Suboptimal dialysis initiation in a retrospective cohort of predialysis patients--predictors of in-hospital dialysis initiation, catheter insertion and one-year mortality

Short Timeframe Prediction of Kidney Failure among Patients with Advanced Chronic Kidney Disease

BACKGROUND

Development of a short timeframe (6-12 months) kidney failure risk prediction model may serve to improve transitions from advanced chronic kidney disease (CKD) to kidney failure and reduce rates of unplanned dialysis. The optimal model for short timeframe kidney failure risk prediction remains unknown.

METHODS

This retrospective study included 1757 consecutive patients with advanced CKD (mean age 66 years, estimated glomerular filtration rate 18 mL/min/1.73 m2). We compared the performance of Cox regression models using (a) baseline variables alone, (b) time-varying variables and machine learning models, (c) random survival forest, (d) random forest classifier in the prediction of kidney failure over 6/12/24 months. Performance metrics included area under the receiver operating characteristic curve (AUC-ROC) and maximum precision at 70% recall (PrRe70). Top-performing models were applied to 2 independent external cohorts.

RESULTS

Compared to the baseline Cox model, the machine learning and time-varying Cox models demonstrated higher 6-month performance [Cox baseline: AUC-ROC 0.85 (95% CI 0.84-0.86), PrRe70 0.53 (95% CI 0.51-0.55); Cox time-varying: AUC-ROC 0.88 (95% CI 0.87-0.89), PrRe70 0.62 (95% CI 0.60-0.64); random survival forest: AUC-ROC 0.87 (95% CI 0.86-0.88), PrRe70 0.61 (95% CI 0.57-0.64); random forest classifier AUC-ROC 0.88 (95% CI 0.87-0.89), PrRe70 0.62 (95% CI 0.59-0.65)]. These trends persisted, but were less pronounced, at 12 months. The random forest classifier was the highest performing model at 6 and 12 months. At 24 months, all models performed similarly. Model performance did not significantly degrade upon external validation.

CONCLUSIONS

When predicting kidney failure over short timeframes among patients with advanced CKD, machine learning incorporating time-updated data provides enhanced performance compared with traditional Cox models.

Social determinants of health and the transition from advanced chronic kidney disease to kidney failure

BACKGROUND

The transition from chronic kidney disease (CKD) to kidney failure is a vulnerable time for patients, with suboptimal transitions associated with increased morbidity and mortality. Whether social determinants of health are associated with suboptimal transitions is not well understood.

METHODS

This retrospective cohort study included 1070 patients with advanced CKD who were referred to the Ottawa Hospital Multi-Care Kidney Clinic and developed kidney failure (dialysis or kidney transplantation) between 2010 and 2021. Social determinant information, including education level, employment status and marital status, was collected under routine clinic protocol. Outcomes surrounding suboptimal transition included inpatient (versus outpatient) dialysis starts, pre-emptive (versus delayed) access creation and pre-emptive kidney transplantation. We examined the association between social determinants of health and suboptimal transition outcomes using multivariable logistic regression.

RESULTS

The mean age and estimated glomerular filtration rate were 63 years and 18 ml/min/1.73 m2, respectively. Not having a high school degree was associated with higher odds for an inpatient dialysis start compared with having a college degree {odds ratio [OR] 1.71 [95% confidence interval (CI) 1.09-2.69]}. Unemployment was associated with higher odds for an inpatient dialysis start [OR 1.85 (95% CI 1.18-2.92)], lower odds for pre-emptive access creation [OR 0.53 (95% CI 0.34-0.82)] and lower odds for pre-emptive kidney transplantation [OR 0.48 (95% CI 0.24-0.96)] compared with active employment. Being single was associated with higher odds for an inpatient dialysis start [OR 1.44 (95% CI 1.07-1.93)] and lower odds for pre-emptive access creation [OR 0.67 (95% CI 0.50-0.89)] compared with being married.

CONCLUSIONS

Social determinants of health, including education, employment and marital status, are associated with suboptimal transitions from CKD to kidney failure.

Predialysis Care Trajectories of Patients With ESKD Starting Dialysis in Emergency in France

Introduction

Emergency dialysis start (EDS) is frequent for patients with chronic kidney disease (CKD). To improve CKD management, new trajectory-based care policies are currently being introduced both in France and in the United States. This study describes the different types of predialysis care trajectories and factors associated with EDS.

Methods

Adults patients who started dialysis in France in 2015 were included. Individual clinical and health care consumption data were retrieved from the French national end-stage kidney disease (ESKD) registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Hierarchical Clustering on Principal Component was used to identify groups of patients with the same health care consumption profile during the 2 years before dialysis start. Logistic regression analysis was used to identify factors associated with EDS.

