Background/Aims: Predialysis care has been associated with improved first-year outcomes. We investigated types of predialysis care associated with improved patient outcomes in patients initiating dialysis with a fistula and at least 2 years of predialysis care. Methods: In this retrospective cohort of incident hemodialysis patients with ≥2 years of Medicare coverage before dialysis initiation, care patterns and patients were determined using Medicare claims. Fistula use at initiation was ascertained from the Medical Evidence Report. Results: Patients aged ≥67 years who initiated hemodialysis with a fistula (n = 14,459) differed demographically and clinically from patients who initiated with other vascular access types; however, 55% had diabetes, 28% heart failure, and 40% ischemic heart disease. In the year preceding initiation, 88% of these patients visited a nephrologist, 66% a cardiologist, 9% an endocrinologist, and 3% a dietician; most underwent routine laboratory measurements. In the first year of dialysis, 50% were hospitalized and 1.3% underwent transplant; the mortality rate remained constant (∼20 per 100 patient-years). Of predialysis care factors evaluated, only fistula placement more than 1 month before dialysis initiation was associated with lower hospitalization and mortality risk and greater likelihood of transplant. Other potentially modifiable factors included more contact with cardiologists and endocrinologists. Conclusion: Patients initiating dialysis with a functioning fistula appear to receive substantial predialysis preparation. This selected population does not show the excess mortality risk often observed early in dialysis treatment. Earlier fistula placement and referral to cardiology and endocrinology appear to be important aspects of predialysis care.

Keywords:
Care patterns, Epidemiology, Outcomes, Vascular access
1.
United States Renal Data System. USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2010.
2.
Bradbury BD, Fissell RB, Albert JM, et al: Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2007;2:89-99.
3.
United States Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2012.
4.
Biesenbach G, Hubmann R, Janko O, Schmekal B, Eichbauer-Sturm G: Predialysis management and predictors for early mortality in uremic patients who die within one year after initiation of dialysis therapy. Ren Fail 2002;24:197-205.
5.
Winkelmayer WC, Owen WF Jr, Levin R, Avorn J: A propensity analysis of late versus early nephrologist referral and mortality on dialysis. J Am Soc Nephrol 2003;14:486-492.
6.
Khan SS, Xue JL, Kazmi WH, et al: Does predialysis nephrology care influence patient survival after initiation of dialysis? Kidney Int 2005;67:1038-1046.
7.
Avorn J, Bohn RL, Levy E, et al: Nephrologist care and mortality in patients with chronic renal insufficiency. Arch Intern Med 2002;162:2002-2006.
8.
Smart NA, Titus TT: Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med 2011;124:1073-1080 e2.
9.
Winkelmayer WC, Liu J, Chertow GM, Tamura MK: Predialysis nephrology care of older patients approaching end-stage renal disease. Arch Intern Med 2011;171:1371-1378.
10.
Hebert PL, Geiss LS, Tierney EF, Engelgau MM, Yawn BP, McBean AM: Identifying persons with diabetes using Medicare claims data. Am J Med Qual 1999;14:270-277.
11.
Black C, Sharma P, Scotland G, et al: Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis. Health Technol Assess 2010;14:1-184.
12.
Stehman-Breen CO, Sherrard DJ, Gillen D, Caps M: Determinants of type and timing of initial permanent hemodialysis vascular access. Kidney Int 2000;57:639-645.
13.
Astor BC, Eustace JA, Powe NR, et al: Timing of nephrologist referral and arteriovenous access use: the CHOICE Study. Am J Kidney Dis 2001;38:494-501.
14.
Avorn J, Winkelmayer WC, Bohn RL, et al: Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure. J Clin Epidemiol 2002;55:711-716.
15.
Bradbury BD, Chen F, Furniss A, et al: Conversion of vascular access type among incident hemodialysis patients: description and association with mortality. Am J Kidney Dis 2009;53:804-814.
16.
Saran R, Dykstra DM, Pisoni RL, et al: Timing of first cannulation and vascular access failure in haemodialysis: an analysis of practice patterns at dialysis facilities in the DOPPS. Nephrol Dial Transplant 2004;19:2334-2340.
17.
Slinin Y, Guo H, Gilbertson DT, et al: Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis. Am J Kidney Dis 2011;58:583-590.
18.
Ibrahim HN, Skeans MA, Li Q, Ishani A, Snyder JJ: Blood transfusions in kidney transplant candidates are common and associated with adverse outcomes. Clin Transplant 2011;25:653-659.
19.
Balasubramaniam GS, Morris M, Gupta A, Mesa IR, Thuraisingham R, Ashman N: Allosensitization rate of male patients awaiting first kidney grafts after leuko-depleted blood transfusion. Transplantation 2012;93:418-422.
20.
Yabu JM, Anderson MW, Kim D, et al: Sensitization from transfusion in patients awaiting primary kidney transplant. Nephrol Dial Transplant 2013;28:2908-2918.
21.
Grams ME, Plantinga LC, Hedgeman E, et al: Validation of CKD and related conditions in existing data sets: a systematic review. Am J Kidney Dis 2011;57:44-54.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.