Trajectories of Kidney Function Decline in the 2 Years Before Initiation of Long-term Dialysis

Department of Medicine, VA Puget Sound Healthcare System and University of Washington, Seattle, WA 98108, USA.
American Journal of Kidney Diseases (Impact Factor: 5.9). 02/2012; 59(4):513-22. DOI: 10.1053/j.ajkd.2011.11.044
Source: PubMed


Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis.
Retrospective cohort study.
5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003.
Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis.
Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation.
We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR < 30 mL/min/1.73 m2 (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m2 per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m2 (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m2 per year), 9.5% had accelerated loss of eGFR from levels > 60 mL/min/1.73 m2 (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m2 per year), and 3.1% experienced catastrophic loss of eGFR from levels > 60 mL/min/1.73 m2 within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation.
There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.

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Available from: Meda E Pavkov, Aug 14, 2014
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    • "For example, Lemley et al. compared GFR courses over time between different groups of albuminuric patients using functional data analysis for longitudinal data [44]. O’Hare et al. studied trajectories of GFR using a latent class growth analysis, implemented in the SAS PROC TRAJ [45]. De Beaudrap et al. also used a latent class growth analysis but with the log of GFR as the outcome to achieve normality [9]. "
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    ABSTRACT: Chronic kidney disease (CKD) is a progressive and usually irreversible disease. Different types of outcomes are of interest in the course of CKD such as time-to-dialysis, transplantation or decline of the glomerular filtration rate (GFR). Statistical analyses aiming at investigating the association between these outcomes and risk factors raise a number of methodological issues. The objective of this study was to give an overview of these issues and to highlight some statistical methods that can address these topics. A literature review of statistical methods published between 2002 and 2012 to investigate risk factors of CKD outcomes was conducted within the Scopus database. The results of the review were used to identify important methodological issues as well as to discuss solutions for each type of CKD outcome. Three hundred and four papers were selected. Time-to-event outcomes were more often investigated than quantitative outcome variables measuring kidney function over time. The most frequently investigated events in survival analyses were all-cause death, initiation of kidney replacement therapy, and progression to a specific value of GFR. While competing risks were commonly accounted for, interval censoring was rarely acknowledged when appropriate despite existing methods. When the outcome of interest was the quantitative decline of kidney function over time, standard linear models focussing on the slope of GFR over time were almost as often used as linear mixed models which allow various numbers of repeated measurements of kidney function per patient. Informative dropout was accounted for in some of these longitudinal analyses. This study provides a broad overview of the statistical methods used in the last ten years for investigating risk factors of CKD progression, as well as a discussion of their limitations. Some existing potential alternatives that have been proposed in the context of CKD or in other contexts are also highlighted.
    BMC Nephrology 03/2014; 15(1):45. DOI:10.1186/1471-2369-15-45 · 1.69 Impact Factor
    • "m2 per year) and another 3.1% experienced catastrophic loss of eGFR from levels >60 ml/min/1.73 m2 within 6 months or less to reach irreversible ESRD.[18] The authors of this report had concluded that there was substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis, perhaps calling for a more flexible approach toward preparing for ESRD.[18] "
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    ABSTRACT: Despite decades of research, a full understanding of chronic kidney disease (CKD)-end stage renal disease (ESRD) progression remains elusive. The common consensus is a predictable, linear, progressive and time-dependent decline of CKD to ESRD. Acute kidney injury (AKI) on CKD is usually assumed to be transient, with recovery as the expected outcome. AKI-ESRD association in current nephrology literature is blamed on the so-called "residual confounding." We had previously described a relationship between AKI events and rapid onset yet irreversible ESRD happening in a continuum in a high-risk CKD cohort. However, the contribution of the syndrome of rapid onset-ESRD (SORO-ESRD) to incident United States ESRD population remained conjectural. In this retrospective analysis, we analyzed serum creatinine trajectories of the last 100 consecutive ESRD patients in 4 Mayo Clinic chronic hemodialysis units to determine the incidence of SORO-ESRD. Excluding 9 patients, 31 (34%) patients, including two renal transplant recipients, had SORO-ESRD: 18 males and 13 females age 72 (range 50-92) years. Precipitating AKI followed pneumonia (8), acutely decompensated heart failure (7), pyelonephritis (4), post-operative (5), sepsis (3), contrast-induced nephropathy (2), and others (2). Time to dialysis was shortest following surgical procedures. Concurrent renin angiotensin aldosterone system blockade was higher with SORO-ESRD - 23% versus 5%, P = 0.0113. In conclusion, SORO-ESRD is not uncommon among the incident general US ESRD population. The implications for ESRD care planning, AV-fistula-first programs, general CKD care and any associations with renal ageing/senescence warrant further study.
    Indian Journal of Nephrology 03/2014; 24(2):75-81. DOI:10.4103/0971-4065.127886
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    • "The findings in our study were similar to a recent analysis of Veterans Affairs (VA) patients in which a “catastrophic loss of eGFR” (defined as loss from levels >60 ml/min/1.73 m2 within 6 months or less) was associated with early mortality [41]. While those patients initiated dialysis at a higher eGFR than our study (in part because the definition of predialysis eGFR was different), both studies highlight the importance of a rapid eGFR decline and its impact on mortality. "
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    ABSTRACT: Central venous catheters (CVCs) are associated with early mortality in dialysis patients. However, some patients progress to end stage renal disease after an acute illness, prior to reaching an estimated glomerular filtration rate (eGFR) at which one would expect to establish alternative access (fistula/peritoneal dialysis catheter). The purpose of this study was to determine if exclusion of this "acute start" patient group alters the association between CVCs and mortality. We conducted a retrospective cohort study of 406 incident dialysis patients from 1 Jan 2006 to 31 Dec 2009. Patients were classified as acute starts if 1) the eGFR was >25 ml/min/1.73 m2, ≤3 months prior to dialysis initiation and declined after an acute event (n = 45), or 2) in those without prior eGFR measurements, there was no supporting evidence of chronic kidney disease on history or imaging (n = 12). Remaining patients were classified as chronic start (n = 349). 98 % and 52 % of acute and chronic starts initiated dialysis with a CVC. There were 148 deaths. The adjusted mortality hazard ratio (HR) for acute vs. chronic start patients was 1.84, (95 % CI [1.19-2.85]). The adjusted mortality HR for patients dialyzing with a CVC compared to alternative access was 1.19 (95 % CI [0.80-1.77]). After excluding acute start patients, the adjusted HR fell to 1.03 (95 % CI [0.67-1.57]). A significant proportion of early dialysis mortality occurs after an acute start. Exclusion of this population attenuates the mortality risk associated with CVCs.
    BMC Nephrology 07/2012; 13(1):72. DOI:10.1186/1471-2369-13-72 · 1.69 Impact Factor
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