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Scherer JS, Tu C, Pisoni RL, Speyer E, Lopes AA, Wen W, Menzaghi F, Cirulli J, Alencar de Pinho N, Pecoits-Filho R, Karaboyas A. CKD-Associated Pruritus and Clinical Outcomes in Nondialysis CKD. Kidney Med 2024; 6:100754. [PMID: 38225976 PMCID: PMC10788264 DOI: 10.1016/j.xkme.2023.100754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Rationale & Objective Itching is a frequent symptom experienced by people with chronic kidney disease (CKD). We investigated the associations of CKD-associated pruritus (CKD-aP) with clinical outcomes. Study Design This was a longitudinal cohort study. Setting & Participants Patients from Brazil, France, and the United States enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013 to 2021, an international prospective cohort study of adults with nondialysis dependent CKD, and an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 were included. Exposure CKD-aP was self-reported by response to the question: "During the past 4 weeks, to what extent were you bothered by itchy skin?" Outcomes The outcomes were as follows: CKD progression, kidney replacement therapy (KRT) initiation, mortality, hospitalization, cardiovascular events, infection events. Analytical Approach Associations with time-to-event outcomes were investigated using Cox proportional hazards models adjusted for potential confounders. Results There were 4,410 patients from 91 clinics with a median age of 69 years and a median eGFR at patient questionnaire completion of 29 (21-38) mL/min/1.73 m2. The proportion of patients not at all, somewhat, moderately, very much, and extremely bothered by itchy skin was 49%, 27%, 13%, 7%, and 3%, respectively. Patients with more advanced stages of CKD, older age, and greater comorbidities reported to be more likely bothered by itchy skin. Among patients at least moderately bothered, 23% were prescribed at least 1 pharmacotherapy (35% in the United States, 19% in France, 4% in Brazil), including antihistamine (10%), gabapentin (6%), topical corticosteroids (4%), pregabalin (3%), or sedating antihistamine (3%). The HR (95% CI) for patients extremely (vs not at all) bothered was 1.74 (1.11-2.73) for all-cause mortality, 1.56 (1.11-2.18) for all-cause hospitalization, and 1.84 (1.22-2.75) for cardiovascular events. As CKD-aP severity increased, patients also had higher rates of infection events (P = 0.04); CKD-aP severity was not associated with KRT initiation (P = 0.20) or CKD progression (P = 0.87). Limitations The limitations were 25% nonresponse rate, recall bias, and residual confounding factors. Conclusions These results demonstrate a strong association between severe itch and clinical outcomes, providing the nephrology community new insights into the possible adverse consequences of CKD-aP in individuals with nondialysis CKD, and warrant further exploration. Plain-Language Summary Chronic kidney disease-associated pruritus (CKD-aP) is a common disturbing symptom of chronic kidney disease (CKD). This article analyzes longitudinal data from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) to describe prevalence of CKD-aP in 4,410 individuals with nondialysis CKD, and its association with clinical outcomes. We found that 51% of the surveyed population were bothered by pruritus. CKD-aP was more prevalent in those with more advanced stages of CKD, older age, and with more comorbid conditions. Compared to those not at all bothered by pruritus, those who were extremely bothered had a higher risk of all-cause mortality, hospitalizations, and cardiovascular events. Severity of CKD-aP was not associated with CKD progression or initiation of kidney replacement therapy.
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Affiliation(s)
- Jennifer S. Scherer
- Division of Geriatrics and Palliative Care and Division of Nephrology, NYU Grossman School of Medicine, New York, NY
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Elodie Speyer
- Centre for Research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Antonio A. Lopes
- Clinical Epidemiology and Evidence-Based Medicine Unit of the Edgard Santos University Hospital and Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | | | | | | | - Natalia Alencar de Pinho
- Centre for Research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
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Scherer JS, Bieber B, de Pinho NA, Masud T, Robinson B, Pecoits-Filho R, Schiedell J, Goldfeld K, Chodosh J, Charytan DM. Conservative Kidney Management Practice Patterns and Resources in the United States: A Cross-Sectional Analysis of CKDopps (Chronic Kidney Disease Outcomes and Practice Patterns Study) Data. Kidney Med 2023; 5:100726. [PMID: 37928753 PMCID: PMC10624579 DOI: 10.1016/j.xkme.2023.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Rationale & Objective Conservative kidney management (CKM) is a viable treatment option for many patients with chronic kidney disease. However, CKM practices and resources in the United States are not well described. We undertook this study to gain a better understanding of factors influencing uptake of CKM by describing: (1) characteristics of patients who choose CKM, (2) provider practice patterns relevant to CKM, and (3) CKM resources available to providers. Study Design Cross-sectional study. Setting & Participants This study is a cross-sectional analysis of data from US nephrology clinics enrolled in the chronic kidney disease Outcomes and Practice Patterns Study (CKDopps) collected between 2014 and 2020. Data for this study includes chart-abstracted characteristics of patients with an estimated glomerular filtration rate ≤30mL/min/1.73m2 (n=1018) and available information on whether a decision had been made to pursue CKM at the time of kidney failure, patient (n=407) reports of discussions about forgoing dialysis, and provider (n=26) responses about CKM delivery and available resources in their health systems. Analytical Approach Descriptive statistics were used to report patient demographics, clinical information, provider demographics, and clinic characteristics. Results Among data from 1018 patients, 68 (7%) were recorded as planning for CKM. These patients were older, had more comorbidities, and were more likely to require assistance with transfers. Of the 407 patient surveys, 18% reported a conversation about forgoing dialysis with their nephrologist. A majority of providers felt comfortable discussing CKM; however, no clinics had a dedicated clinic or protocol for CKM. Limitations Inconsistent survey terminology and unlinked patient and provider responses. Conclusions Few patients reported discussion of forgoing dialysis with their providers and even fewer anticipated a choice of CKM on reaching kidney failure. Most providers were comfortable discussing CKM, but practiced in clinics that lacked dedicated resources. Further research is needed to improve the implementation of a CKM pathway. Plain-Language Summary For older comorbid adults with kidney failure, conservative kidney management (CKM) can be an appropriate treatment choice. CKM is a holistic approach with treatment goals of maximizing quality of life and preventing progression of chronic kidney disease (CKD) without initiation of dialysis. We investigated US CKM practices and found that among 1018 people with CKD, only 7% were planning for CKM. Of 407 surveyed patients, 18% reported a conversation with their provider about forgoing dialysis. In contrast, most providers felt comfortable discussing CKM; however, none reported working in an environment with a dedicated CKM clinic or protocol. Our data show the need for further CKM education in the United States as well as dedicated resources for its delivery.
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Affiliation(s)
- Jennifer S. Scherer
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Geriatrics and Palliative Care, New York, NY
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Nephrology, New York, NY
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Natalia Alencar de Pinho
- CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Université Paris Saclay, Université Versailles Saint-Quentin en Yvelines, Institut national de la santé et de la recherche médicale (Inserm), Equipe Epidémiologie Clinique, Villejuif, France
| | - Tahsin Masud
- Emory University, Department of Internal Medicine, Atlanta, GA
| | - Bruce Robinson
- University of Michigan, Department of Internal Medicine, Division of Nephrology, Ann Arbor, MI
| | | | - Joy Schiedell
- NYU Grossman School of Medicine, Department of Population Health, Division of Biostatistics, New York, NY
| | - Keith Goldfeld
- NYU Grossman School of Medicine, Department of Population Health, Division of Biostatistics, New York, NY
| | - Joshua Chodosh
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Geriatrics and Palliative Care, New York, NY
- VA New York Harbor Healthcare System, New York, NY
| | - David M. Charytan
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Nephrology, New York, NY
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Chu CD, McCulloch CE, Hsu RK, Powe NR, Bieber B, Robinson BM, Raina R, Pecoits-Filho R, Tuot DS. Utility of the Kidney Failure Risk Equation and Estimated GFR for Estimating Time to Kidney Failure in Advanced CKD. Am J Kidney Dis 2023; 82:386-394.e1. [PMID: 37301501 PMCID: PMC10588536 DOI: 10.1053/j.ajkd.2023.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/12/2023] [Indexed: 06/12/2023]
Abstract
RATIONALE & OBJECTIVE The Kidney Failure Risk Equation (KFRE) predicts the 2-year risk of kidney failure for patients with chronic kidney disease (CKD). Translating KFRE-predicted risk or estimated glomerular filtration rate (eGFR) into time to kidney failure could inform decision making for patients approaching kidney failure. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS CKD Outcomes and Practice Patterns Study (CKDOPPS) cohort of patients with an eGFR<60mL/min/1.73m2 from 34 US nephrology practices (2013-2021). EXPOSURE 2-year KFRE risk or eGFR. OUTCOME Kidney failure defined as initiation of dialysis or kidney transplantation. ANALYTICAL APPROACH Accelerated failure time (Weibull) models used to estimate the median, 25th, and 75th percentile times to kidney failure starting from KFRE values of 20%, 40%, and 50%, and from eGFR values of 20, 15, and 10mL/min/1.73m2. We examined variability in time to kidney failure by age, sex, race, diabetes status, albuminuria, and blood pressure. RESULTS Overall, 1,641 participants were included (mean age 69±13 years; median eGFR of 28mL/min/1.73m2 [IQR 20-37mL/min/1.73 m2]). Over a median follow-up period of 19 months (IQR, 12-30 months), 268 participants developed kidney failure, and 180 died before reaching kidney failure. The median estimated time to kidney failure was widely variable across patient characteristics from an eGFR of 20mL/min/1.73m2 and was shorter for younger age, male sex, Black (versus non-Black), diabetes (vs no diabetes), higher albuminuria, and higher blood pressure. Estimated times to kidney failure were comparably less variable across these characteristics for KFRE thresholds and eGFR of 15 or 10mL/min/1.73m2. LIMITATIONS Inability to account for competing risks when estimating time to kidney failure. CONCLUSIONS Among those with eGFR<15mL/min/1.73m2 or KFRE risk>40%), both KFRE risk and eGFR showed similar relationships with time to kidney failure. Our results demonstrate that estimating time to kidney failure in advanced CKD can inform clinical decisions and patient counseling on prognosis, regardless of whether estimates are based on eGFR or the KFRE. PLAIN-LANGUAGE SUMMARY Clinicians often talk to patients with advanced chronic kidney disease about the level of kidney function expressed as the estimated glomerular filtration rate (eGFR) and about the risk of developing kidney failure, which can be estimated using the Kidney Failure Risk Equation (KFRE). In a cohort of patients with advanced chronic kidney disease, we examined how eGFR and KFRE risk predictions corresponded to the time patients had until reaching kidney failure. Among those with eGFR<15mL/min/1.73m2 or KFRE risk > 40%), both KFRE risk and eGFR showed similar relationships with time to kidney failure. Estimating time to kidney failure in advanced CKD using either eGFR or KFRE can inform clinical decisions and patient counseling on prognosis.
