis patients

Background/Aims

Inflammation is an established mortality risk factor in chronic kidney disease (CKD) patients. Although a previous report showed that uremic Caucasian patients with inflammation had signs of global DNA hypermethylation, it is still unknown whether DNA hypermethylation is linked to inflammatory markers including a marker of bacterial infections in Japanese CKD patients.

Methods

In 44 consecutive incident dialysis patients (26 males, mean age 59 ± 12 years) without clinical signs of infection, global DNA methylation was evaluated in peripheral blood DNA using the HpaII/MspI ratio by the luminometric methylation assay method. A lower ratio of HpaII/MspI indicates global DNA hypermethylation. Procalcitonin (PCT), a marker of inflammation due to bacterial infections, was measured using an immunochromatographic assay.

Results

The patients were divided into hyper- and hypomethylation groups based on the median value of the HpaII/MspI ratio 0.31 (range 0.29–0.37). Whereas patients in the hypermethylation group had higher ferritin levels [133.0 (51.5–247.3) vs. 59.5 (40.0–119.0) ng/ml; p = 0.046], there were no significant differences in age, gender, diabetes, smoking, anemia or serum albumin levels. However, the HpaII/MspI ratio showed significant negative correlations with PCT (ρ = −0.32, p = 0.035) and ferritin (ρ = −0.33, p = 0.027) in Spearman's rank test. In a multiple linear regression analysis, PCT and ferritin were associated with a lower HpaII/MspI ratio (R² = 0.24, p = 0.013).

Conclusion

In this study, global DNA hypermethylation was associated with ferritin and, most likely, PCT, suggesting that inflammation induced by subclinical bacterial infection promoted DNA methylation.

Chronic kidney disease Markov model comparing paricalcitol to calcitriol for secondary hyperparathyroidism: a US perspective

OBJECTIVE

The objective of this study was to determine the cost effectiveness of paricalcitol versus calcitriol for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease in the United States setting.

METHODS

A Markov process model was developed employing data sources from the published literature, paricalcitol clinical trials and observational studies, official US price/tariff lists and national population statistics. The comparator was calcitriol, a non-selective vitamin D receptor activator (VDRA) medication. The primary perspective of the study was that of the third-party payer in the US. The efficacy outcomes (reduction in secondary hyperparathyroidism (SHPT), reduction in proteinuria, complications and mortality) were extrapolated to: number of life-years gained (LYG) and number of quality-adjusted life-years (QALYs). Clinical and economic outcomes were discounted at 3.5%.

RESULTS

The reference case analysis was a 10-year time horizon based on a comparison of paricalcitol with calcitriol, which is started in chronic kidney disease (CKD) stage 3 and continued in CKD stage 4 and CKD stage 5. The use of paricalcitol leads to a cost saving of US$1941. The inclusion of indirect costs leads to a cost saving of US$2528. The use of paricalcitol leads to an increase in life-years gained (0.47 years) and a gain in QALYs (0.43). The use of paricalcitol results in a dominant outcome from the perspective of the third-party payer, as well as from the societal perspective. One-way sensitivity analyses and probabilistic sensitivity analyses confirmed the robustness of the model.

CONCLUSION

This model showed that the favorable clinical benefit of paricalcitol results in positive short and long-term health economic benefits. This study suggests that the use of paricalcitol in patients with early chronic kidney disease may be cost-effective from the third-party payer perspective in the US versus calcitriol. Additional comparative studies are necessary to validate these results.

Changes in survival among elderly patients initiating dialysis from 1990 to 1999

BACKGROUND

Over the past decade, there has been a steep rise in the number of people with complex medical problems who require dialysis. We sought to determine the life expectancy of elderly patients after starting dialysis and to identify changes in survival rates over time.

METHODS

All patients aged 65 years or older who began dialysis in Canada between 1990 and 1999 were identified from the Canadian Organ Replacement Register. We used Cox proportional hazards models to examine the effect that the period during which dialysis was initiated (era 1, 1990-1994; era 2, 1995-1999) had on patient survival, after adjusting for diabetes, sex and comorbidity. Patients were followed from initiation of dialysis until death, transplantation, loss to follow-up or study end (Dec. 31, 2004).

RESULTS

A total of 14,512 patients aged 65 years or older started dialysis between 1990 and 1999. The proportion of these patients who were 75 years or older at the start of dialysis increased from 32.7% in era 1 (1990-1994) to 40.0% in era 2 (1995-1999). Despite increased comorbidity over the 2 study periods, the unadjusted 1-, 3- and 5-year survival rates among patients aged 65-74 years at dialysis initiation rose from 74.4%, 44.9% and 25.8% in era 1 to 78.1%, 51.5% and 33.5% in era 2. The respective survival rates among those aged 75 or more at dialysis initiation increased from 67.2%, 32.3% and 14.2% in era 1 to 69.0%, 36.7% and 20.3% in era 2. This survival advantage persisted after adjustment for diabetes, sex and comorbidity in both age groups (65-74 years: hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.72- 0.81; 75 years or more: HR 0.86, 95% CI 0.80-0.92).

INTERPRETATION

Survival after dialysis initiation among elderly patients has improved from 1990 to 1999, despite an increasing burden of comorbidity. Physicians may find these data useful when discussing prognosis with elderly patients who are initiating dialysis.

Secondary hyperparathyroidism is associated with higher cost of care among chronic kidney disease patients with cardiovascular comorbidities

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and mortality, and incurs a substantial cost. Secondary hyperparathyroidism (SHPT) is a major complication associated with CKD and has been linked with cardiovascular disease, leading to poor outcomes.

