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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    • "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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    • "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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