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Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California-San Francisco, San Francisco, California.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California
| | - Raymond K Hsu
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Neil R Powe
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio; Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | - Delphine S Tuot
- Department of Medicine, University of California-San Francisco, San Francisco, California
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Canney M, Induruwage D, Tang M, Alencar de Pinho N, Er L, Zhao Y, Djurdjev O, Ahn YH, Behnisch R, Calice-Silva V, Chesnaye NC, de Borst MH, Dember LM, Dionne J, Ebert N, Eder S, Fenton A, Fukagawa M, Furth SL, Hoy WE, Imaizumi T, Jager KJ, Jha V, Kang HG, Kitiyakara C, Mayer G, Oh KH, Onu U, Pecoits-Filho R, Reichel H, Richards A, Schaefer F, Schaeffner E, Scheppach JB, Sola L, Ulasi I, Wang J, Yadav AK, Zhang J, Feldman HI, Taal MW, Stengel B, Levin A. Regional Variation in Hemoglobin Distribution Among Individuals With CKD: the ISN International Network of CKD Cohorts. Kidney Int Rep 2023; 8:2056-2067. [PMID: 37850014 PMCID: PMC10577366 DOI: 10.1016/j.ekir.2023.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Despite recognized geographic and sex-based differences in hemoglobin in the general population, these factors are typically ignored in patients with chronic kidney disease (CKD) in whom a single therapeutic range for hemoglobin is recommended. We sought to compare the distribution of hemoglobin across international nondialysis CKD populations and evaluate predictors of hemoglobin. Methods In this cross-sectional study, hemoglobin distribution was evaluated in each cohort overall and stratified by sex and estimated glomerular filtration rate (eGFR). Relationships between candidate predictors and hemoglobin were assessed from linear regression models in each cohort. Estimates were subsequently pooled in a random effects model. Results A total of 58,613 participants from 21 adult cohorts (median eGFR range of 17-49 ml/min) and 3 pediatric cohorts (median eGFR range of 26-45 ml/min) were included with broad geographic representation. Hemoglobin values varied substantially among the cohorts, overall and within eGFR categories, with particularly low mean hemoglobin observed in women from Asian and African cohorts. Across the eGFR range, women had a lower hemoglobin compared to men, even at an eGFR of 15 ml/min (mean difference 5.3 g/l, 95% confidence interval [CI] 3.7-6.9). Lower eGFR, female sex, older age, lower body mass index, and diabetic kidney disease were all independent predictors of a lower hemoglobin value; however, this only explained a minority of variance (R2 7%-44% across cohorts). Conclusion There are substantial regional differences in hemoglobin distribution among individuals with CKD, and the majority of variance is unexplained by demographics, eGFR, or comorbidities. These findings call for a renewed interest in improving our understanding of hemoglobin determinants in specific CKD populations.
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Affiliation(s)
- Mark Canney
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ontario, Canada
| | | | - Mila Tang
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
| | | | - Lee Er
- Methodology and Analytics, BC Renal, Vancouver, British Columbia, Canada
| | - Yinshan Zhao
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- Methodology and Analytics, BC Renal, Vancouver, British Columbia, Canada
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Rouven Behnisch
- Institute of Medical Biometry, University Hospital Heidelberg, Germany
| | - Viviane Calice-Silva
- Research Department, Pro-rim Foundation, Joinville-SC, Brazil
- School of Medicine, UNIVILLE, Joinville-SC, Brazil
| | - Nicholas C. Chesnaye
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
- ERA Registry, Amsterdam UMC Location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Laura M. Dember
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Janis Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
| | - Natalie Ebert
- Institute of Public Health, Charité Universitätsmedizin Berlin, Germany
| | - Susanne Eder
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria
| | - Anthony Fenton
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wendy E. Hoy
- University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Anatomy and Cell Biology, Monash University, Clayton, Victoria, Australia
- Centre for Chronic Disease, University of Queensland, Brisbane, Queensland, Australia
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan. Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Kitty J. Jager
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
- ERA Registry, Amsterdam UMC Location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Chagriya Kitiyakara
- Departments of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, South Korea
| | - Ugochi Onu
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Roberto Pecoits-Filho
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontifica Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Anna Richards
- Value Evidence and Outcomes, GSK, Brentford, Middlesex, UK
| | - Franz Schaefer
- Pediatric Nephrology Division, University Children's Hospital, Heidelberg, Germany
| | - Elke Schaeffner
- Institute of Public Health, Charité Universitätsmedizin Berlin, Germany
| | | | - Laura Sola
- Hemodialysis Unit, CASMU-IAMPP, Montevideo, Uruguay
| | - Ifeoma Ulasi
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
- Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Peking University Institute of Nephrology, Peking University Health Science Center, Beijing, China
| | - Ashok K. Yadav
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jianzhen Zhang
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, University of Nottingham School of Medicine, Nottingham, UK
| | - Bénédicte Stengel
- CESP, University Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, Villejuif, France
| | - Adeera Levin
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
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Hain D, Bednarski D, Cahill M, Dix A, Foote B, Haras MS, Pace R, Gutiérrez OM. Iron-Deficiency Anemia in CKD: A Narrative Review for the Kidney Care Team. Kidney Med 2023; 5:100677. [PMID: 37415621 PMCID: PMC10319843 DOI: 10.1016/j.xkme.2023.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Anemia is a common complication of chronic kidney disease (CKD) and is associated with increased mortality and reduced health-related quality of life. Anemia is characterized by a decrease in hemoglobin, the iron-rich protein that the body uses for oxygen transport. Iron is required to produce hemoglobin, and disruptions in the iron homeostasis can lead to iron-deficiency anemia. Management of anemia in individuals with CKD is typically performed by a team of physicians, nurse practitioners, physician assistants, or registered nurses. Throughout the care continuum, the management can be enhanced by multidisciplinary care, and individuals with CKD can benefit from the involvement of other specialties, with dietitians/nutritionists playing an important role. However, a key area of unmet clinical need is how to assess and address iron-deficiency anemia. This review aims to provide an overview of iron-deficiency anemia in CKD and how this may be diagnosed and managed by the entire kidney care team, such as describing the mechanisms underlying iron homeostasis, the complications of iron-deficiency anemia, and the current challenges associated with its diagnosis and treatment in CKD. Opportunities for each multidisciplinary team member to add value to the care of individuals with CKD and iron-deficiency anemia are also described.
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Affiliation(s)
- Debra Hain
- Florida Atlantic University, Boca Raton, FL
| | - Donna Bednarski
- Detroit Medical Center Harper University Hospital, Detroit, MI
| | | | - Amy Dix
- Akebia Therapeutics Inc, Cambridge, MA
| | | | - Mary S. Haras
- Georgetown University School of Nursing, Washington, DC
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Calice-Silva V, Muenz D, Wong MMY, McCullough K, Charytan D, Reichel H, Robinson B, Stengel B, Massy ZA, Pecoits-Filho R. International practice patterns of dyslipidemia management in patients with chronic kidney disease under nephrology care: is it time to review guideline recommendations? Lipids Health Dis 2023; 22:67. [PMID: 37231413 DOI: 10.1186/s12944-023-01833-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND In contrast to guidelines related to lipid therapy in other areas, 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend conducting a lipid profile upon diagnosis of chronic kidney disease (CKD) and treating all patients older than 50 years without defining a target for lipid levels. We evaluated multinational practice patterns for lipid management in patients with advanced CKD under nephrology care. METHODS We analyzed lipid-lowering therapy (LLT), LDL- cholesterol (LDL-C) levels, and nephrologist-specified LDL-C goal upper limits in adult patients with eGFR < 60 ml/min from nephrology clinics in Brazil, France, Germany, and the United States (2014-2019). Models were adjusted for CKD stage, country, cardiovascular risk indicators, sex, and age. RESULTS LLT treatment differed significantly by country, from 51% in Germany to 61% in the US and France (p = 0.002) for statin monotherapy. For ezetimibe with or without statins, the prevalence was 0.3% in Brazil to 9% in France (< 0.001). Compared with patients not taking lipid-lowering therapy, LDL-C was lower among treated patients (p < 0.0001) and differed significantly by country (p < 0.0001). At the patient level, the LDL-C levels and statin prescription did not vary significantly by CKD stage (p = 0.09 LDL-C and p = 0.24 statin use). Between 7-23% of untreated patients in each country had LDL-C ≥ 160 mg/dL. Only 7-17% of nephrologists believed that LDL-C should be < 70 mg/dL. CONCLUSION There is substantial variation in practice patterns regarding LLT across countries but not across CKD stages. Treated patients appear to benefit from LDL-C lowering, yet a significant proportion of hyperlipidemia patients under nephrologist care are not receiving treatment.
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Affiliation(s)
- Viviane Calice-Silva
- Pro-Kidney Foundation, Joinville, Brazil
- University of Joinville's Region - UNIVILLE, Joinville, Brazil
| | - Daniel Muenz
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 3989 Research Park Dr, Ann Arbor, MI, 48108, USA
| | - Michelle M Y Wong
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Keith McCullough
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 3989 Research Park Dr, Ann Arbor, MI, 48108, USA
| | - David Charytan
- Nephrology Division, New York University Grossman School of Medicine, New York, NY, USA
| | - Helmut Reichel
- Nephrological Center Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - Bruce Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 3989 Research Park Dr, Ann Arbor, MI, 48108, USA
| | - Benedicte Stengel
- Université Paris Saclay, Université Versailles Saint-Quentin en Yvelines, Institut National de La Santé Et de La Recherche Médicale (Inserm), Villejuif, France
- Centre de Recherche en Epidémiologie Et Santé Des Populations (CESP), Equipe Epidémiologie Clinique, Villejuif, France
| | - Ziad A Massy
- Université Paris Saclay, Université Versailles Saint-Quentin en Yvelines, Institut National de La Santé Et de La Recherche Médicale (Inserm), Villejuif, France
- Centre de Recherche en Epidémiologie Et Santé Des Populations (CESP), Equipe Epidémiologie Clinique, Villejuif, France
- Department of Nephrology, CHU Ambroise Paré, APHP, Boulogne, France
| | - Roberto Pecoits-Filho
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 3989 Research Park Dr, Ann Arbor, MI, 48108, USA.
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Imakura A, Tsunoda R, Kagawa R, Yamagata K, Sakurai T. DC-COX: Data collaboration Cox proportional hazards model for privacy-preserving survival analysis on multiple parties. J Biomed Inform 2023; 137:104264. [PMID: 36462599 DOI: 10.1016/j.jbi.2022.104264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
The demand for the privacy-preserving survival analysis of medical data integrated from multiple institutions or countries has been increased. However, sharing the original medical data is difficult because of privacy concerns, and even if it could be achieved, we have to pay huge costs for cross-institutional or cross-border communications. To tackle these difficulties of privacy-preserving survival analysis on multiple parties, this study proposes a novel data collaboration Cox proportional hazards (DC-COX) model based on a data collaboration framework for horizontally and vertically partitioned data. By integrating dimensionality-reduced intermediate representations instead of the original data, DC-COX obtains a privacy-preserving survival analysis without iterative cross-institutional communications or huge computational costs. DC-COX enables each local party to obtain an approximation of the maximum likelihood model parameter, the corresponding statistic, such as the p-value, and survival curves for subgroups. Based on a bootstrap technique, we introduce a dimensionality reduction method to improve the efficiency of DC-COX. Numerical experiments demonstrate that DC-COX can compute a model parameter and the corresponding statistics with higher performance than the local party analysis. Particularly, DC-COX demonstrates outstanding performance in essential feature selection based on the p-value compared with the existing methods including the federated learning-based method.
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Affiliation(s)
- Akira Imakura
- Faculty of Engineering, Information and Systems, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8573, Japan.
| | - Ryoya Tsunoda
- University of Tsukuba Hospital, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan.
| | - Rina Kagawa
- Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Kunihiro Yamagata
- Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Tetsuya Sakurai
- Faculty of Engineering, Information and Systems, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8573, Japan.
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8
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Pecoits-Filho R, McCullough K, Muenz D, Quinn CM, Budden J, Golden J, de Arellano AR, Tillmann FP, Duttlinger J, Calice-Silva V, Massy ZA, Bieber B, Robinson BM, Fliser D, Reichel H. Patiromer utilization in patients with advanced chronic kidney disease under nephrology care in Germany. Clin Kidney J 2022; 16:176-183. [PMID: 36726438 PMCID: PMC9871846 DOI: 10.1093/ckj/sfac209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
Background Hyperkalemia (HK) is a frequent condition in patients with chronic kidney disease (CKD) that is associated with high morbidity and mortality. Patiromer has recently been introduced as a potassium binder. Data on patiromer use in patients with CKD in the real-world setting in Europe are lacking. We describe time to discontinuation and changes in serum potassium levels among German CKD stage 3-5 patients starting patiromer. Methods Duration of patiromer use was estimated by Kaplan-Meier curve, starting at patiromer initiation and censoring for death, dialysis, transplant or loss to follow-up. Serum potassium levels and renin-angiotensin-aldosterone system inhibitor (RAASi) use are described at baseline and during follow-up, restricted to patients remaining on patiromer. Results We identified 140 patiromer users within our analysis sample [81% CKD stage 4/5, 83% receiving RAASi, and median K+ 5.7 (5.4, 6.3) mmol/L]. Thirty percent of patiromer users had prior history of polystyrene sulfonate use. Overall, 95% of patiromer users stayed on treatment past 1 month, with 53% continuing for over a year. Mean serum potassium levels decreased after patiromer initiation and remained stable under treatment during follow-up (up to 180 days). Among these patients, 73%-82% used RAASis during the time periods before and after patiromer initiation, with no obvious trend indicating discontinuation. Conclusion Real-world evidence of patiromer use in Germany shows that, in line with what has been observed in clinical trials, patients on patiromer have a reduction in serum potassium when used long-term. Moreover, most patients on patiromer do not discontinue treatment prior to 1 year after initiation.
