Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters
- 213 Downloads
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.
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.
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.
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.
KeywordsMortality End-stage renal disease transition Chronic kidney disease Epidemiology Comparative outcomes
The authors would like to thank Joanie Chung and David Yi for their work on programming and data extraction for this study. The authors also would like to thank Jose Pio for his literature support and administrative assistance on this study. Finally, we would like to thank and acknowledge the members and patients of KPSC who are the source for our findings and the foundation for why we perform research at KPSC. The results presented in this paper have not been published previously in whole or part, except in abstract format.
JJS and SJJ contributed to research area and study design; HZ and JS were involved in data acquisition; JJS, SJJ, HZ, JS, KKZ, and CPK participated in analysis or interpretation of data; JJS and SJJ were involved in study supervision; HZ was involved in statistical analysis; JJS drafted the manuscript; SJJ, HZ, SFS, KKZ, CPK, SH, and JS were involved in critical revision of the manuscript for important intellectual content; SFS and SJJ participated in administrative, technical, or material support. Each author contributed important intellectual content during the manuscript drafting or revision and accepts accountability of the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. JJS takes responsibility that this study has been reported honestly, accurately, and transparently; that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.
This study was funded by 5U01DK102163 from the National Institute of Health (NIH) to CPK and KKZ. This study was also supported by the Kaiser Permanente Southern California Clinician Investigator Award (JJS).
Compliance with ethical standards
Conflict of interest
All author declares that they have no conflict of interest
- 1.Saran R, Robinson B, Abbott KC, Agodoa LY, Ayanian J, Bragg-Gresham J, Balkrishnan R, Chen JL, Cope E, Eggers PW, Gillen D, Gipson D, Hailpern SM, Hall YN, Han Y, He K, Herman W, Heung M, Hutton D, Jacobsen SJ, Kalantar-Zadeh K, Kovesdy CP, Li Y, Lu Y, Molnar MZ, Morgenstern H, Nallamothu B, Nguyen DV, O’Hare AM, Obi Y, Plattner B, Pisoni R, Port FK, Rao P, Ravel V, Rhee CM, Sakhuja A, Schaubel DE, Selewski DT, Sim JJ, Song P, Streja E, Kurella Tamura M, Tentori F, White S, Woodside K, Hirth RA, Shahinian V (2017) US renal data system 2016 Annual data report: epidemiology of kidney disease in the United States. American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation 69 (3S1):A7–A8. https://doi.org/10.1053/j.ajkd.2016.12.004Google Scholar
- 4.Robinson BM, Zhang J, Morgenstern H, Bradbury BD, Ng LJ, McCullough KP, Gillespie BW, Hakim R, Rayner H, Fort J, Akizawa T, Tentori F, Pisoni RL (2014) Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int 85(1):158–165. https://doi.org/10.1038/ki.2013.252 CrossRefPubMedGoogle Scholar
- 6.Bradbury BD, Fissell RB, Albert JM, Anthony MS, Critchlow CW, Pisoni RL, Port FK, Gillespie BW (2007) Predictors of early mortality among incident US hemodialysis patients in the dialysis outcomes and practice patterns study (DOPPS). Clin J Am Soc Nephrol 2(1):89–99. https://doi.org/10.2215/cjn.01170905 CrossRefPubMedGoogle Scholar
- 7.Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC, Taiwan Society of N (2010) Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. In: Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association–European Renal Association 25 (8):2616–2624. https://doi.org/10.1093/ndt/gfq308
- 8.Lukowsky LR, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh K (2012) Patterns and predictors of early mortality in incident hemodialysis patients: new insights. Am J Nephrol 35 (6):548–558. https://doi.org/10.1159/000338673
- 10.2020 HP https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-kidney-disease/objectives. Accessed 30 Jan 2017
- 11.USRDS https://www.usrds.org/2016/view/v1_08.aspx. Accessed 30 Jan 2017