Results

Among the 8856 patients included in the analysis, 2681 (30.3%) had EDS. The Hierarchical Clustering on Principal Component identified six types of predialysis care trajectories in which EDS rate ranged from 13.8% to 61.8%. After adjustment for the patients’ characteristics, less frequent or lack of follow-up with a nephrologist was associated with higher risk of EDS (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.17–1.50 and OR: 1.83; 95% CI: 1.58–2.12), but not follow-up with a general practitioner.

Conclusions

The care trajectories during the 2 years before dialysis start were heterogeneous and patients with a lesser or lack of follow-up with a nephrologist were more likely to start dialysis in emergency, regardless of the frequency of follow-up by a general practitioner (GP). New CKD policies should include actions to strengthen CKD screening and referral to nephrologists.

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature

Background:

Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD).

Objective:

To determine common definitions and patient risk factors for unplanned dialysis.

Design:

Systematic review.

Setting:

MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018.

Patients:

Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included.

Measurements:

Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis.

Methods:

Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale.

Results:

From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3).

Limitations:

Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking.

Conclusions:

Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.

Patient Engagement in Kidney Research: Opportunities and Challenges Ahead

Purpose of Review:

Patient engagement in research is increasingly recognized as an important component of the research process and may facilitate translation of research findings. To heighten awareness on this important topic, this review presents opportunities and challenges of patient engagement in research, drawing on specific examples from 4 areas of Canadian kidney research conducted by New Investigators in the Kidney Research Scientist Core Education and National Training (KRESCENT) Program.

Sources of Information:

Research expertise, published reports, peer-reviewed articles, and research funding body websites.

Methods:

In this review, the definition, purpose, and potential benefits of patient engagement in research are discussed. Approaches toward patient engagement that may help with translation and uptake of research findings into clinical practice are highlighted. Opportunities and challenges of patient engagement are presented in both basic science and clinical research with the following examples of kidney research: (1) precision care in focal and segmental glomerulosclerosis, (2) systems biology approaches to improve management of chronic kidney disease and enhance kidney graft survival, (3) reducing the incidence of suboptimal dialysis initiation, and (4) use of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) in kidney practice.

Key Findings:

Clinical research affords more obvious opportunities for patient engagement. The most obvious step at which to engage patients is in the setting of research priorities. Engagement at all stages of the research cycle may prove to be more challenging, and requires a detailed plan, along with funds and infrastructure to ensure that it is not merely tokenistic. Basic science research is several steps removed from the clinical application and involves complex scientific concepts, which makes patient engagement inherently more difficult.

Limitations:

This is a narrative review of the literature that has been partly influenced by the perspectives and experiences of the authors and focuses on research conducted by the authors. The evidence base to support the suggested benefits of patient engagement in research is currently limited.

Implications:

The formal incorporation of patients’ priorities, perspectives, and experiences is now recognized as a key component of the research process. If patients and researchers are able to effectively work together, this could enhance research quality and efficiency. To effectively engage patients, proper infrastructure and dedicated funding are needed. Going forward, a rigorous evaluation of patient engagement strategies and their effectiveness will be needed.

Epidemiology and Risk Factors for Early Mortality After Dialysis Initiation

Confronted with the decision to initiate dialysis, patients and caregivers often seek information about how expected survival chances evolve, both initially and afterward, providing the patient survives beyond arbitrary periods of time. Large registry data, used to examine these issues, may be subject to early ascertainment bias, such as those accruing from nonregistration of with end-stage kidney disease who die shortly after dialysis initiation and inclusion of patients with acute kidney injury with slower than typical recovery rates. Despite these caveats, available studies have suggested that mortality hazards are much higher in the first 3 months of renal replacement therapy. Prominent modifiable associations of early mortality include late referral to nephrology services, initial dialysis with vascular catheters, and, most problematically, higher glomerular filtration rates at initiation of renal replacement therapy. Despite their imperfections, currently available information is relatively user-unfriendly and could be better leveraged to help patients and treatment teams make better decisions.

Risk factors for unplanned and crash dialysis starts: a protocol for a systematic review and meta-analysis

BACKGROUND

Many patients with kidney failure "crash" onto dialysis or initiate dialysis in an unplanned fashion. There are varying definitions, but essentially, a patient is labeled as having a crash dialysis start if he or she has little to no care by a nephrologist prior to starting dialysis. A patient is labeled as having an unplanned dialysis start when he or she starts dialysis with a catheter or during a hospitalization. Given the high prevalence and poor outcomes associated with crash and unplanned dialysis starts, it is important to establish a better understanding of patient risk factors.

METHODS

We will conduct a systematic review and meta-analysis with a focus on both crash and unplanned dialysis starts. The first objective will be to determine patient risk factors for crash and unplanned dialysis starts. Secondary objectives will be to determine the most common criteria used to define both crash and unplanned dialysis starts and to determine outcomes associated with crash and unplanned dialysis starts. We will search MEDLINE, EMBASE and Cochrane Library from inception to the present date for all studies that report the characteristics and outcomes of patients who have crash vs. non-crash dialysis starts or unplanned vs. planned dialysis starts. We will also extract from included studies the criteria used to define crash and unplanned dialysis starts. If there are any eligible randomized controlled trials, quality assessment will be performed using the Cochrane Risk of Bias Assessment Tool. Observational studies will be evaluated using the Newcastle-Ottawa Scale. Data will be pooled in meta-analysis if deemed appropriate.