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Affiliation(s)
| | | | - Daniel Muenz
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | | | | | - Frank-Peter Tillmann
- Department of Medicine I – Nephrology, Transplantation & Medical Intensive Care, University Witten/Herdecke, Medical Center Cologne-Merheim, Cologne, Germany
| | | | | | - Ziad A Massy
- Department of Nephrology, CHU Ambroise Paré, APHP, Boulogne, France,Center for Research in Epidemiology and Population Health (CESP), University Paris Saclay, University Versailles Saint-Quentin en Yvelines, National Institute of Health, Clinical Epidemiology Team, Villejuif, France,Division of Nephrology, Ambroise Paré Universitry Hospital, APHP, Paris, France
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Danilo Fliser
- Saarland University Medical Centre, Homburg, Germany
| | - Helmut Reichel
- Nephrological Center, Villingen-Schwenningen, Baden-Württemberg, Germany
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9
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Alencar de Pinho N, Henn L, Raina R, Reichel H, Lopes AA, Combe C, Speyer E, Bieber B, Robinson BM, Stengel B, Pecoits-Filho R. Understanding International Variations in Kidney Failure Incidence and Initiation of Replacement Therapy. Kidney Int Rep 2022; 7:2364-2375. [DOI: 10.1016/j.ekir.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022] Open
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10
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Aquino JA, Oliveira CL, Otoni A, Sanches C, Guedes JVM, Morais DB, Mendonça TS, Morais FA, Baldoni AO. Progression of chronic kidney disease in non- dialysis patients: a retrospective cohort. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e20249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Alba Otoni
- Federal University of São João Del-Rei, Brazil
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11
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Zee J, Muenz D, McCullough KP, Bieber B, Metzger M, Alencar de Pinho N, Lopes AA, Fliser D, Robinson BM, Young E, Pisoni RL, Stengel B, Pecoits-Filho R, Combe C, Duttlinger J, Fliser D, Jacquelinet C, Lonnemann G, Lopes A, Massy Z, Pecoits-Filho R, Reichel H, Stengel B, Wada T, Yamagata K. Potential Surrogate Outcomes for Kidney Failure in Advanced CKD: Evaluation of Power and Predictive Ability in CKDopps. Kidney Med 2021; 4:100395. [PMID: 35243307 PMCID: PMC8861958 DOI: 10.1016/j.xkme.2021.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Rationale & Objective Potential surrogate end points for kidney failure have been proposed in chronic kidney disease (CKD); however, they must be evaluated to ensure accurate, powerful, and harmonized research, particularly among patients with advanced CKD. The aim of the current study was to investigate the power and predictive ability of surrogate kidney failure end points in a population with moderate-to-advanced CKD. Study Design Analysis of longitudinal data of a large multinational CKD observational study (Chronic Kidney Disease Outcomes and Practice Patterns Study). Setting & Participants CKD stage 3-5 patients from Brazil, France, Germany, and the United States. Outcomes Reaching an estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2 or eGFR decline of ≥40%, and composite end points of these individual end points. Analytical Approach Each end point was used as a time-varying indicator in the Cox model to predict the time to kidney replacement therapy (KRT; dialysis or transplant) and was compared by the number of events and prediction accuracy. Results 8,211 patients had a median baseline eGFR of 27 mL/min/1.73 m2 (interquartile range, 21-36 mL/min/1.73 m2) and 1,448 KRT events over a median follow-up of 2.7 years (interquartile range, 1.2-3.0 years). Among CKD stage 4 patients, the eGFR < 15 mL/min/1.73 m2 end point had higher prognostic ability than 40% eGFR decline, but the end points were similar for CKD stage 3 patients. The combination of eGFR < 15 mL/min/1.73 m2 and 40% eGFR decline had the highest prognostic ability for predicting KRT, regardless of the CKD stage. Including KRT in the composite can increase the number of events and, therefore, the power. Limitations Variable visit frequency resulted in variable eGFR measurement frequency. Conclusions The composite end point can be useful for CKD progression studies among patients with advanced CKD. Harmonized use of this approach has the potential to accelerate the translation of new discoveries to clinical practice by identifying risk factors and treatments for kidney failure.
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12
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Hecking M, Tu C, Zee J, Bieber B, Hödlmoser S, Reichel H, Sesso R, Port FK, Robinson BM, Carrero JJ, Tong A, Combe C, Stengel B, Pecoits-Filho R. Sex-Specific Differences in Mortality and Incident Dialysis in the Chronic Kidney Disease Outcomes and Practice Patterns Study. Kidney Int Rep 2021; 7:410-423. [PMID: 35257054 PMCID: PMC8897674 DOI: 10.1016/j.ekir.2021.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/18/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction More men than women start kidney replacement therapy (KRT) although the prevalence of chronic kidney disease (CKD) is higher in women than men. We therefore aimed at analyzing sex-specific differences in clinical outcomes among 8237 individuals with CKD in stages 3 to 5 from Brazil, France, Germany, and the United States participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps). Methods Fine and Gray models, evaluating the effect of sex on time to events, were adjusted for age, Black race (model A); plus diabetes, cardiovascular disease, albuminuria (model B); plus estimated glomerular filtration rate (eGFR) slope during the first 12 months after enrollment and first eGFR after enrollment (model C). Results There were more men than women at baseline (58% vs. 42%), men were younger than women, and men had higher eGFR (28.9 ± 11.5 vs. 27.0 ± 10.8 ml/min per 1.73 m2). Over a median follow-up of 2.7 and 2.5 years for men and women, respectively, the crude dialysis initiation and pre-emptive transplantation rates were higher in men whereas that of pre-KRT death was more similar. The adjusted subdistribution hazard ratios (SHRs) between men versus women for dialysis were 1.51 (1.27–1.80) (model A), 1.32 (1.10–1.59) (model B), and 1.50 (1.25–1.80) (model C); for pre-KRT death, were 1.25 (1.02–1.54) (model A), 1.14 (0.92–1.40) (model B), and 1.15 (0.93–1.42) (model C); for transplantation, were 1.31 (0.73–2.36) (model A), 1.44 (0.76–2.74) (model B), and 1.53 (0.79–2.94) (model C). Conclusion Men had a higher probability of commencing dialysis before death, unexplained by CKD progression alone. Although the causal mechanisms are uncertain, this finding helps interpret the preponderance of men in the dialysis population.
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13
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Liabeuf S, Laville SM, Bieber B, Tu C, Stengel B, Wong MMY, Calice da Silva V, Fliser D, Robinson BM, Pecoits-Filho R, Massy ZA. Prescription of Direct Oral Anticoagulants to Patients With Moderate-to-Advanced CKD: Too Little or Just Right? Kidney Int Rep 2021; 6:2496-500. [PMID: 34514213 DOI: 10.1016/j.ekir.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022] Open
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14
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Alencar de Pinho N, Capgras JB, Speyer É, Combe C, Fouque D, Frimat L, Massy Z, Ayav C, Liabeuf S, Lange C, Jacquelinet C, Stengel B, Pascal C, Laville M; au nom du groupe d’étude de la cohorte Chronic Kidney Disease-Renal Epidemiology Information Network (CKD-REIN). [CKD care in French nephrology practices]. Nephrol Ther 2021:S1769-7255(21)00146-2. [PMID: 34384728 DOI: 10.1016/j.nephro.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/14/2021] [Accepted: 06/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND To be able to assess the impact of the bundled payment system on real-life management of patients with chronic kidney disease, an overview of patient-care management before its implementation is needed. PATIENTS AND METHODS We describe patterns of nephrology care over 3 years in 2835 patients with moderate to severe chronic kidney disease, who were followed-up from 2013 to 2019 in the CKD-REIN cohort study. Compliance with health authority guidelines during this period is also studied. RESULTS At baseline, patients' mean age was 67 years, 65% were men, and 43% had chronic kidney disease stage 4 or 5. The mean number of nephrology visits increased from 1.1 to 2.7 per year, from chronic kidney disease stage 3A to stage 5. The minimum number of nephrology visits as recommended by health authorities was achieved in 84%, 63%, and 33% of patients with chronic kidney disease stages 3B, 4, and 5, respectively. In chronic kidney disease stages 4 and 5, only 34% and 40% of patients had seen a dietitian, and 33% and 54% had received information about treatment options, respectively. The average waiting time for a first appointment with a nephrologist was longer, 60 days and its duration shorter, 30 vs 38 to 40 minutes, in university hospitals compared with non-university hospitals and private clinics. CONCLUSION The significant gap between received and recommended care reflects human resources and organizational limits in chronic kidney disease management in the nephrology setting. Improvements with bundled payment are expected.
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15
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Okubo R, Kondo M, Tsunoda R, Nagai K, Kai H, Saito C, Hoshino J, Okada H, Narita I, Wada T, Kashihara N, Robinson B, Yamagata K. Physical functioning in patients with chronic kidney disease stage G3b-5 in Japan: The reach-J CKD cohort study. Nephrology (Carlton) 2021; 26:981-987. [PMID: 34312938 DOI: 10.1111/nep.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
AIM Chronic kidney disease (CKD) is an important public health problem. Recently, CKD has been found to be associated with poor physical functioning in community-dwelling elderly individuals. However, the physical functioning of non-dialysis (ND) patients with advanced CKD treated by nephrologists is unknown. METHODS Patients with ND-CKD stage G3b-5 who participated in a nationwide Reach-J CKD cohort study were included in this study. Physical functioning and physical activity were assessed by the Katz Index, Lawton-Body instrumental activities of daily living (IADL) scale, and Rapid Assessment of Physical Activity questionnaire of the international CKD Outcomes and Practice Patterns Study (CKDopps) questionnaires. Dichotomies between good and poor physical functioning and physical activity scores were explored. RESULTS Among 1628 patients, 84.3% had good physical functioning. Poor physical functioning was more common with older age (p < .001), higher CKD stage (p < .05), and comorbid conditions such as diabetes (p < .001), cardiovascular disease (p < .05), cerebrovascular disease (p < .001), and cancer (non-skin) (p < .05). Forty percent of the patients were inactive. Physical inactivity was more common with older age (p < .001) and higher CKD stage (p < .001). CONCLUSION A minority, but sizeable proportion of patients with advanced CKD treated by nephrologists in Japan have some disability in ADLs/IADLs. Nephrologists need to routinely assess the physical functioning and physical activity of patients with advanced CKD to provide individualized guidance and comprehensive support to these patients for their daily life.
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Affiliation(s)
- Reiko Okubo
- Department of Health Care Policy and Health Economics, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masahide Kondo
- Department of Health Care Policy and Health Economics, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Ryoya Tsunoda
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kei Nagai
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hirayasu Kai
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chie Saito
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,R&D Center for Smart Wellness City Policies, University of Tsukuba, Ibaraki, Japan
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16
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Guedes M, Muenz DG, Zee J, Bieber B, Stengel B, Massy ZA, Mansencal N, Wong MMY, Charytan DM, Reichel H, Waechter S, Pisoni RL, Robinson BM, Pecoits-Filho R. Serum Biomarkers of Iron Stores Are Associated with Increased Risk of All-Cause Mortality and Cardiovascular Events in Nondialysis CKD Patients, with or without Anemia. J Am Soc Nephrol 2021; 32:2020-2030. [PMID: 34244326 PMCID: PMC8455257 DOI: 10.1681/asn.2020101531] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/29/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Approximately 30%-45% of patients with nondialysis CKD have iron deficiency. Iron therapy in CKD has focused primarily on supporting erythropoiesis. In patients with or without anemia, there has not been a comprehensive approach to estimating the association between serum biomarkers of iron stores, and mortality and cardiovascular event risks. METHODS The study included 5145 patients from Brazil, France, the United States, and Germany enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study, with first available transferrin saturation (TSAT) and ferritin levels as exposure variables. We used Cox models to estimate hazard ratios (HRs) for all-cause mortality and major adverse cardiovascular events (MACE), with progressive adjustment for potentially confounding variables. We also used linear spline models to further evaluate functional forms of the exposure-outcome associations. RESULTS Compared with patients with a TSAT of 26%-35%, those with a TSAT ≤15% had the highest adjusted risks for all-cause mortality and MACE. Spline analysis found the lowest risk at TSAT 40% for all-cause mortality and MACE. Risk of all-cause mortality, but not MACE, was also elevated at TSAT ≥46%. Effect estimates were similar after adjustment for hemoglobin. For ferritin, no directional associations were apparent, except for elevated all-cause mortality at ferritin ≥300 ng/ml. CONCLUSIONS Iron deficiency, as captured by TSAT, is associated with higher risk of all-cause mortality and MACE in patients with nondialysis CKD, with or without anemia. Interventional studies evaluating the effect on clinical outcomes of iron supplementation and therapies for alternative targets are needed to better inform strategies for administering exogenous iron.