- 12.Lash JP, Go AS, Appel LJ, He J, Ojo A, Rahman M, Townsend RR, Xie D, Cifelli D, Cohan J, Fink JC, Fischer MJ, Gadegbeku C, Hamm LL, Kusek JW, Landis JR, Narva A, Robinson N, Teal V, Feldman HI (2009) Chronic Renal Insufficiency Cohort (CRIC) study: baseline characteristics and associations with kidney function. Clin J Am Soc Nephrol 4(8):1302–1311. https://doi.org/10.2215/CJN.00070109 CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Mariani L, Stengel B, Combe C, Massy ZA, Reichel H, Fliser D, Pecoits-Filho R, Lopes AA, Yamagata K, Wada T, Wong MM, Speyer E, Port FK, Pisoni RL, Robinson BM (2016) The CKD outcomes and practice patterns study (CKDopps): rationale and methods. Am J Kidney Dis 68(3):402–413. https://doi.org/10.1053/j.ajkd.2016.03.414 CrossRefPubMedGoogle Scholar
- 14.Kalantar-Zadeh K, Kovesdy CP, Streja E, Rhee CM, Soohoo M, Chen JL, Molnar MZ, Obi Y, Gillen D, Nguyen DV, Norris KC, Sim JJ, Jacobsen SS (2017) Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced chronic kidney disease. Nephrol Dial Trans Off Pub Eur Dial Trans Assoc Eur Renal Assoc. https://doi.org/10.1093/ndt/gfw357 CrossRefGoogle Scholar
- 15.Levey AS, de Jong PE, Coresh J, El Nahas M, Astor BC, Matsushita K, Gansevoort RT, Kasiske BL, Eckardt KU (2011) The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int 80(1):17–28. https://doi.org/10.1038/ki.2010.483 CrossRefPubMedGoogle Scholar
- 17.Rutkowski M, Mann W, Derose S, Selevan D, Pascual N, Diesto J, Crooks P (2009) Implementing KDOQI CKD definition and staging guidelines in Southern California Kaiser Permanente. Am J Kidney Dis Off J Natl Kidney Found 53(3 Suppl 3):S86–99. https://doi.org/10.1053/j.ajkd.2008.07.052 CrossRefGoogle Scholar
- 19.Naimark DM, Grams ME, Matsushita K, Black C, Drion I, Fox CS, Inker LA, Ishani A, Jee SH, Kitamura A, Lee JP, Nally J, Peralta CA, Rothenbacher D, Ryu S, Tonelli M, Coresh J, Gansevoort RT, Yatsuya H, Warnock DG, Woodward M, de Jong PE, Consortium CKDP (2016) Past decline versus current eGFR and subsequent mortality risk. J Am Soc Nephrol JASN 27(8):2456–2466. https://doi.org/10.1681/ASN.2015060688 CrossRefPubMedGoogle Scholar
- 21.Fischer MJ, Stroupe KT, Kaufman JS, O’Hare AM, Browning MM, Sohn MW, Huo Z, Hynes DM (2016) Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis. BMC Nephrol 17(1):103. https://doi.org/10.1186/s12882-016-0324-5 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA (2010) A randomized, controlled trial of early versus late initiation of dialysis. N England J Med 363(7):609–619. https://doi.org/10.1056/NEJMoa1000552 CrossRefGoogle Scholar
- 23.Yamagata K, Nakai S, Iseki K, Tsubakihara Y (2012) Late dialysis start did not affect long-term outcome in Japanese dialysis patients: long-term prognosis from Japanese Society for [corrected] dialysis therapy registry. Therapeutic Apheresis Dial 16(2):111–120. https://doi.org/10.1111/j.1744-9987.2011.01052.x CrossRefGoogle Scholar
- 30.Thamer M, Kaufman JS, Zhang Y, Zhang Q, Cotter DJ, Bang H (2015) Predicting early death among elderly dialysis patients: development and validation of a risk score to assist shared decision making for dialysis initiation. Am J Kidney Dis Off J Natl Kidney Found 66 (6):1024–1032. https://doi.org/10.1053/j.ajkd.2015.05.014
- 31.Verberne WR, Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ (2016) Comparative survival among older adults with advanced kidney disease managed conservatively versus with dialysis. Clin J Am Soc Nephrol 11(4):633–640. https://doi.org/10.2215/CJN.07510715 CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Sim JJ, Rutkowski MP, Selevan DC, Batech M, Timmins R, Slezak JM, Jacobsen SJ, Kanter MH (2015) Kaiser permanente creatinine safety program: a mechanism to ensure widespread detection and care for chronic kidney disease. Am J Med 128 (11):1204–1211. https://doi.org/10.1016/j.amjmed.2015.05.037
- 35.Sim JJ, Handler J, Jacobsen SJ, Kanter MH (2014) Systemic implementation strategies to improve hypertension: the Kaiser permanente southern California experience. Can J Cardiol 30 (5):544–552. https://doi.org/10.1016/j.cjca.2014.01.003
- 36.Eckardt KU, Gillespie IA, Kronenberg F, Richards S, Stenvinkel P, Anker SD, Wheeler DC, de Francisco AL, Marcelli D, Froissart M, Floege J, Committee AROS (2015) High cardiovascular event rates occur within the first weeks of starting hemodialysis. Kidney Int 88(5):1117–1125. https://doi.org/10.1038/ki.2015.117 CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Rocco MV, Yan G, Gassman J, Lewis JB, Ornt D, Weiss B, Levey AS, Hemodialysis Study G (2002) Comparison of causes of death using HEMO Study and HCFA end-stage renal disease death notification classification systems. In: The National Institutes of Health-funded Hemodialysis. Health Care Financing Administration. American journal of kidney diseases: the official journal of the National Kidney Foundation 39 (1):146–153Google Scholar