"Cumulative and Consistent" Care Predicts Outcomes after RRT

Many patients meeting the traditional criteria for “early care” for chronic kidney disease (CKD) do not receive adequate care just before renal replacement therapy (RRT) is begun, according to a study in Kidney International.

The analysis included 12,143 adult patients with ESRD who began receiving RRT (mainly hemodialysis) in Ontario between 1998 and 2008. Of those, 24.1 percent met the traditional definition of late referral for CKD care (after 6 months). The rates and impact of alternative measures of CKD care were assessed, including cumulative care, based on total number of visits, and consistency of care in the critical period immediately before RRT. The latter measure stipulated visits in at least 3 of the 6 months before the start of RRT.

Although more than three-fourths of patients met the definition of early CKD care, just 38.3 percent of this group had more than 10 cumulative visits and received consistent care during the critical period before RRT. Mortality 1 year after the start of RRT was 15.8 percent overall. This risk was significantly increased with late care: adjusted odds ratio (OR) 1.31.

Survival was better for patients with more cumulative visits: OR 0.75 with six to 10 visits and 0.68 with 10 or more visits (compared with one to five visits). Patients receiving consistent care during the critical period also had improved survival: OR 0.73. Other significant predictors included age, diabetes, higher morbidity, and type of RRT (lower risk with peritoneal dialysis or transplantation).

The study suggests that measures of cumulative care and consistency of care before the beginning of RRT, rather than just “early CKD care,” have an important impact on one-year mortality. The investigators conclude: “It is not just when a patient is first seen that matters, but also that patients are seen frequently and regularly to allow for timely interventions, such as access planning, in order to optimize outcomes” [Singhal R, et al. Inadequate predialysis care and mortality after initiation of renal replacement therapy. Kidney Int 2014; 86:399–406].