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Affiliation(s)
- Murilo Guedes
- Pontificia Universidade Catolica do Parana, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Daniel G Muenz
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Ziad A Massy
- Université Paris Saclay, Villejuif, France.,Service de Néphrologie et Dialyse, Assistance Publique Hôpitaux de Paris, Hôpital Universitaire Ambroise Paré, Boulogne Billancourt, France
| | - Nicolas Mansencal
- Service de Cardiologie Assistance Publique Hôpitaux de Paris, Hôpital Universitaire Ambroise Paré, Boulogne Billancourt, France
| | - Michelle M Y Wong
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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17
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Fages V, de Pinho NA, Hamroun A, Lange C, Combe C, Fouque D, Frimat L, Jacquelinet C, Laville M, Ayav C, Liabeuf S, Pecoits-Filho R, Massy ZA, Boucquemont J, Stengel B. Urgent-start dialysis in patients referred early to a nephrologist-the CKD-REIN prospective cohort study. Nephrol Dial Transplant 2021; 36:1500-1510. [PMID: 33944928 DOI: 10.1093/ndt/gfab170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists. METHODS The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that 'initiated imminently or <48 hours after presentation to correct life-threatening manifestations' according to the Kidney Disease: Improving Global Outcomes 2018 definition. RESULTS Over a 4-year (interquartile range 3.0-4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08-4.25] or with low health literacy [2.22 (95% CI 1.28-3.84)], heart failure [2.60 (95% CI 1.47-4.57)] or hyperpolypharmacy [taking >10 drugs; 2.14 (95% CI 1.17-3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19-1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70-0.94)] for each visit. CONCLUSIONS This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.
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Affiliation(s)
- Victor Fages
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.,Service de Néphrologie, Dialyse, Transplantation Rénale et Aphérèse, CHU de Lille, Lille, France
| | - Natalia Alencar de Pinho
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France
| | - Aghilès Hamroun
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.,Service de Néphrologie, Dialyse, Transplantation Rénale et Aphérèse, CHU de Lille, Lille, France
| | - Céline Lange
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.,Agence de Biomédecine, La Plaine Saint-Denis, France
| | - Christian Combe
- Service de Néphrologie, Transplantation, Dialyse, Aphérèses, CHU de Bordeaux, Bordeaux, France.,INSERM Unité 1026, Université de Bordeaux, Bordeaux, France
| | - Denis Fouque
- Université Claude Bernard Lyon1, CarMeN INSERM 1060, Lyon, France.,Service de Néphrologie, Lyon-Sud Hospital, Pierre-Bénite, France
| | - Luc Frimat
- Service de Néphrologie, Université de Lorraine, APEMAC, CHRU de Nancy - Hôpitaux de Brabois, Nancy, France
| | - Christian Jacquelinet
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.,Agence de Biomédecine, La Plaine Saint-Denis, France
| | - Maurice Laville
- Université Claude Bernard Lyon1, CarMeN INSERM 1060, Lyon, France.,Association Utilisation Rein Artificiel Région Lyonnaise, Lyon, France
| | - Carole Ayav
- CHRU de Nancy, Université de Lorraine, INSERM, CIC Epidémiologie Clinique, Hôpitaux de Brabois, Nancy, France
| | - Sophie Liabeuf
- Département de Recherche Clinique, Service de Pharmacologie Clinique, CHU d'Amiens, Université de Picardie Jules Verne, INSERM U-1088, Amiens, France
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Pontificia Universidade Catolica do Prana, Curitiba, Brazil
| | - Ziad A Massy
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.,Service de Néphrologie-Dialyse, CHU Ambroise Paré, APHP, Boulogne-Billancourt, France
| | - Julie Boucquemont
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France
| | - Bénédicte Stengel
- UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France
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Hoshino J, Tsunoda R, Nagai K, Kai H, Saito C, Ito Y, Asahi K, Kondo M, Iseki K, Iseki C, Okada H, Kashihara N, Narita I, Wada T, Combe C, Pisoni RL, Robinson BM, Yamagata K. Comparison of annual eGFR decline among primary kidney diseases in patients with CKD G3b-5: results from a REACH-J CKD cohort study. Clin Exp Nephrol 2021; 25:902-10. [PMID: 33881641 DOI: 10.1007/s10157-021-02059-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Disease-specific trajectories of renal function in advanced chronic kidney disease (CKD) are not well defined. Here, we compared these trajectories in the estimated glomerular filtration rate (eGFR) by CKD stages. METHODS Patients with multiple eGFR measurements during the 5-year preregistration period of the REACH-J study were enrolled. Mean annual eGFR declines were calculated from linear mixed effect models with the adjustment variables of baseline CKD stage, age, sex and the current CKD stage and the level of proteinuria (CKDA1-3). RESULTS Among 1,969 eligible patients with CKDG3b-5, the adjusted eGFR decline (ml/min/1.73 m2/year) was significantly faster in diabetic kidney disease (DKD) patients and polycystic kidney disease (PKD) patients than in patients with other kidney diseases (DKD, - 2.96 ± 0.13; PKD, - 2.82 ± 0.17; and others, - 1.95 ± 0.05, p < 0.01). The declines were faster with higher CKD stages. In DKD patients, the eGFR decline was significantly faster in CKDG5 than CKDG4 (- 4.10 ± 0.18 vs - 2.76 ± 0.20, p < 0.01), while these declines in PKD patients were similar. The eGFR declines in PKD patients were significantly faster than DKD patients in CKDG4 (- 2.92 ± 0.23 vs - 2.76 ± 0.20, p < 0.01) and in CKDA2 (- 3.36 ± 0.35 vs - 1.40 ± 0.26, p < 0.01). CONCLUSION Our study revealed the disease-specific annual eGFR declines by CKD stages and the level of proteinuria. Comparing to the other kidney diseases, the declines in PKD patients were getting faster from early stages of CKD. These results suggest the importance of CKD managements in PKD patients from the early stages.
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19
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Pecoits-Filho R, James G, Carrero JJ, Wittbrodt E, Fishbane S, Sultan AA, Heerspink HJL, Hedman K, Kanda E, Chen HT, Kashihara N, Sloand J, Kosiborod M, Kumar S, Lainscak M, Arnold M, Lam CSP, Holmqvist B, Pollock C, Fenici P, Stenvinkel P, Medin J, Wheeler DC. Methods and rationale of the DISCOVER CKD global observational study. Clin Kidney J 2021; 14:1570-1578. [PMID: 34249352 PMCID: PMC8264307 DOI: 10.1093/ckj/sfab046] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Indexed: 12/20/2022] Open
Abstract
Background Real-world data for patients with chronic kidney disease (CKD), specifically pertaining to clinical management, metabolic control, treatment patterns, quality of life (QoL) and dietary patterns, are limited. Understanding these gaps using real-world, routine care data will improve our understanding of the challenges and consequences faced by patients with CKD, and will facilitate the long-term goal of improving their management and prognosis. Methods DISCOVER CKD follows an enriched hybrid study design, with both retrospective and prospective patient cohorts, integrating primary and secondary data from patients with CKD from China, Italy, Japan, Sweden, the UK and the USA. Data will be prospectively captured over a 3-year period from >1000 patients with CKD who will be followed up for at least 1 year via electronic case report form entry during routine clinical visits and also via a mobile/tablet-based application, enabling the capture of patient-reported outcomes (PROs). In-depth interviews will be conducted in a subset of ∼100 patients. Separately, secondary data will be retrospectively captured from >2 000 000 patients with CKD, extracted from existing datasets and registries. Results The DISCOVER CKD program captures and will report on patient demographics, biomarker and laboratory measurements, medical histories, clinical outcomes, healthcare resource utilization, medications, dietary patterns, physical activity and PROs (including QoL and qualitative interviews). Conclusions The DISCOVER CKD program will provide contemporary real-world insight to inform clinical practice and improve our understanding of the epidemiology and clinical and economic burden of CKD, as well as determinants of clinical outcomes and PROs from a range of geographical regions in a real-world CKD setting.
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Affiliation(s)
- Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Steven Fishbane
- Division of Nephrology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | | | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | | | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Carolyn S P Lam
- National Heart Centre, Singapore.,Duke-NUS Medical School, Singapore
| | | | - Carol Pollock
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | | | - Peter Stenvinkel
- Division of Renal Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
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20
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Guedes M, Muenz D, Zee J, Lopes MB, Waechter S, Stengel B, Massy ZA, Speyer E, Ayav C, Finkelstein F, Sesso R, Pisoni RL, Robinson BM, Pecoits-Filho R. Serum biomarkers of iron stores are associated with worse physical health-related quality of life (HRQoL) in non-dialysis dependent chronic kidney disease (NDD-CKD) patients with or without anemia. Nephrol Dial Transplant 2021; 36:1694-1703. [PMID: 33624825 PMCID: PMC8396397 DOI: 10.1093/ndt/gfab050] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/28/2022] Open
Abstract
Background Iron deficiency (ID) is a common condition in nondialysis-dependent chronic kidney disease (NDD-CKD) patients that is associated with poorer clinical outcomes. However, the effect of ID on health-related quality of life (HRQoL) in this population is unknown. We analyzed data from a multinational cohort of NDD-CKD Stages 3–5 patients to test the association between transferrin saturation (TSAT) index and ferritin with HRQoL. Methods Patients from Brazil (n = 205), France (n = 2015) and the USA (n = 293) in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps, 2013–2019) were included. We evaluated the association of TSAT and ferritin (and functional and absolute ID, defined as TSAT ≤20% and ferritin ≥300 or <50 ng/mL) on pre-specified HRQoL measures, including the 36-item Kidney Disease Quality of Life physical component summary (PCS) and mental component summary (MCS) as the primary outcomes. Models were adjusted for confounders including hemoglobin (Hb). Results TSAT ≤15% and ferritin <50 ng/mL and ≥300 ng/mL were associated with worse PCS scores, but not with MCS. Patients with composite TSAT ≤20% and ferritin <50 or ≥300 ng/mL had lower functional status and worse PCS scores than those with a TSAT of 20–30% and ferritin 50–299 ng/mL. Patients with a lower TSAT were less likely to perform intense physical activity. Adjustment for Hb only slightly attenuated the observed effects. Conclusions Low TSAT levels, as well as both low TSAT with low ferritin and low TSAT with high ferritin, are associated with worse physical HRQoL in NDD-CKD patients, even after accounting for Hb level. Interventional studies of iron therapy on HRQoL among NDD-CKD individuals are needed to confirm these findings.