METHODS

We analyzed retrospective studies for the prevalence of congestive heart failure (CHF) and acute myocardial infarction/ischemic heart disease (AMI/IHD) in pre-dialysis CKD patients to estimate the additional hospitalization cost incurred secondary to high parathyroid hormone (PTH) levels. Two models were developed to estimate the contribution of elevated PTH levels towards hospitalization costs in CKD patients with CHF and AMI/IHD.

RESULTS

Cost contributions were estimated for the time intervals relative to initiation of dialysis, with the largest contributions estimated for the 3- to 1-month period prior to initiation of dialysis, $205.24 per patient-month at risk for CHF and $69.44-111.75 per patient-month at risk for AMI/IHD, without and with major complications, respectively.

CONCLUSION

Higher PTH levels are associated with a high prevalence of CHF and AMI/IHD. Our cost analyses show that elevated PTH levels contribute significantly toward the overall cost of care among CKD patients with CHF and AMI/IHD. The contribution of elevated PTH levels toward hospitalization cost is highest during the months directly leading up to initiation of dialysis. Further studies are required to evaluate the relationship between hyperparathyroidism and cardiovascular disease, and its impact on economic outcomes.

[Hospitalization of peritoneal dialysis patients: the impact of peritonitis episodes on the hospitalization rate]

Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.

Renal insufficiency and the risk of infection from pacemaker or defibrillator surgery

BACKGROUND

Pacemakers and implanted cardioverter defibrillator (ICD) infection rates are rising. Renal insufficiency impairs immune function and is known to increase the risk of infection following implantation of orthopedic hardware. The purpose of the current study is to characterize the risk factors for pacemaker and ICD infection and to evaluate the role of renal insufficiency in this complication.

METHODS AND RESULTS

A large (n = 4,856) single center experience with pacemaker and ICD procedures was reviewed. Of these, 141 were extractions of infected devices and 76 of these patients had been implanted in the Emory system and had preimplant creatinine information available for analysis. These cases were compared to 76 control patients undergoing device implantation matched by date of implant who had no infective complications. Demographic and clinical data from both groups were compared using both univariate and multivariate analysis. The overall rate of infection was 1.5%. Patients with device infection were more likely to have congestive heart failure (CHF), be diabetic, have generator exchanges, and to take warfarin than controls. There was no difference in the prevalence of coronary disease, atrial fibrillation, steroid use, or malignancy between the two groups. Elevated creatinine (Cr > or = 1.5 mg/dL) was much more frequent in patients with infection than in controls (38% vs 12%, odds ratio 4.6, P < 0.001). Moderate to severe renal disease (GFR < or = 60 cc/min/1.73 m2) was the most potent risk factor for infection, with a prevalence of 42% in infected patients versus 13% in controls (odds ratio of 4.8).

CONCLUSIONS

Renal insufficiency dramatically increases the risk of infection complicating pacemaker or ICD surgery. This association should be part of the risk-benefit consideration prior to device implantation. Additional study of more extensive perioperative antibiotic therapy in this subset of patients is warranted.

The morbidity and cost implications of hemodialysis clinical performance measures

Clinical performance measures, including dialysis dose, hemoglobin, albumin, and vascular access, are the focus of monitoring and quality improvement activities. However, little is known about the implications of clinical performance measures for hospital utilization and health care costs. We obtained clinical performance measures and hospitalization records for a national random sample of 10,650 hemodialysis patients and analyzed the relationship between changes in clinical performance measures and hospital utilization after adjustment for patient demographic and medical characteristics. Higher hemoglobin, higher albumin, and fistula or graft use were independently associated with fewer hospitalizations, fewer hospital days, and decreased Medicare inpatient reimbursement. For example, a 0.5 g/dL higher hemoglobin, a 0.25 g/dL higher albumin, fistula use, and graft use were associated with hospitalization rate ratios of 0.90 (95% confidence interval 0.85, 0.96), 0.64 (0.53, 0.77), 0.60 (0.52, 0.69), and 0.79 (0.71, 0.89), respectively. Moreover, there was a 2-3-fold variation in hospital utilization across end-stage renal disease networks that was still evident after adjustment for patient characteristics and clinical performance measures. Clinical performance measures, especially albumin and vascular access, are strongly associated with hospital utilization and health care costs. These results highlight the importance of targeting nutrition and vascular access in quality improvement efforts. The marked variation in hospital utilization across networks deserves further examination.

Chronic kidney disease: the distribution of health care dollars

BACKGROUND

The cost of care for end-stage renal disease (ESRD) is known to be high. The factors responsible for higher ESRD cost develop during chronic kidney disease (CKD), where the data on distribution of cost are limited.

METHODS

This retrospective cohort study of 1995 through 1998 incident dialysis patients was performed to study the distribution of costs during the 24 months prior to initiation of dialysis. Patient data were obtained from the Centers for Medicare and Medicaid Services (CMS). Patients who were Medicare eligible for at least 2 years prior to initiation of dialysis were included in the study. Financial data were obtained from Medicare Part A and Part B claims and inflationary adjustments were made. The study period was divided into four segments based on overall distribution of cost.

RESULTS

The mean age was 75 years, 51% were males, 73% were white, and 22% were black. Overall, patient comorbidity increased significantly during the study years. Cost showed a sharp increase in the last 6 months prior to initiation of dialysis. Hospitalization was the major component of cost throughout study period. Patients who initiated hemodialysis incurred a higher cost compared to patients who initiated other modes of kidney replacement therapy. Patients with diabetes or cardiovascular disease incurred higher cost compared to those who had no diabetes or cardiovascular disease, respectively.

CONCLUSION

These data showed that hospitalization was the major component of the sharp increase in cost around the initiation of dialysis. Increased comorbidity was associated with higher cost. A focus on timely management of CKD may prevent future morbidity and costs.