Pre-Dialysis Visits to a Nephrology Department and Major Cardiovascular Events in Patients Undergoing Dialysis

Early referral to nephrological care improves long-term survival and hospitalization after dialysis initiation, independent of optimal dialysis start - a call for harmonization of reimbursement policies

Early treatment of kidney disease can slow disease progression and reduce the increased risk of mortality associated with end-stage kidney disease. However, uncertainty exists whether early referral (ER) to nephrological care per se or an optimal dialysis start impacts patient outcome after dialysis initiation. We determined the effect of ER and suboptimal dialysis start on the 3-year mortality and hospitalizations after dialysis initiation. Between January 2015 and July 2018, 349 patients with ≥1 month of follow-up started dialysis at nine Romanian dialysis clinics. After excluding patients with COVID-19 during follow-up, 254 patients (97 ER and 157 late referral) were included in this retrospective study. The observational period was truncated at 3 years, death, or loss to follow-up. Clinical and laboratory data were retrieved from the quality database of the nephrological care providers. Patients were followed for a median (25-75%) of 36 (16-36) months. At dialysis start, ER patients had higher hemoglobin, phosphate, and albumin levels and started dialysis less often via a central dialysis catheter (p < 0.001 for each). Logistic regression analysis demonstrated an independent lower risk for frequent hospitalizations for ER patients (odds ratio 0.22 (95% confidence interval 0.1-0.485), p < 0.001), and Cox regression analysis revealed an improved survival (hazard ratio 0.540 (95% confidence interval 0.325-0.899), p = 0.02), both independent of optimal dialysis start. In conclusion, early referral to nephrological care was associated with improved survival and lower hospitalization rates during the three years after dialysis initiation, independent of optimal dialysis start. These results strongly support the reimbursement of nephrological care before dialysis initiation.

Dialysis decision-making process by Chinese American patients at an urban, academic medical center: a retrospective chart review

BACKGROUND

Clinical practice guidelines emphasize shared decision-making for kidney replacement treatment, yet little is known about the influence of cultural differences on that process. We undertook a retrospective chart review to explore the process and timing of dialysis decision making and initiation in Chinese American patients to provide quality kidney care for this population.

DESIGN

Participants received outpatient care at Tufts Medical Center and dialysis at Dialysis Clinic, Inc. Boston or Somerville, MA from 2001-2021. Clinic chart review sourced demographic, clinical, and end-of-life care information from 180 participants (82 Chinese American, 98 other) from stage 4 chronic kidney disease (CKD) and dialysis initiation.

RESULTS

Chinese American participants were older (mean 70 vs. 59, p < 0.0001), less likely to speak English (12% vs. 87%, p < 0.0001), and used interpreter services more (80% vs. 11%, p < 0.0001). Chinese American participants had more visits (median 14 vs. 10, p = 0.005); were more often accompanied by family members (75% vs. 40%, p < 0.001); and had significantly lower rates of healthcare proxy documentation (35% vs. 55%, p = 0.006). There was no statistical difference in months between first CKD 4 visit and first dialysis. Both groups started dialysis at the same average eGFR and with similar rates of permanent dialysis access. Chinese American participants had significantly lower serum albumin at dialysis initiation (mean 3.3 g/dL vs 3.7 g/dL, p = 0.0003). Documentation reflected a low number of conversations about non-dialytic care, end-of-life planning, or palliative care in both groups across all visits.

CONCLUSION

The time between CKD 4 and dialysis initiation was the same in both groups, suggesting a similar overall outcome of care. Chart documentation suggests that Chinese American participants had a significantly higher number of visits with nephrologists where discussion about dialysis was noted and were more likely to have a family member present at the visit. Fewer Chinese American participants completed healthcare proxies. Among all study participants, healthcare proxy, code status, and palliative care discussions were reported less frequently than expected. These findings highlight opportunities for collaboration between palliative care clinicians and nephrologists.

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.