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Affiliation(s)
- Murilo Guedes
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Daniel Muenz
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | - Bénédicte Stengel
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | - Ziad A Massy
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France.,France, Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt/Paris, France
| | - Elodie Speyer
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | - Carole Ayav
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | | | | | | | | | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Pontificia Universidade Catolica do Parana, Curitiba, Brazil
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21
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Lopes MB, Tu C, Zee J, Guedes M, Pisoni RL, Robinson BM, Foote B, Hedman K, James G, Lopes AA, Massy Z, Reichel H, Sloand J, Waechter S, Wong MMY, Pecoits-Filho R. A real-world longitudinal study of anemia management in non-dialysis-dependent chronic kidney disease patients: a multinational analysis of CKDopps. Sci Rep 2021; 11:1784. [PMID: 33469061 DOI: 10.1038/s41598-020-79254-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
Previously lacking in the literature, we describe longitudinal patterns of anemia prescriptions for non-dialysis-dependent chronic kidney disease (NDD-CKD) patients under nephrologist care. We analyzed data from 2818 Stage 3-5 NDD-CKD patients from Brazil, Germany, and the US, naïve to anemia medications (oral iron, intravenous [IV] iron, or erythropoiesis stimulating agent [ESA]) at enrollment in the CKDopps. We report the cumulative incidence function (CIF) of medication initiation stratified by baseline characteristics. Even in patients with hemoglobin (Hb) < 10 g/dL, the CIF at 12 months for any anemia medication was 40%, and 28% for ESAs. Patients with TSAT < 20% had a CIF of 26% and 6% for oral and IV iron, respectively. Heart failure was associated with earlier initiation of anemia medications. IV iron was prescribed to < 10% of patients with iron deficiency. Only 40% of patients with Hb < 10 g/dL received any anemia medication within a year. Discontinuation of anemia treatment was very common. Anemia treatment is initiated in a limited number of NDD-CKD patients, even in those with guideline-based indications to treat. Hemoglobin trajectory and a history of heart failure appear to guide treatment start. These results support the concept that anemia is sub-optimally managed among NDD-CKD patients in the real-world setting.
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22
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Stengel B, Muenz D, Tu C, Speyer E, Alencar de Pinho N, Combe C, Yamagata K, Reichel H, Fliser D, Massy ZA, Lopes AA, Jadoul M, Winkelmayer WC, Pisoni RL, Robinson BM, Pecoits-Filho R; CKDopps investigators. Adherence to the Kidney Disease: Improving Global Outcomes CKD Guideline in Nephrology Practice Across Countries. Kidney Int Rep 2021; 6:437-48. [PMID: 33615069 DOI: 10.1016/j.ekir.2020.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/11/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world. Methods We used baseline data from the CKD Outcomes and Practice Patterns Study (2013-2017), a 4-country cohort of patients with estimated glomerular filtration rate <60 ml/min per 1.73 m2 recruited from national samples of nephrology clinics, to describe adherence to measures for monitoring and delaying CKD progression. Data were collected as in clinical practice, except laboratory measures per protocol in France. Results The mean age ranged from 65 years in Brazil to 72 years in Germany. Albuminuria (mostly proteinuria) was measured routinely in 36% to 43% of patients in Brazil, Germany, and the United States. Blood pressure control (≤140/90 mm Hg) ranged from 49% in France to 76% in Brazil; <40% of patients had blood pressure ≤130/80 mm Hg everywhere but Brazil (52%). More than 40% of nephrologists in Brazil reported a systolic blood pressure target ≤130 mm Hg for nondiabetic patients without proteinuria, but only 19% to 24% elsewhere. Prescription of renin-angiotensin aldosterone system inhibitors ranged from 52% in the United States to 81% in Germany. Dietary advice was more frequent for salt than protein intake; dietitian visits were uncommon. In nondiabetic patients, achievement of all 3 targets including blood pressure ≤130/80 mm Hg, renin-angiotensin aldosterone system inhibition, and dietary advice, ranged from 10% in the United States to 32% in Brazil; in treated diabetic patients, this ranged from 6% to 11% after including hemoglobin A1c target. Conclusion Adherence to recommendations to slow CKD progression is low in typical practice settings, and substantial variation among countries for some indicates opportunities for improvement.
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23
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van Rijn MH, Alencar de Pinho N, Wetzels JF, van den Brand JA, Stengel B. Worldwide Disparity in the Relation Between CKD Prevalence and Kidney Failure Risk. Kidney Int Rep 2020; 5:2284-2291. [PMID: 33305122 PMCID: PMC7710841 DOI: 10.1016/j.ekir.2020.09.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/21/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction The incidence of kidney replacement therapy (KRT) for kidney failure varies internationally much more than chronic kidney disease (CKD) prevalence. This ecologic study investigated the relation of CKD prevalence to KRT and mortality risks by world region. Methods We used data from Global Burden of Disease and KRT registries worldwide with linear models to estimate the percentages of variance in KRT incidence and all-cause mortality explained by age-adjusted prevalence of CKD stages 3 to 5, overall and by gender, in 61 countries classified in 3 regions: high income (n = 28), Eastern and Central Europe (n = 15), and other (n = 18). Results The incidence of KRT ranged from 89 to 378 per million population in high-income regions, 32 to 222 per million population in Central and Eastern Europe, and 22 to 493 per million population in the other region; age-adjusted CKD prevalence ranged from 5.5% to 10.4%, 7.6% to 13.7%, and 7.4% to 13.1%, respectively. The relation between these indicators was positive in high-income countries, negative in Central and Eastern Europe, and null in the other region. Age-adjusted CKD prevalence explained 40% of the variance in KRT incidence (P < 0.001) in high-income countries. The explained variance of age-adjusted mortality was close to 0 in high-income countries and positive at 19% (P = 0.10) in Central and Eastern Europe and at 11% (P = 0.17) in the other region. Results were consistent by gender. Conclusion This study raises awareness on the significant part of the gaps in KRT incidence across countries not explained by the number of individuals with CKD, even in high-income countries where access to KRT is not limited.
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Affiliation(s)
- Marieke H.C. van Rijn
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Université Paris-Saclay, Université de Versailles-Saint-Quentin-en-Yvelines, University Paris Sud, INSERM, Clinical Epidemiology Team, Centre for Research in Epidemiology and Population Health, Villejuif, France
| | - Natalia Alencar de Pinho
- Université Paris-Saclay, Université de Versailles-Saint-Quentin-en-Yvelines, University Paris Sud, INSERM, Clinical Epidemiology Team, Centre for Research in Epidemiology and Population Health, Villejuif, France
- Correspondence: Natalia Alencar de Pinho, Clinical Epidemiology Team, Centre for Research in Epidemiology and Population Health, INSERM U1018, 16, avenue Paul Vaillant Couturier, 94807 Villejuif, France.
| | - Jack F. Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan A.J.G. van den Brand
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benedicte Stengel
- Université Paris-Saclay, Université de Versailles-Saint-Quentin-en-Yvelines, University Paris Sud, INSERM, Clinical Epidemiology Team, Centre for Research in Epidemiology and Population Health, Villejuif, France
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Hoshino J, Muenz D, Zee J, Sukul N, Speyer E, Guedes M, Lopes AA, Asahi K, van Haalen H, James G, Dhalwani N, Pecoits-Filho R, Bieber B, Robinson BM, Pisoni RL, Lopes A, Pecoits-Filho R, Combe C, Jacquelinet C, Massy Z, Stengel B, Duttlinger J, Fliser D, Lonnemann G, Reichel H, Wada T, Yamagata K, Pisoni R, Robinson B, Calice da Silva V, Sesso R, Speyer E, Asahi K, Hoshino J, Narita I, Perlman R, Port F, Sukul N, Wong M, Young E, Zee J. Associations of Hemoglobin Levels With Health-Related Quality of Life, Physical Activity, and Clinical Outcomes in Persons With Stage 3-5 Nondialysis CKD. J Ren Nutr 2020; 30:404-414. [DOI: 10.1053/j.jrn.2019.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 11/11/2022] Open
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25
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Guedes M, Robinson BM, Obrador G, Tong A, Pisoni RL, Pecoits-Filho R. Management of Anemia in Nondialysis Chronic Kidney Disease: Current Recommendations, Real-World Practice, and Patient Perspectives. Kidney360 2020; 1:855-862. [PMID: 35372964 DOI: 10.34067/kid.0001442020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
In nondialysis CKD (ND-CKD), anemia is a multifactorial and complex condition in which several dysfunctions dynamically contribute to a reduction in circulating hemoglobin (Hb) levels in red blood cells. Anemia is common in CKD and represents an important and modifiable risk factor for poor clinical outcomes. Importantly, symptoms related to anemia, including reduced physical functioning and fatigue, have been identified as high priorities by patients with CKD. The current management of anemia in ND-CKD (i.e., parameters to initiate treatment, Hb and iron indexes targets, choice of therapies, and effect of treatment on clinical and patient-reported outcomes) remains controversial. In this review article, we explore the epidemiology of anemia in ND-CKD and revise current recommendations and controversies in its management. Exploring data from real-world clinical practices, particularly from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps), we highlight the current challenges to translating current recommendations to clinical practice, providing patients' perspectives of anemia and how it affects their quality of life. Finally, we summarize recent advances in the field of anemia that may change the way this condition will be managed in the future.
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Affiliation(s)
- Murilo Guedes
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan.,School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Bruce M Robinson
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gregorio Obrador
- School of Medicine, Universidad Panamericana-Campus México, Mexico City, Mexico
| | - Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ronald L Pisoni
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Roberto Pecoits-Filho
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan.,School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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26
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Reichel H, Zee J, Tu C, Young E, Pisoni RL, Stengel B, Duttlinger J, Lonnemann G, Robinson BM, Pecoits-Filho R, Fliser D. Chronic kidney disease progression and mortality risk profiles in Germany: results from the Chronic Kidney Disease Outcomes and Practice Patterns Study. Nephrol Dial Transplant 2020; 35:803-810. [PMID: 31953939 PMCID: PMC7203560 DOI: 10.1093/ndt/gfz260] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/07/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) progression among German patients in a representative setting has not been described previously. The Verband Deutsche Nierenzentren and Chronic Kidney Disease Outcomes and Practice Patterns Study established a longitudinal observational cohort among German CKD patients to research variations in patient care and outcomes in real-world nephrology practices. METHODS A cohort of CKD Stages 3 (25%) and 4 (75%) patients was established from German nephrologist-run CKD clinics in 2013-16. Linear models were used to determine the estimated glomerular filtration rate (eGFR) slope during follow-up and Cox models were used to assess outcomes of end-stage kidney disease (ESKD) and death. RESULTS A total of 1834 patients (median age 75 years, 58% male, 42% diabetics, median baseline eGFR 25 mL/min/1.73 m2) were followed for a median of 29 months. More than 50% had slow or no decline and 17% declined ≥5 mL/min/1.73 m2/year. After 4.5 years, the incidence of ESKD was 8% and of deaths without ESKD 16% among patients with eGFR ≥30 mL/min/1.73 m2 and 37% and 19% for eGFR <30 mL/min/1.73 m2. Adjusted models showed higher risks of ESKD or death for patients with worse kidney function at baseline, male sex, diabetes and higher blood pressure; a higher risk of ESKD with higher albuminuria; and a higher risk of death with older age or cardiovascular comorbidity. CONCLUSIONS Routine nephrology care of patients in Germany comprises mostly elderly patients, many with slow CKD progression. Identification of risk factors for CKD progression and mortality may help guide resources by closer follow-up of high-risk patients.
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Affiliation(s)
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Eric Young
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Bénédicte Stengel
- French National Institute of Health and Medical Research, Villejuif, France
| | | | | | | | | | - Danilo Fliser
- Internal Medicine - Nephrology and Hypertension, University Hospital of the Saarland, Homburg, Germany
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27
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Kainz A, Berner C, Ristl R, Simon A, Stamm T, Zitt E, Kramar R, Antlanger M, Kautzky-Willer A, Schmaldienst S, Schernhammer E, Port FK, Carrero JJ, Jager KJ, Hecking M. Sex-specific analysis of haemodialysis prevalence, practices and mortality over time: the Austrian Dialysis Registry from 1965 to 2014. Nephrol Dial Transplant 2020; 34:1026-1035. [PMID: 30476247 DOI: 10.1093/ndt/gfy322] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite a higher prevalence of chronic kidney disease among women, more men than women start renal replacement therapy (RRT). We hypothesized that gender differences in health care access exist and therefore aimed at determining whether characteristics and outcomes of haemodialysis patients over time differ by sex. METHODS We studied all 28 323 adults who began haemodialysis during 1965-2014 in the Austrian Dialysis Registry, analysing trends in patient characteristics by sex and decade with mortality (via Cox regression), which was compared with the mortality of the Austrian general population. RESULTS More men than women started haemodialysis (60.1% men versus 39.9% women overall), with minor differences among decades and age groups. The male:female mortality rate ratio in the general population ranged from 1.2 to 2.4 for age groups >18 years and in haemodialysis patients ranged from 0.80 to 1.3 (closer to 1 than in the general population, but consistently >1 in Decades 3-5). In recent decades, diabetes and hypertension replaced glomerulonephritis as the primary cause of end-stage renal disease in both men and women. Interaction analyses showed the mortality risk associated with haemodialysis access (only recorded in Decade 5) was significantly lower for men than for women. CONCLUSIONS The male:female mortality rate ratio and the proportion of women starting haemodialysis were remarkably stable, which does not support the hypothesis of gender differences in health care/haemodialysis access or could imply that such differences might have persisted over decades. Future research should expand to other countries and other forms of RRT.
