Low renal replacement therapy incidence among slowly progressing elderly chronic kidney disease patients referred to nephrology care: an observational study

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Abstract

Background

Elderly patients with advanced chronic kidney disease (CKD) have a high risk of death before reaching end-stage kidney disease. In order to allocate resources, such as advanced care nephrology where it is most needed, it is essential to know which patients have the highest absolute risk of advancing to renal replacement therapy (RRT).

Methods

We included all nephrology-referred CKD stage 3b-5 patients in Sweden 2005–2011 included in the Swedish renal registry (SRR-CKD) who had at least two serum creatinine measurements one year apart (+/− 6 months). We followed these patients to either initiation of RRT, death, or September 30, 2013. Decline in estimated glomerular filtration rate (eGFR) (%) was estimated during the one-year baseline period. The patients in the highest tertile of progression (>18.7% decline in eGFR) during the initial year of follow-up were classified as “fast progressors”. We estimated the cumulative incidence of RRT and death before RRT by age, eGFR and progression status using competing risk models.

Results

There were 2119 RRT initiations (24.2%) and 2060 deaths (23.5%) before RRT started. The median progression rate estimated during the initial year was −8.8% (Interquartile range [IQR] - 24.5–6.5%). A fast initial progression rate was associated with a higher risk of RRT initiation (Sub Hazard Ratio [SHR] 2.24 (95% confidence interval [CI] 2.00–2.51) and also a higher risk of death before RRT initiation (SHR 1.27 (95% CI 1.13–1.43). The five year probability of RRT was highest in younger patients (<65 years) with fast initial progression rate (51% in CKD stage 4 and 76% in stage 5), low overall in patients >75 years with a slow progression rate (7, 13, and 25% for CKD stages 3b, 4 and 5 respectively), and slightly higher in elderly patients with a fast initial progression rate (28% in CKD stage 4 and 47% in CKD stage 5) or with diabetic kidney disease.

Conclusions

The 5-year probability of RRT was low among referred slowly progressing CKD patients >75 years of age because of the competing risk of death.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0473-1) contains supplementary material, which is available to authorized users.

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Most cited references 17

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Decline in estimated glomerular filtration rate and subsequent risk of end-stage renal disease and mortality.

Josef Coresh, Tanvir Turin, Kunihiro Matsushita … (2014)

The established chronic kidney disease (CKD) progression end point of end-stage renal disease (ESRD) or a doubling of serum creatinine concentration (corresponding to a change in estimated glomerular filtration rate [GFR] of −57% or greater) is a late event. To characterize the association of decline in estimated GFR with subsequent progression to ESRD with implications for using lesser declines in estimated GFR as potential alternative end points for CKD progression. Because most people with CKD die before reaching ESRD, mortality risk also was investigated. Individual meta-analysis of 1.7 million participants with 12,344 ESRD events and 223,944 deaths from 35 cohorts in the CKD Prognosis Consortium with a repeated measure of serum creatinine concentration over 1 to 3 years and outcome data. Transfer of individual participant data or standardized analysis of outputs for random-effects meta-analysis conducted between July 2012 and September 2013, with baseline estimated GFR values collected from 1975 through 2012. End-stage renal disease (initiation of dialysis or transplantation) or all-cause mortality risk related to percentage change in estimated GFR over 2 years, adjusted for potential confounders and first estimated GFR. The adjusted hazard ratios (HRs) of ESRD and mortality were higher with larger estimated GFR decline. Among participants with baseline estimated GFR of less than 60 mL/min/1.73 m2, the adjusted HRs for ESRD were 32.1 (95% CI, 22.3-46.3) for changes of −57% in estimated GFR and 5.4 (95% CI, 4.5-6.4) for changes of −30%. However, changes of −30% or greater (6.9% [95% CI, 6.4%-7.4%] of the entire consortium) were more common than changes of −57% (0.79% [95% CI, 0.52%-1.06%]). This association was strong and consistent across the length of the baseline period (1 to 3 years), baseline estimated GFR, age, diabetes status, or albuminuria. Average adjusted 10-year risk of ESRD (in patients with a baseline estimated GFR of 35 mL/min/1.73 m2) was 99% (95% CI, 95%-100%) for estimated GFR change of −57%, was 83% (95% CI, 71%-93%) for estimated GFR change of −40%, and was 64% (95% CI, 52%-77%) for estimated GFR change of −30% vs 18% (95% CI, 15%-22%) for estimated GFR change of 0%. Corresponding mortality risks were 77% (95% CI, 71%-82%), 60% (95% CI, 56%-63%), and 50% (95% CI, 47%-52%) vs 32% (95% CI, 31%-33%), showing a similar but weaker pattern. Declines in estimated GFR smaller than a doubling of serum creatinine concentration occurred more commonly and were strongly and consistently associated with the risk of ESRD and mortality, supporting consideration of lesser declines in estimated GFR (such as a 30% reduction over 2 years) as an alternative end point for CKD progression.

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Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. A collaborative meta-analysis of kidney disease population cohorts.

