Dataset Information

Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study.

ABSTRACT: BACKGROUND:The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined. OBJECTIVE:The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD). RESEARCH DESIGN:This was a population-based cohort study. SUBJECTS:Older (65?y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan. MEASURES:A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes. RESULTS:Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with-lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24-0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92-1.05). CONCLUSION:Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.

SUBMITTER: Fukuma S

PROVIDER: S-EPMC7289129 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study.

Fukuma Shingo S Ikenoue Tatsuyoshi T Shimizu Sayaka S Norton Edward C EC Saran Rajiv R Yanagita Motoko M Kato Genta G Nakayama Takeo T Fukuhara Shunichi S

Medical care 20200701 7

<h4>Background</h4>The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined.<h4>Objective</h4>The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD).<h4>Research design</h4>This was a population-based cohort study.<h4>Subjects</h4>Older (65 y and above) CKD patients diagnosed between October 2010 and Septe ...[more]

PMID: 31985583

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Project description:Background and objectivesThe transition from CKD to ESRD can be particularly unstable, with high rates of death and hospitalizations. Few studies have examined medication use during this critical period. We examined patterns of antihypertensive medication use from the four quarters before and eight quarters after incident ESRD treated with maintenance dialysis.Design, setting, participants, & measurementsWe used the US Renal Data System to identify patients aged ≥67 years initiating dialysis for ESRD between January 2008 and December 2010 with Medicare Part D and a low-income subsidy. We ascertained the incidence of AKI and hyperkalemia during each quarter on the basis of having at least 1 payment claim for the condition. We used Poisson regression with robust SEMs to formally test for changes in the trend and level of antihypertensive medication use in a series of intervention analyses.ResultsThe number of antihypertensive drugs used increased as patients neared ESRD, peaking at an average of 3.4 in the quarter immediately preceding dialysis initiation, then declining to 2.2 medications by 2 years later. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was stable at approximately 40%, even among patients with coronary disease and systolic heart failure, and did not correlate with AKI or hyperkalemia. Dialysis initiation was associated with a 40% (95% confidence interval, 38% to 43%) lower adjusted level of diuretic use, which continued to decline after ESRD. Three- and four-drug combinations that included a diuretic were most common before ESRD, whereas after ESRD, one- and two-drug β-blocker or calcium-channel blocker-based combinations were most common.ConclusionsThe use of antihypertensive medications, particularly angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and diuretics, may be suboptimal during the transition from CKD to ESRD, especially in patients with coronary disease or systolic heart failure. Future studies are needed to identify strategies to increase the appropriate use of antihypertensive medications during this critical transition period.

Project description:Data on risk factors predicting rapid progression to end-stage renal disease (ESRD) or short-term kidney function decline (i.e., within 1 year) in chronic kidney disease (CKD) are rare but urgently needed to plan treatment. This study describes the association and predictive value of urinary uromodulin (uUMOD) for rapid progression of CKD.We assessed uUMOD, demographic/treatment parameters, estimated glomerular filtration rate (eGFR), and proteinuria in 230 CKD patients stage I-V. ESRD and 25% decline of eGFR was documented at the end of follow-up period and used as a composite endpoint. Association between logarithmic uUMOD and eGFR/proteinuria was calculated using linear regression analysis, adjusting for age, gender, and body mass index. We performed multivariable Cox proportional hazard regression analysis to evaluate the association of uUMOD with the composite endpoint. Therefore, patients were categorized into quartiles. The predictive value of uUMOD for the above outcomes was assessed using receiver-operating characteristic (ROC) curve analysis.Follow-up was 57.3?±?18.7 weeks, baseline age was 60 (18;92) years, and eGFR was 38 (6;156) mL/min/1.73?m. Forty-seven (20.4%) patients reached the composite endpoint. uUMOD concentrations were directly associated with eGFR and inversely associated with proteinuria (??=?0.554 and ??=?-0.429, P?<?.001). In multivariable Cox regression analysis, the first 2 quartiles of uUMOD concentrations had a hazard ratio (HR) of 3.589 [95% confidence interval (95% CI) 1.002-12.992] and 5.409 (95% CI 1.444-20.269), respectively, in comparison to patients of the highest quartile (?11.45??g/mL) for the composite endpoint. In ROC-analysis, uUMOD predicted the composite endpoint with good sensitivity (74.6%) and specificity (76.6%) at an optimal cut-off at 3.5??g/mL and area under the curve of 0.786 (95% CI 0.712-0.860, P?<?.001).uUMOD was independently associated with ESRD/rapid loss of eGFR. It might serve as a robust predictor of rapid kidney function decline and help to better schedule arrangements for future treatment.

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Dataset Information

Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study.

Publications

Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study.

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