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Affiliation(s)
- Alexander Kainz
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Carolin Berner
- First Medical Department, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Amrei Simon
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Reinhard Kramar
- Austrian Dialysis and Transplant Registry, Rohr im Kremstal, Austria
| | - Marlies Antlanger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Eva Schernhammer
- Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics and Center for Gender Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kitty J Jager
- European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Manfred Hecking
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Stengel B, Metzger M, Combe C, Jacquelinet C, Briançon S, Ayav C, Fouque D, Laville M, Frimat L, Pascal C, Herpe YE, Morel P, Deleuze JF, Schanstra JP, Lange C, Legrand K, Speyer E, Liabeuf S, Robinson BM, Massy ZA. Risk profile, quality of life and care of patients with moderate and advanced CKD: The French CKD-REIN Cohort Study. Nephrol Dial Transplant 2020; 34:277-286. [PMID: 29635335 DOI: 10.1093/ndt/gfy058] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/01/2018] [Indexed: 12/20/2022] Open
Abstract
Background The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study was designed to investigate the determinants of prognosis and care of patients referred to nephrologists with moderate and advanced chronic kidney disease (CKD). We examined their baseline risk profile and experience. Methods We collected bioclinical and patient-reported information from 3033 outpatients with CKD and estimated glomerular filtration rates (eGFRs) of 15-60 mL/min/1.73 m2 treated at 40 nationally representative public and private facilities. Results The patients' median age was 69 (60-76) years, 65% were men, their mean eGFR was 33 mL/min/1.73 m2, 43% had diabetes, 24% had a history of acute kidney injury (AKI) and 57% had uncontrolled blood pressure (BP; >140/90 mmHg). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%) and have cardiovascular disease (59% versus 42%), albuminuria >30 mg/mmol (or proteinuria > 50) (40% versus 30%) (all P < 0.001) and a higher median risk of end-stage renal disease within 5 years, predicted by the kidney failure risk equation {12% [interquartile range (IQR) 3-37%] versus 9% [3-31%], P = 0.008}. During the previous year, 60% of patients reported one-to-two nephrologist visits and four or more general practitioner visits; only 25% saw a dietician and 75% were prescribed five or more medications daily. Physical and mental quality of life (QoL) were poor, with scores <50/100. Conclusions The CKD-REIN study highlights high-risk profiles of cohort members and identifies several priorities, including improving BP control and dietary counselling and increasing doctors' awareness of AKI, polypharmacy and QoL. Trial registration ClinicalTrials.gov identifier: NCT03381950.
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Affiliation(s)
- Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France
| | - Marie Metzger
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France
| | - Christian Combe
- Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,INSERM, U1026, Université Bordeaux Segalen, Bordeaux, France
| | - Christian Jacquelinet
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Agence de la Biomédecine, Saint-Denis, France
| | - Serge Briançon
- Department of Clinical Epidemiology, University Hospital of Nancy, INSERM CIC-EC 1433, Nancy, France.,EA4360 Apemac, Université de Lorraine, Université Paris-Descartes, Nancy, France
| | - Carole Ayav
- Department of Clinical Epidemiology, University Hospital of Nancy, INSERM CIC-EC 1433, Nancy, France
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon-Sud, Université de Lyon, UCBL, Carmen, Pierre-Bénite, France
| | - Maurice Laville
- Department of Nephrology, Centre Hospitalier Lyon-Sud, Université de Lyon, UCBL, Carmen, Pierre-Bénite, France
| | - Luc Frimat
- EA4360 Apemac, Université de Lorraine, Université Paris-Descartes, Nancy, France.,Department of Nephrology, CHU de Nancy, Vandoeuvre-lès-Nancy, France
| | - Christophe Pascal
- Institute for Education and Research in Health Care and Social Service, Jean Moulin Lyon 3 university, Lyon, France
| | - Yves-Edouard Herpe
- Biobanque de Picardie, Amiens, France.,Department of Clinical Pharmacology, Centre Hospitalier Universitaire, Amiens, France
| | - Pascal Morel
- Etablissement Français du Sang, Bourgogne Franche Comté, Besançon, France
| | - Jean-François Deleuze
- Centre National de Recherche en Génomique Humaine (CNRGH), Institut de Biologie François-Jacob, CEA, Evry, France
| | - Joost P Schanstra
- INSERM U1048, Institute of Cardiovascular and Metabolic Disease, Toulouse, France.,Université Toulouse III Paul-Sabatier, Toulouse, France
| | - Céline Lange
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Agence de la Biomédecine, Saint-Denis, France
| | - Karine Legrand
- Department of Clinical Epidemiology, University Hospital of Nancy, INSERM CIC-EC 1433, Nancy, France.,EA4360 Apemac, Université de Lorraine, Université Paris-Descartes, Nancy, France
| | - Elodie Speyer
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France
| | - Sophie Liabeuf
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Department of Clinical Pharmacology, Centre Hospitalier Universitaire, Amiens, France
| | | | - Ziad A Massy
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Department of Nephrology, CHU Ambroise Paré, Boulogne, France
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Liabeuf S, McCullough K, Young EW, Pisoni R, Zee J, Reichel H, Pecoits-Filho R, Port FK, Stengel B, Csomor PA, Metzger M, Robinson B, Massy ZA. International variation in the management of mineral bone disorder in patients with chronic kidney disease: Results from CKDopps. Bone 2019; 129:115058. [PMID: 31493530 DOI: 10.1016/j.bone.2019.115058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) is commonly associated with mineral and bone metabolism disorders, but these are less frequently studied in non-dialysis CKD patients than in dialysis patients. We examined and described international variation in mineral and bone disease (MBD) markers and their treatment and target levels in Stage 3-5 CKD patients. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Prospective cohort study of 7658 adult patients with eGFR <60mL/min/1.73m2, excluding dialysis or transplant patients, participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, Germany, and the US. CKD-MBD laboratory markers included serum levels of phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH), and 25-hydroxyvitamin D (25-D). MBD treatment data included phosphate binders and vitamin D (nutritional and active). Nephrologist survey data were collected on target MBD marker levels. RESULTS Over two-thirds of the patients had MBD markers measured at time intervals in line with practice guidelines. P and iPTH increased and Ca decreased gradually from eGFR 60-20mL/min/1.73m2 and more sharply for eGFR<20. 25-D showed no relation to eGFR. Nephrologist survey data indicated marked variation in upper target P and iPTH levels. Among patients with P>5.5mg/dL, phosphate binder use was 14% to 43% across the four countries. Among patients with PTH >300pg/mL, use of active (calcitriol and related analogs) vitamin D was 12%-51%, and use of any (active or nutritional) vitamin D was 60%-87%. CONCLUSIONS Although monitoring of CKD-MBD laboratory markers by nephrologists in CKDopps countries is consistent with guidelines, target levels vary notably and prescription of medications to treat abnormalities in these laboratory markers is generally low in these cross-sectional analyses. While there are opportunities to increase treatment of hyperphosphatemia, hyperparathyroidism, and vitamin D deficiency in advanced CKD, the effect on longer-term complications of these conditions requires study.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacology Department and Laboratory EA 7517, Amiens University Hospital, 80000 Amiens, France
| | | | - Eric W Young
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Pontifícia Universidade Católica Do Paraná, Nephrology, Do Paraná, Brazil
| | | | - Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | | | - Marie Metzger
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ziad A Massy
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France; Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France.
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30
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Wong MMY, Tu C, Li Y, Perlman RL, Pecoits-Filho R, Lopes AA, Narita I, Reichel H, Port FK, Sukul N, Stengel B, Robinson BM, Massy ZA, Pisoni RL. Anemia and iron deficiency among chronic kidney disease Stages 3-5ND patients in the Chronic Kidney Disease Outcomes and Practice Patterns Study: often unmeasured, variably treated. Clin Kidney J 2019; 13:613-624. [PMID: 32905241 PMCID: PMC7467578 DOI: 10.1093/ckj/sfz091] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/21/2019] [Indexed: 12/17/2022] Open
Abstract
Background International variation in anemia assessment and management practices in chronic kidney disease (CKD) is poorly understood. Methods We performed a cross-sectional analysis of anemia laboratory monitoring, prevalence and management in the prospective Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps). A total of 6766 participants with CKD Stages 3a–5ND from nephrology clinics in Brazil, France, Germany and the USA were included. Results Among patients with anemia (hemoglobin <12 g/dL), 36–58% in Brazil, the USA and Germany had repeat hemoglobin measured and 40–61% had iron indices measured within 3 months of the index hemoglobin measurement. Anemia was more common in the USA and Brazil than in France and Germany across CKD stages. Higher ferritin and lower iron saturation (TSAT) levels were observed with lower hemoglobin levels, and higher ferritin with more advanced CKD. The proportion of anemic patients with ferritin <100 ng/mL or TSAT <20% ranged from 42% in Brazil to 53% in France and Germany, and of these patients, over 40% in Brazil, Germany and the USA, compared with 27% in France, were treated with oral or intravenous iron within 3 months after hemoglobin measurement. The proportion of patients with hemoglobin <10 g/dL treated with erythropoiesis-stimulating agents ranged from 28% in the USA to 57% in Germany. Conclusions Hemoglobin and iron stores are measured less frequently than per guidelines. Among all regions, there was a substantial proportion of anemic patients with iron deficiency who were not treated with iron, highlighting an area for practice improvement in CKD care.
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Affiliation(s)
- Michelle M Y Wong
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Yun Li
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Rachel L Perlman
- Department of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Roberto Pecoits-Filho
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, PR, Brazil
| | - Antonio A Lopes
- Faculdade de Medicina da Bahia School of Medicine, Universidade Federal da Bahia, Salvador, Brazil
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | | | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, and Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor MI, USA
| | - Nidhi Sukul
- Department of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Benedicte Stengel
- CESP, Center for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris-Sud, UVSQ, Inserm UMRS 1018, Villejuif, France
| | | | - Ziad A Massy
- CESP, Center for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris-Sud, UVSQ, Inserm UMRS 1018, Villejuif, France.,Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt/Paris, France
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Pecoits‐Filho R, Fliser D, Tu C, Zee J, Bieber B, Wong MMY, Port F, Combe C, Lopes AA, Reichel H, Narita I, Stengel B, Robinson BM, Massy Z. Prescription of renin-angiotensin-aldosterone system inhibitors (RAASi) and its determinants in patients with advanced CKD under nephrologist care. J Clin Hypertens (Greenwich) 2019; 21:991-1001. [PMID: 31169352 PMCID: PMC6771881 DOI: 10.1111/jch.13563] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/24/2019] [Accepted: 05/05/2019] [Indexed: 01/09/2023]
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) are recommended for chronic kidney disease (CKD) patients. In this study, we describe RAASi prescription patterns in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, Germany, France, and the United States (US). 5870 patients (mean age 66-72 years; congestive heart failure [CHF] in 11%-19%; diabetes in 43%-54%; serum potassium ≥5 in 20%-35%) were included. RAASi prescription was more common in Germany (80%) and France (77%) than Brazil (66%) and the United States (52%), where the prevalence of prescription decreases particularly in patients with CKD stage 5. In the multivariable regression model, RAASi prescription was least common in the United States and more common in patients who were younger, had diabetes, hypertension, or less advanced CKD. In conclusion, RAASi prescription patterns vary by country, and by demographic and clinical characteristics. RAASi appear to be underused, even among patients with strong class-specific recommendations. Although the reasons for this variation could not be fully identified in this cross-sectional observation, our data indicate that the risk of hyperkalemia may contribute to the underuse of this class of agents in moderate to advanced CKD.