DISCUSSION

The results of this review will inform the design of strategies to help reduce the incidence of crash and unplanned dialysis starts.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42016032916.

Early nephrology care provided by the nephrologist alone is not sufficient to mitigate the social and psychological aspects of chronic kidney disease

OBJECTIVE

Patients with chronic kidney disease who receive early nephrology care have a better prognosis with maintenance dialysis. We aimed to determine whether early referral to a nephrologist can also improve the psychological burden of having chronic kidney disease.

SUBJECTS AND METHODS

Thirty-nine patients with chronic kidney disease that required hemodialysis were studied: 19 had a $ 6-month history of nephrology care (Group1), and 20 had never received any prior nephrology care (Group2). All patients participated in a semi-structured interview that addressed their perceived knowledge and psychological aspects related to CKD and hemodialysis. Demographic and laboratory data as well as socioeconomic status were evaluated.

RESULTS

In both groups, most of the patients were of low socioeconomic status. Group 1 had significantly better laboratory parameters (p<0.05). The patients' answers to the questions showed no differences between the groups: 63% of Group 1 and 55% of Group 2 reported that they had no prior knowledge about dialysis; 58% and 40%, respectively, reported that they ''don't completely understand what the doctor says''; and 74% and 85%, respectively, believed that their ''kidneys would work again''.

CONCLUSION

Pre-dialysis nephrology care improves the clinical conditions of the patients with chronic kidney disease but is insufficient for minimizing other aspects of having chronic kidney disease.

Economic burden of chronic kidney disease

OBJECTIVES

To define the cost of care and evaluate interventions associated with improving outcomes and delaying the progression of chronic kidney disease (CKD).

METHODS

Using the PubMed database, a systematic review of the literature was conducted describing (i) the cost of care associated with treating earlier stages of CKD, and (ii) the role of early referral, erythropoiesis-stimulating proteins and anti-hypertensive agents in improving clinical outcomes and reducing the cost of CKD.

RESULTS

The higher costs associated with treatment of the CKD population are largely due to higher rates and duration of comorbidity-driven hospitalizations. Studies suggest that early referral to a nephrologist, use of erythropoiesis-stimulating proteins and anti-hypertensive agents may be associated with better outcomes and lower costs. In some instances, however, higher target haemoglobin levels could have harmful effects in CKD patients.

CONCLUSION

The substantial costs incurred during earlier stages of CKD increase markedly during the transition to renal replacement and remain elevated thereafter. An increase in awareness among health care providers may result in more timely interventions. More proactive management, in turn, can lead to improved clinical and economic outcomes through the slowing of disease progression and prevention of comorbidities.

Pre-dialysis clinic attendance improves quality of life among hemodialysis patients

BACKGROUND

Although previous research has demonstrated that referral to pre-dialysis clinics is associated with favourable objective outcomes, the benefit of a pre-dialysis clinic from the perspective of patient-perceived subjective outcomes, such as quality of life (QOL), is less well defined.

METHODS

A retrospective incident cohort study was conducted to determine if pre-dialysis clinic attendance was a predictor of better QOL scores measured within the first six months of hemodialysis (HD) initiation. Inclusion criteria were HD initiation from January 1 1998 to January 1 2000, diagnosis of chronic renal failure, and completion of the QOL questionnaire within six months of HD initiation. Patients receiving HD for less than four weeks were excluded. An incident cohort of 120 dialysis patients was identified, including 74 patients who attended at least one pre-dialysis clinic and 46 patients who did not. QOL was measured using the SF 36-Item Health Survey. Independent variables included age, sex, diabetes, pre-dialysis clinic attendance and length of attendance, history of ischemic heart disease, stroke, peripheral vascular disease, heart failure, malignancy, and chronic lung disease, residual creatinine clearance at dialysis initiation, and kt/v, albumin and hemoglobin at the time of QOL assessment. Bivariate and multivariate linear regression analyses were used to identify predictors of QOL scores.

RESULTS

Multivariate analysis suggested that pre-dialysis clinic attendance was an independent predictor of higher QOL scores in four of eight health domains (physical function, p < 0.01; emotional role limitation, p = 0.01; social function, p = 0.01; and general health, p = 0.03), even after statistical adjustment for age, sex, residual renal function, kt/v, albumin, and co-morbid disease. Pre-dialysis clinic attendance was also an independent predictor of the physical component summary score (p = 0.03).

CONCLUSIONS

We conclude that pre-dialysis clinic attendance favourably influences patient-perceived quality of life within six months of dialysis initiation.