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Risk of ESRD and death in patients with CKD not referred to a nephrologist: a 7-year prospective study.

ABSTRACT: BACKGROUND AND OBJECTIVES: Rising prevalence of CKD requires active involvement of general practitioners to limit ESRD and mortality risk. However, the outcomes of patients with CKD exclusively managed by general practitioners are ill defined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We prospectively evaluated 30,326 adult patients with nondialysis CKD stages 1-5 who had never received consultation in tertiary nephrology care recruited from 700 general practitioner offices in Italy during 2002 and 2003. CKD stages were classified as stages 1 and 2 (GFR ? 60 ml/min per 1.73 m(2) and either albuminuria or an International Classification of Diseases, Ninth Revision, Clinical Modification code for kidney disease), stage 3a (GFR=59-45), stage 3b (GFR=44-30), stage 4 (GFR=29-15), and stage 5 (GFR<15). Primary outcome was the risk of ESRD (dialysis or transplantation) or all-cause death. RESULTS: Overall 64% of patients were in stage 3a, and 4.5% of patients were in stages 3b-5. Patients with stages 1 and 2 were younger, were predominantly men, more frequently had diabetes, and had lower prevalence of previous cardiovascular disease than patients with stages 3a-5. Hypertension was frequent in all CKD stages (80%-94%), whereas there was a lower prevalence of dyslipidemia, albuminuria, and obesity associated with more advanced CKD. During the follow-up (median=7.2 years; interquartile range=4.7-7.7), 6592 patients died and 295 started ESRD. Compared with stages 1 and 2 (reference), mortality risk (hazard ratio, 95% confidence interval) was higher in stages 3b-5 (1.66, 1.49-1.86, 2.75, 2.41-3.13 and 2.54, 2.01-3.22, respectively) but not stage 3a (1.11, 0.99-1.23). Similarly, ESRD risk (hazard ratio, 95% confidence interval) was not higher at stage 3a (1.44, 0.79-2.64) but was greater in stages 3b-5 (11.0, 6.3-19.5, 91.2, 53.2-156.2 and, 122.8, 67.9-222.0, respectively). Among modifiable risk factors, anemia and albuminuria significantly predicted either outcome, whereas hypertension only predicted mortality. CONCLUSIONS: In patients with CKD not referred to nephrology, risks of ESRD and mortality were higher in those with CKD stages 3b-5.

SUBMITTER: Minutolo R

PROVIDER: S-EPMC4152817 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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Risk of ESRD and death in patients with CKD not referred to a nephrologist: a 7-year prospective study.

Minutolo Roberto R Lapi Francesco F Chiodini Paolo P Simonetti Monica M Bianchini Elisa E Pecchioli Serena S Cricelli Iacopo I Cricelli Claudio C Piccinocchi Gaetano G Conte Giuseppe G De Nicola Luca L

Clinical journal of the American Society of Nephrology : CJASN 20140729 9

<h4>Background and objectives</h4>Rising prevalence of CKD requires active involvement of general practitioners to limit ESRD and mortality risk. However, the outcomes of patients with CKD exclusively managed by general practitioners are ill defined.<h4>Design, setting, participants, & measurements</h4>We prospectively evaluated 30,326 adult patients with nondialysis CKD stages 1-5 who had never received consultation in tertiary nephrology care recruited from 700 general practitioner offices in ...[more]

PMID: 25074838

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Project description:BackgroundFrailty is a construct developed to characterize a state of reduced functional capacity in older adults. However, there are limited data describing the prevalence or consequences of frailty in middle-aged patients with chronic kidney disease (CKD).Study designObservational study.Setting & participants336 non-dialysis-dependent patients with stages 1-4 CKD with estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m(2) (by the CKD-EPI [CKD Epidemiology Collaboration] serum creatinine-based equation) or evidence of microalbuminuria enrolled in the Seattle Kidney Study, a clinic-based cohort study. Findings were compared with community-dwelling older adults in the Cardiovascular Health Study.OutcomePrevalence and determinants of frailty in addition to its association with the combined outcome of all-cause mortality or renal replacement therapy.MeasurementsWe defined frailty according to established criteria as 3 or more of the following characteristics: slow gait, weakness, unintentional weight loss, exhaustion, and low physical activity. We estimated kidney function using serum cystatin C concentrations (eGFR(cys)) to minimize confounding due to relationships of serum creatinine levels with muscle mass and frailty.ResultsThe mean age of the study population was 59 years and mean eGFR(cys) was 51 mL/min/1.73 m(2). The prevalence of frailty (14.0%) was twice that of the much older non-CKD reference population (P < 0.01). The most common frailty components were physical inactivity and exhaustion. After adjustment including diabetes, eGFR(cys) categories of <30 and 30-44 mL/min/1.73 m(2) were associated with a 2.8- (95% CI, 1.3-6.3) and 2.1 (95% CI, 1.0-4.7)-fold greater prevalence of frailty compared with GFR(cys) ≥60 mL/min/1.73 m(2). There were 63 events during a median 987 days of follow-up. After adjustment, the frailty phenotype was associated with an estimated 2.5 (95% CI, 1.4-4.4)-fold greater risk of death or dialysis therapy.LimitationsCross-sectional study design obscures inference regarding temporal relationships between CKD and frailty.ConclusionsFrailty is relatively common in middle-aged patients with CKD and is associated with lower eGFR(cys) and increased risk of death or dialysis therapy.

Project description:Nutrition is linked strongly with health outcomes in chronic kidney disease (CKD). However, few studies have examined relationships between dietary patterns and health outcomes in persons with CKD.Observational cohort study.3,972 participants with CKD (defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 or albumin-creatinine ratio ? 30 mg/g at baseline) from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a prospective cohort study of 30,239 black and white adults at least 45 years of age.5 empirically derived dietary patterns identified by factor analysis: "convenience" (Chinese and Mexican foods, pizza, and other mixed dishes), "plant-based" (fruits and vegetables), "sweets/fats" (sugary foods), "Southern" (fried foods, organ meats, and sweetened beverages), and "alcohol/salads" (alcohol, green-leafy vegetables, and salad dressing).All-cause mortality and end-stage renal disease (ESRD).816 deaths and 141 ESRD events were observed over approximately 6 years of follow-up. There were no statistically significant associations of convenience, sweets/fats, or alcohol/salads pattern scores with all-cause mortality after multivariable adjustment. In Cox regression models adjusted for sociodemographic factors, energy intake, comorbid conditions, and baseline kidney function, higher plant-based pattern scores (indicating greater consistency with the pattern) were associated with lower risk of mortality (HR comparing fourth to first quartile, 0.77; 95% CI, 0.61-0.97), whereas higher Southern pattern scores were associated with greater risk of mortality (HR comparing fourth to first quartile, 1.51; 95% CI, 1.19-1.92). There were no associations of dietary patterns with incident ESRD in multivariable-adjusted models.Missing dietary pattern data, potential residual confounding from lifestyle factors.A Southern dietary pattern rich in processed and fried foods was associated independently with mortality in persons with CKD. In contrast, a diet rich in fruits and vegetables appeared to be protective.

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Risk of ESRD and death in patients with CKD not referred to a nephrologist: a 7-year prospective study.

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Risk of ESRD and death in patients with CKD not referred to a nephrologist: a 7-year prospective study.

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