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Affiliation(s)
- Roberto Pecoits‐Filho
- School of MedicinePontificia Universidade Catolica do ParanaCuritibaBrazil
- Arbor Research Collaborative for HealthAnn ArborMichigan
| | - Danilo Fliser
- Department of Internal Medicine IVSaarland University Medical CenterHomburgGermany
| | - Charlotte Tu
- Arbor Research Collaborative for HealthAnn ArborMichigan
| | - Jarcy Zee
- Arbor Research Collaborative for HealthAnn ArborMichigan
| | - Brian Bieber
- Arbor Research Collaborative for HealthAnn ArborMichigan
| | - Michelle M. Y. Wong
- Arbor Research Collaborative for HealthAnn ArborMichigan
- Department of MedicineUniversity of British ColumbiaVancouverCanada
| | - Friedrich Port
- Arbor Research Collaborative for HealthAnn ArborMichigan
- Department of Internal Medicine, Michigan Medicine, and Department of Epidemiology, School of Public HealthUniversity of MichiganAnn ArborMichigan
| | - Christian Combe
- Service de Néphrologie Transplantation DialyseCentre Hospitalier Universitaire de BordeauxBordeauxFrance
| | - Antonio A. Lopes
- Faculdade de Medicina da Bahia School of MedicineUniversidade Federal da BahiaBrazil
| | | | - Ichiei Narita
- Division of Clinical Nephrology and RheumatologyNiigata University Graduate School of Medical and Dental ScienceNiigataJapan
| | - Benedicte Stengel
- CESP, Center for Research in Epidemiology and Population HealthUniversity Paris‐Saclay, University Paris‐Sud, UVSQVillejuifFrance
| | | | - Ziad Massy
- CESP, Center for Research in Epidemiology and Population HealthUniversity Paris‐Saclay, University Paris‐Sud, UVSQVillejuifFrance
- Division of NephrologyAmbroise Paré University Hospital, APHPBoulogneBillancourt/ParisFrance
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Sukul N, Speyer E, Tu C, Bieber BA, Li Y, Lopes AA, Asahi K, Mariani L, Laville M, Rayner HC, Stengel B, Robinson BM, Pisoni RL. Pruritus and Patient Reported Outcomes in Non-Dialysis CKD. Clin J Am Soc Nephrol 2019; 14:673-681. [PMID: 30975656 PMCID: PMC6500934 DOI: 10.2215/cjn.09600818] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 02/20/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Among patients on hemodialysis, pruritus has been associated with poorer mental and physical quality of life, sleep quality, depression, and mortality. We evaluated patients with nondialysis CKD to describe the prevalence of pruritus, identify associated factors, and investigate associations with patient-reported outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using cross-sectional data from patient questionnaires in the CKD Outcomes and Practice Patterns Study (CKDopps), we asked patients with CKD stages 3-5 (nondialysis) from the United States, Brazil, and France to identify how much they were bothered by pruritus. Response options ranged from "not at all" to "extremely." Log-Poisson regression, yielding prevalence ratios, was used to evaluate associations of moderate-to-extreme pruritus with patient characteristics, CKD stage, self-reported depression symptoms, and restless sleep. Mixed linear regression was used to examine associations between pruritus and physical and mental component summary scores, with lower scores indicating poorer quality of life. RESULTS Of the 5658 CKDopps patients enrolled in the United States, Brazil, and France, 3780 (67%) answered the pruritus question. The prevalence of moderate-to-extreme pruritus was 24%, and more likely in older patients, women, and those with stage 5 CKD, lung disease, diabetes, and physician-diagnosed depression. In adjusted models, patients with moderate pruritus had physical and mental component summary scores 3.5 (95% confidence interval [95% CI], -4.6 to -2.3) and 2.3 (95% CI, -3.2 to -1.5) points lower, respectively, than patients without pruritus, and they also had a higher adjusted prevalence of patient-reported depression (prevalence ratio, 1.83; 95% CI, 1.58 to 2.11) and restless sleep (prevalence ratio, 1.69; 95% CI, 1.49 to 1.91) compared with patients without pruritus. These patient-reported outcomes were progressively worse with increasing severity of pruritus. CONCLUSIONS Our findings demonstrate high prevalence of pruritus in nondialysis CKD, as well as strong associations of pruritus with poor health-related quality of life, self-reported depression symptoms, and self-reported poor sleep.
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Affiliation(s)
- Nidhi Sukul
- Department of Internal Medicine, Division of Nephrology and
| | - Elodie Speyer
- Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, Université Versailles Saint Quentin, UMRS 1018, Villejuif, France
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Yun Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Antonio A Lopes
- Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | - Koichi Asahi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Laura Mariani
- Department of Internal Medicine, Division of Nephrology and
| | - Maurice Laville
- Nephrology Department, Lyon Sud Hospital, Lyon University, Laboratoire de Recherche en Cardiovasculaire, Métabolisme, diabétologie et Nutrition INSERM U 1060, Pierre Benite, France; and
| | - Hugh C Rayner
- Department of Renal Medicine, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, Université Versailles Saint Quentin, UMRS 1018, Villejuif, France
| | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Navaneethan SD, Akeroyd JM, Ramsey D, Ahmed ST, Mishra SR, Petersen LA, Muntner P, Ballantyne C, Winkelmayer WC, Ramanathan V, Virani SS. Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD. Clin J Am Soc Nephrol 2018; 13:1842-1850. [PMID: 30498000 PMCID: PMC6302320 DOI: 10.2215/cjn.03830318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/01/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with diabetes and concomitant CKD (eGFR 15-59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2). RESULTS Among those with eGFR 30-59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%-47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%-79%) for hemoglobin measurement, 66% (62%-69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%-87%) for statin prescription, 47% (42%-53%) for achieving BP<140/90 mm Hg, and 13% (7%-16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15-29 ml/min per 1.73 m2. CONCLUSIONS Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.
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Affiliation(s)
| | - Julia M. Akeroyd
- Section of Health Services Research, and
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - David Ramsey
- Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and
| | - Sarah T. Ahmed
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - Shiva Raj Mishra
- Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and
| | - Laura A. Petersen
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christie Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Venkat Ramanathan
- Selzman Institute for Kidney Health, Section of Nephrology
- Section of Nephrology
| | - Salim S. Virani
- Section of Health Services Research, and
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Balkau B, Metzger M, Andreelli F, Frimat L, Speyer E, Combe C, Laville M, Jacquelinet C, Briançon S, Ayav C, Massy Z, Pisoni RL, Stengel B, Fouque D. Impact of sex and glucose-lowering treatments on hypoglycaemic symptoms in people with type 2 diabetes and chronic kidney disease. The French Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) Study. Diabetes Metab 2018; 45:175-183. [PMID: 29706470 DOI: 10.1016/j.diabet.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022]
Abstract
AIM To describe current practices of glucose-lowering treatments in people with diabetes and chronic kidney disease (CKD), the associated glucose control and hypoglycaemic symptoms, with an emphasis on sex differences. METHODS Among the 3033 patients with CKD stages 3-5 recruited into the French CKD-REIN study, 645 men and 288 women had type 2 diabetes and were treated by glucose-lowering drugs. RESULTS Overall, 31% were treated only with insulin, 28% with combinations of insulin and another drug, 42% with non-insulin glucose-lowering drugs. In CKD stage 3, 40% of patients used metformin, 12% at stages 4&5, similar for men and women; in CKD stage 3, 53% used insulin, similar for men and women, but at stages 4&5, 59% of men and 77% of women used insulin. Patients were reasonably well controlled, with a median HbA1c of 7.1% (54mmol/mol) in men, 7.4% (57mmol/mol) in women (P=0.0003). Hypoglycaemic symptoms were reported by 40% of men and 59% of women; they were not associated with the estimated glomerular filtration rate, nor with albuminuria or with HbA1c in multivariable analyses, but they were more frequent in people treated with insulin, particularly with fast-acting and pre-mixed insulins. CONCLUSION Glucose-lowering treatment, HbA1c and hypoglycaemic symptoms were sex dependent. Metformin use was similar in men and women, but unexpectedly low in CKD stage 3; its use could be encouraged rather than resorting to insulin. Hypoglycaemic symptoms were frequent and need to be more closely monitored, with appropriate patient-education, especially in women.
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Affiliation(s)
- B Balkau
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - M Metzger
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - F Andreelli
- Diabetology, CHU Pitié-Salpétrière, APHP, Paris, France
| | - L Frimat
- Lorraine Univ, Paris-Descartes Univ, Apemac, EA 4360, Nancy, France; Nephrology Department, CHU de Nancy, Vandoeuvre-lès-Nancy, France
| | - E Speyer
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - C Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Inserm, U1026, Univ Bordeaux Segalen, Bordeaux, France
| | - M Laville
- Department of Nephrology, Centre Hospitalier Lyon Sud, Univ Lyon, UCBL, Carmen, Pierre-Bénite, France
| | - C Jacquelinet
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France; Agence de la Biomédecine, Saint-Denis, France
| | - S Briançon
- Inserm CIC-1433, CHRU Nancy, Clinical Epidemiology, Vandoeuvre-lès-Nancy, France
| | - C Ayav
- Inserm CIC-1433, CHRU Nancy, Clinical Epidemiology, Vandoeuvre-lès-Nancy, France
| | - Z Massy
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France; Nephrology Department, CHU Ambroise Paré, Boulogne, France
| | - R L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
| | - B Stengel
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France.
| | - D Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Univ Lyon, UCBL, Carmen, Pierre-Bénite, France
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Sim JJ, Zhou H, Shi J, Shaw SF, Henry SL, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters. Int Urol Nephrol 2018. [PMID: 29532308 DOI: 10.1007/s11255-018-1837-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.
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Affiliation(s)
- John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, 4700 Sunset Bl, Los Angeles, CA, USA.
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Shayna L Henry
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, CA, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Eder S, Leierer J, Kerschbaum J, Rosivall L, Wiecek A, de Zeeuw D, Mark PB, Heinze G, Rossing P, Heerspink HL, Mayer G. A Prospective Cohort Study in Patients with Type 2 Diabetes Mellitus for Validation of Biomarkers (PROVALID) - Study Design and Baseline Characteristics. Kidney Blood Press Res 2018; 43:181-190. [PMID: 29466797 DOI: 10.1159/000487500] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The prevalence of diabetes mellitus type 2 and kidney disease in these patients varies widely between European countries. METHODS In addition to store bio-samples the "Prospective cohort study in patients with type 2 diabetes mellitus for validation of biomarkers" collects information on history, physical status, laboratory measurements and medication in 4000 patients with diabetes mellitus type 2, being taken care of at the primary level of healthcare in 5 European countries (Austria, Hungary, Netherlands, Poland and Scotland). Next to comparing the rate of loss of eGFR between the countries, a further objective of the PROVALID study is to determine the 5-year cumulative incidence of renal and cardiovascular outcomes. RESULTS The mean age of the population recruited is 62.9±10 years, 54.6% are male and the mean BMI is 30.9±5.4 kg/m2. Metabolic control (median HBA1c 6.8 % (6.2; 7.5)) is achieved via administration of metformin in 67.4% of the patients and insulin in 30.3%. Median systolic and diastolic blood pressure at recruitment is 135 (125; 146) and 80 (72; 85) mmHg, 65.4% of subjects received RAAS blocking agents. Mean eGFR is 80.7±29.2 ml/min/1.73m2 and median baseline albumin/creatinine ratio 8.3 mg (IQR: 3.8 and 25.1). CONCLUSION PROVALID will provide information on incidence and progression of renal and cardiovascular disease and therapy in patients with type 2 diabetes mellitus in different European countries. Thus, in contrast to many other cohort studies we will be able to associate national clinical practise pattern with outcome in this highly vulnerable patient population.