Brad C. Astor, Kunihiro Matsushita, Ron T. Gansevoort … (2011)

We studied here the independent associations of estimated glomerular filtration rate (eGFR) and albuminuria with mortality and end-stage renal disease (ESRD) in individuals with chronic kidney disease (CKD). We performed a collaborative meta-analysis of 13 studies totaling 21,688 patients selected for CKD of diverse etiology. After adjustment for potential confounders and albuminuria, we found that a 15 ml/min per 1.73 m² lower eGFR below a threshold of 45 ml/min per 1.73 m² was significantly associated with mortality and ESRD (pooled hazard ratios (HRs) of 1.47 and 6.24, respectively). There was significant heterogeneity between studies for both HR estimates. After adjustment for risk factors and eGFR, an eightfold higher albumin- or protein-to-creatinine ratio was significantly associated with mortality (pooled HR 1.40) without evidence of significant heterogeneity and with ESRD (pooled HR 3.04), with significant heterogeneity between HR estimates. Lower eGFR and more severe albuminuria independently predict mortality and ESRD among individuals selected for CKD, with the associations stronger for ESRD than for mortality. Thus, these relationships are consistent with CKD stage classifications based on eGFR and suggest that albuminuria provides additional prognostic information among individuals with CKD.

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World-wide, mortality is a high risk soon after initiation of hemodialysis

Bruce Robinson, Jinyao Zhang, Hal Morgenstern … (2013)

Mortality rates for maintenance hemodialysis patients are much higher than the general population and are even greater soon after starting dialysis. Here we analyzed mortality patterns in 86,886 patients in 11 countries focusing on the early dialysis period using data from the Dialysis Outcomes and Practice Patterns Study; a prospective cohort study of in-center hemodialysis. The primary outcome was all-cause mortality, using time-dependent Cox regression, stratified by study phase adjusted for age, sex, race, and diabetes. The main predictor was time since dialysis start as divided into early (up to 120 days), intermediate (121–365 days), and late (over 365 days) periods. Mortality rates (deaths/100 patient-years) were 26.7 (95% confidence intervals 25.6, 27.9), 16.9 (16.2, 17.6), and 13.7 (13.5, 14.0) in the early, intermediate, and late periods, respectively. In each country, mortality was higher in the early compared to the intermediate period with an adjusted range from 3.10 (2.22, 4.32) in Japan to 1.15 (0.87, 1.53) in the United Kingdom. Adjusted mortality rates were similar for intermediate and late periods. The ratio of elevated mortality rates in the early to the intermediate period increased with age. Within each period, mortality was higher in the United States than in most other countries. Thus, internationally, the early hemodialysis period is a high-risk time for all countries studied, with substantial differences in mortality between countries. Efforts to improve outcomes should focus on the transition period and first few months of dialysis.

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Author and article information

Contributors

Ulrika Hahn Lundström: ulrika.hahnlundstrom@gmail.com

Alessandro Gasparini: ag475@leicester.ac.uk

Rino Bellocco: rino.bellocco@ki.se

Abdul Rashid Qureshi: tony.qureshi@ki.se

Juan-Jesus Carrero: juan.jesus.carrero@ki.se

Marie Evans:

ORCID: http://orcid.org/0000-0001-8650-5795

+46 8 585 83414 , marie.evans@ki.se

Journal

Journal ID (nlm-ta): BMC Nephrol

Journal ID (iso-abbrev): BMC Nephrol

Title: BMC Nephrology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2369

Publication date (Electronic): 10 February 2017

Publication date PMC-release: 10 February 2017

Publication date Collection: 2017

Volume: 18

Electronic Location Identifier: 59

Affiliations

[1 ]ISNI 0000 0000 9241 5705, GRID grid.24381.3c, Division of Renal Medicine, Department CLINTEC, , Karolinska Institutet and Karolinska University Hospital, ; Stockholm, Sweden

[2 ]ISNI 0000 0001 2174 1754, GRID grid.7563.7, Department of Statistics and Quantitative Methods, , University Milano-Bicocca, ; Milan, Italy

[3 ]ISNI 0000 0004 1937 0626, GRID grid.4714.6, Department of Medical Epidemiology and Biostatistics, , Karolinska Institutet, ; Stockholm, Sweden

[4 ]ISNI 0000 0004 1937 0626, GRID grid.4714.6, Center for Molecular Medicine, , Karolinska Institutet, ; Stockholm, Sweden

[5 ]ISNI 0000 0000 9241 5705, GRID grid.24381.3c, Renal Department M99, , Karolinska University Hospital Huddinge, ; Stockholm, SE-14186 Sweden

Author information

Marie Evans http://orcid.org/0000-0001-8650-5795

Article

Publisher ID: 473

DOI: 10.1186/s12882-017-0473-1

PMC ID: 5303237

PubMed ID: 28187786

SO-VID: 63e286ce-5234-4b2e-81e6-8368b41be441

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 16 September 2016

Date accepted : 1 February 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100004348, Stockholms Läns Landsting;

Award ID: SLL20150252

Award ID: ALF Medicine

Award Recipient : Juan-Jesus Carrero Marie Evans

Funded by: FundRef http://dx.doi.org/10.13039/501100002803, Fondazione Cariplo;

Award ID: EXTRA

Award Recipient : Alessandro Gasparini

Funded by: FundRef http://dx.doi.org/10.13039/501100003793, Hjärt-Lungfonden;

Custom metadata

ScienceOpen disciplines: Nephrology

Keywords: renal replacement therapy,chronic kidney disease,estimated glomerular filtration rate,mortality,end-stage kidney disease,progression rate,epidemiology

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ScienceOpen disciplines: Nephrology

Keywords: renal replacement therapy, chronic kidney disease, estimated glomerular filtration rate, mortality, end-stage kidney disease, progression rate, epidemiology

Low renal replacement therapy incidence among slowly progressing elderly chronic kidney disease patients referred to nephrology care: an observational study

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Abstract

Background

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Results

Conclusions

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Karger: Nephrology

Most cited references 17

Decline in estimated glomerular filtration rate and subsequent risk of end-stage renal disease and mortality.

Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. A collaborative meta-analysis of kidney disease population cohorts.

World-wide, mortality is a high risk soon after initiation of hemodialysis

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