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Affiliation(s)
- Susanne Eder
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Leierer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Julia Kerschbaum
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Laszlo Rosivall
- International Nephrology Research and Training Center, Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Andrzej Wiecek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Georg Heinze
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Peter Rossing
- Novo Nordisk Foundation Center for Basic Metabolic Research, Metabolism Center, University of Copenhagen, Copenhagen, Denmark
| | - Hiddo L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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See EJ, Alrukhaimi M, Ashuntantang GE, Bello AK, Bellorin-Font E, Benghanem Gharbi M, Braam B, Feehally J, Harris DC, Jha V, Jindal K, Kalantar-Zadeh K, Kazancioglu R, Levin A, Lunney M, Okpechi IG, Olanrewaju TO, Osman MA, Perl J, Qarni B, Rashid HU, Rateb A, Rondeau E, Samimi A, Sikosana ML, Sola L, Tchokhonelidze I, Wiebe N, Yang CW, Ye F, Zemchenkov A, Zhao MH, Johnson DW. Global coverage of health information systems for kidney disease: availability, challenges, and opportunities for development. Kidney Int Suppl (2011) 2018; 8:74-81. [PMID: 30675441 PMCID: PMC6336215 DOI: 10.1016/j.kisu.2017.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Development and planning of health care services requires robust health information systems to define the burden of disease, inform policy development, and identify opportunities to improve service provision. The global coverage of kidney disease health information systems has not been well reported, despite their potential to enhance care. As part of the Global Kidney Health Atlas, a cross-sectional survey conducted by the International Society of Nephrology, data were collected from 117 United Nations member states on the coverage and scope of kidney disease health information systems and surveillance practices. Dialysis and transplant registries were more common in high-income countries. Few countries reported having nondialysis chronic kidney disease and acute kidney injury registries. Although 62% of countries overall could estimate their prevalence of chronic kidney disease, less than 24% of low-income countries had access to the same data. Almost all countries offered chronic kidney disease testing to patients with diabetes and hypertension, but few to high-risk ethnic groups. Two-thirds of countries were unable to determine their burden of acute kidney injury. Given the substantial heterogeneity in the availability of health information systems, especially in low-income countries and across nondialysis chronic kidney disease and acute kidney injury, a global framework for prioritizing development of these systems in areas of greatest need is warranted.
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Affiliation(s)
- Emily J. See
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Gloria E. Ashuntantang
- Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde I, Yaounde, Cameroon
| | - Aminu K. Bello
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Ezequiel Bellorin-Font
- Division of Nephrology and Kidney Transplantation, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
| | - Mohammed Benghanem Gharbi
- Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco
| | - Branko Braam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - John Feehally
- Department of Infection, Inflammation and Immunity, University Hospitals of Leicester, University of Leicester, Leicester, UK
| | - David C. Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India
- University of Oxford, Oxford, UK
| | - Kailash Jindal
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | | | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | | | - Mohamed A. Osman
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Bilal Qarni
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Harun Ur Rashid
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Ahmed Rateb
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
- Université Paris VI, Paris, France
| | - Arian Samimi
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Majid L.N. Sikosana
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Laura Sola
- Division Epidemiologia, Direccion General de Salud–Ministerio Salud Publica, Montevideo, Uruguay
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Natasha Wiebe
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersberg, Russia
- Department of Nephrology and Dialysis, Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Key Lab of Renal Disease, Ministry of Health of China, Beijing, China
- Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - David W. Johnson
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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Wu J, Suk-Ouichai C, Dong W, Antonio EC, Derweesh IH, Lane BR, Demirjian S, Li J, Campbell SC. Analysis of survival for patients with chronic kidney disease primarily related to renal cancer surgery. BJU Int 2017; 121:93-100. [PMID: 28834125 DOI: 10.1111/bju.13994] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To evaluate predictors of long-term survival for patients with chronic kidney disease primarily due to surgery (CKD-S). Patients with CKD-S have generally good survival that approximates patients who do not have CKD even after renal cancer surgery (RCS), yet there may be heterogeneity within this cohort. PATIENTS AND METHODS From 1997 to 2008, 4 246 patients underwent RCS at our centre. The median (interquartile range [IQR]) follow-up was 9.4 (7.3-11.0) years. New baseline glomerular filtration rate (GFR) was defined as highest GFR between nadir and 6 weeks after RCS. We retrospectively evaluated three cohorts: no-CKD (new baseline GFR of ≥60 mL/min/1.73 m2 ); CKD-S (new baseline GFR of <60 mL/min/1.73 m2 but preoperative GFR of ≥60 mL/min/1.73 m2 ); and CKD due to medical aetiologies who then require RCS (CKD-M/S, preoperative and new baseline GFR both <60 mL/min/1.73 m2 ). Analysis focused primarily on non-renal cancer-related survival (NRCRS) for the CKD-S cohort. Kaplan-Meier analysis assessed the longitudinal impact of new baseline GFR (45-60 mL/min/1.73 m2 vs <45 mL/min/1.73 m2 ) and Cox regression evaluated relative impact of preoperative GFR, new baseline GFR, and relevant demographics/comorbidities. RESULTS Of the 4 246 patients who underwent RCS, 931 had CKD-S and 1 113 had CKD-M/S, whilst 2 202 had no-CKD even after RCS. Partial/radical nephrectomy (PN/RN) was performed in 54%/46% of the patients, respectively. For CKD-S, 641 patients had a new baseline GFR of 45-60 mL/min/1.73 m2 and 290 had a new baseline GFR of <45 mL/min/1.73 m2 . Kaplan-Meier analysis showed significantly reduced NRCRS for patients with CKD-S with a GFR of <45 mL/min/1.73 m2 compared to those with no-CKD or CKD-S with a GFR of 45-60 mL/min/1.73 m2 (both P ≤ 0.004), and competing risk analysis confirmed this (P < 0.001). Age, gender, heart disease, and new baseline GFR were all associated independently with NRCRS for patients with CKD-S (all P ≤ 0.02). CONCLUSION Our data suggest that CKD-S is heterogeneous, and patients with a reduced new baseline GFR have compromised survival, particularly if <45 mL/min/1.73 m2 . Our findings may have implications regarding choice of PN/RN in patients at risk of developing CKD-S.
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Affiliation(s)
- Jitao Wu
- Glickman Urological and Kidney Institute, Cleveland, OH, USA.,Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Chalairat Suk-Ouichai
- Glickman Urological and Kidney Institute, Cleveland, OH, USA.,Division of Urology, Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wen Dong
- Glickman Urological and Kidney Institute, Cleveland, OH, USA.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | | | - Ithaar H Derweesh
- Department of Urology, University of California San Diego Health System, San Diego, CA, USA
| | - Brian R Lane
- Division of Urology, Spectrum Health, Michigan State University, Grand Rapids, MI, USA
| | - Sevag Demirjian
- Glickman Urological and Kidney Institute, Cleveland, OH, USA
| | - Jianbo Li
- Glickman Urological and Kidney Institute, Cleveland, OH, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
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Bello AK, Ronksley PE, Tangri N, Singer A, Grill A, Nitsch D, Queenan JA, Lindeman C, Soos B, Freiheit E, Tuot D, Mangin D, Drummond N. A national surveillance project on chronic kidney disease management in Canadian primary care: a study protocol. BMJ Open 2017; 7:e016267. [PMID: 28780553 PMCID: PMC5629677 DOI: 10.1136/bmjopen-2017-016267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Effective chronic disease care is dependent on well-organised quality improvement (QI) strategies that monitor processes of care and outcomes for optimal care delivery. Although healthcare is provincially/territorially structured in Canada, there are national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) as important facilitators for national QI-based studies to improve chronic disease care. The goal of our study is to improve the understanding of how patients with chronic kidney disease (CKD) are managed in primary care and the variation across practices and provinces and territories to drive improvements in care delivery. METHODS AND ANALYSIS The CPCSSN database contains anonymised health information from the electronic medical records for patients of participating primary care practices (PCPs) across Canada (n=1200). The dataset includes information on patient sociodemographics, medications, laboratory results and comorbidities. Leveraging validated algorithms, case definitions and guidelines will help define CKD and the related processes of care, and these enable us to: (1) determine prevalent CKD burden; (2) ascertain the current practice pattern on risk identification and management of CKD and (3) study variation in care indicators (eg, achievement of blood pressure and proteinuria targets) and referral pattern for specialist kidney care. The process of care outcomes will be stratified across patients' demographics as well as provider and regional (provincial/territorial) characteristics. The prevalence of CKD stages 3-5 will be presented as age-sex standardised prevalence estimates stratified by province and as weighted averages for population rates with 95% CIs using census data. For each PCP, age-sex standardised prevalence will be calculated and compared with expected standardised prevalence estimates. The process-based outcomes will be defined using established methods. ETHICS AND DISSEMINATION The CPCSSN is committed to high ethical standards when dealing with individual data collected, and this work is reviewed and approved by the Network Scientific Committee. The results will be published in peer-reviewed journals and presented at relevant national and international scientific meetings.
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Affiliation(s)
- Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - John A Queenan
- Department of Family Medicine, Epidemiologist for the Canadian Primary Care Sentinel Surveillance Network, Queen's University in Kingston, Ontario, Canada
| | - Cliff Lindeman
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Boglarka Soos
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Freiheit
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Delphine Tuot
- Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Neil Drummond
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
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Hoshino J, Nagai K, Kai H, Saito C, Ito Y, Asahi K, Kondo M, Iseki K, Iseki C, Okada H, Kashihara N, Narita I, Wada T, Combe C, Pisoni RL, Robinson BM, Yamagata K. A nationwide prospective cohort study of patients with advanced chronic kidney disease in Japan: The Reach-J CKD cohort study. Clin Exp Nephrol 2018; 22:309-17. [DOI: 10.1007/s10157-017-1453-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/15/2017] [Indexed: 11/30/2022]
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Vega A, Abad S, Macías N, Aragoncillo I, Santos A, Galán I, Cedeño S, Manuel López-Gómez J. Low lean tissue mass is an independent risk factor for mortality in patients with stages 4 and 5 non-dialysis chronic kidney disease. Clin Kidney J 2017; 10:170-175. [PMID: 28396734 PMCID: PMC5381238 DOI: 10.1093/ckj/sfw126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/07/2016] [Indexed: 01/25/2023] Open
Abstract
Background: Mortality in patients with stages 4 and 5 chronic kidney disease (CKD) is higher than in the general population. Body composition predicts mortality. Our objective was to evaluate the effect of body composition on mortality in patients with stages 4 and 5 non-dialysis CKD. Methods: We performed a prospective study of 356 patients with stages 4 and 5 non-dialysis CKD. At baseline, we recorded general characteristics, history of cardiovascular events, body composition, serum inflammatory markers, nutrition and cardiac biomarkers. Body composition was analysed using bioimpedance spectroscopy. We recorded the lean tissue index (LTI), fat tissue index (FTI) and overhydration (OH). During a median (range) follow-up of 22 (3-49) months, we recorded mortality, cardiovascular events and progress to renal replacement therapy. Results: At baseline, mean (± standard deviation) age was 67 ± 13 years (men 64%; diabetes 36%). Mean body mass index was 28.2 ± 12.8 kg/m2, the FTI was 12.3 ± 5.6 kg/m2, the LTI was 15.7 ± 3.4 kg/m2 and median (interquartile range) OH was 0.6 (-0.4 to 1.5) L. Sixty-four (18%) patients died during follow-up. The univariate Cox analysis showed an association between mortality and age, low LTI, high Charlson comorbidity index, previous cardiovascular events, OH, low albumin and prealbumin levels, and high C-reactive protein levels. Kaplan-Meier analysis revealed higher survival in patients with a higher LTI (log-rank, 9.47; P = 0.002). The multivariate Cox analysis confirmed an association between mortality and low LTI (P = 0.031), previous cardiovascular events (P = 0.003) and high Charlson comorbidity index (P = 0.01). We did not find any association between body composition and cardiovascular events or renal replacement therapy. Conclusions: A low LTI is an independent factor for mortality in patients with stages 4 and 5 CKD.
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Affiliation(s)
- Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alba Santos
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Galán
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Santiago Cedeño
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Fuller DS, Robinson BM. Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2017; 12:190-199. [PMID: 28062678 PMCID: PMC5220653 DOI: 10.2215/cjn.03930416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS-rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS-rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition period from advanced CKD to dialysis remain poor, and policy initiatives and performance accountability in this area remain insufficient. Innovative models of comprehensive care in advanced CKD and the early dialysis period which are more amenable to policy oversight are needed. In summary, facility variation is typically larger than prevailing longitudinal trends, and should not be overlooked. The combination of nationally representative observational databases (e.g., the Dialysis Outcomes and Practice Patterns Study) and ESRD registries can provide policy makers with additional tools to evaluate facility variation, develop policies, and monitor unintended effects.
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Affiliation(s)
| | - Bruce M. Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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