Objectives

Serum creatinine-based estimated glomerular filtration rate equations and muscle mass are powerful markers of health and mortality risk. However, the serum creatinine-to-cystatin-C ratio may be a better indicator of health status. The objective of this study was to describe the relationship between creatinine-to-cystatin-C ratio and all-cause mortality when stratifying patients as per race and as per chronic kidney disease status.

Methods

This was a retrospective cohort study examining black and nonblack US veterans between October 2004 and September 2019, with baseline cystatin C and creatinine data from those not on dialysis during the study period. Veterans were divided into four creatinine-to-cystatin-C ratio groups: <0.75, 0.75-<1.00, 1.0-<1.25, and ≥1.25. The primary outcome of interest was all-cause mortality subsequent to the cystatin C laboratory measure.

Results

Among 22,316 US veterans, the mean (± standard deviation) age of the cohort was 67 ± 14 years, 5% were female, 82% were nonblack, and 18% were black. The proportion of black veterans increased across creatinine-to-cystatin-C ratio groups. In the fully adjusted model, compared with the reference (creatinine-to-cystatin-C ratio: 1.00-<1.25), a creatinine-to-cystatin-C ratio <0.75 had the highest mortality risk among both black and nonblack veterans (nonblack: hazard ratio [HR] [95% confidence interval {CI}]: 3.01 [2.78-3.26] and black: 4.17 [3.31-5.24]). A creatinine-to-cystatin-ratio ≥1.25 was associated with lower death risk than the referent in both groups (nonblack: HR [95% CI]: 0.89 [0.80-0.99] and black: HR [95% CI]: 0.55 [0.45-0.69]). However, there was a significant difference in the effect by race (Wald's P-value: <0.01).

Conclusions

Higher creatinine-to-cystatin-C ratios indicate better health status and are strongly associated with lower mortality risk regardless of the kidney function level, and the relation was similar for both black and nonblack veterans, but with different strengths of effect across racial groups. Thereby, use of a fixed race coefficient in estimating kidney function may be biased.

Background

Transitioning to maintenance hemodialysis (HD) is a vulnerable period for persons with end-stage renal disease (ESRD), punctuated by high rates of depression, hospitalizations and death. Screening for depression during this time may help to improve patient outcomes but formal inquiry has yet to be conducted. Among a national Veteran cohort, we examined whether depression screening in the year prior to HD initiation led to improved outcomes in the year thereafter.

Methods

Associations between pre-ESRD depression screening and post-ESRD outcomes were examined with Cox proportional hazards models (mortality) and Poisson regression models (hospitalization). Hierarchal adjustment models accounted for sociodemographic, clinical, pre-ESRD care and dialysis characteristics.

Results

The final analytic cohort of the study was 30 013 Veterans of whom 64% underwent pre-ESRD depression screening. During the 12 months post-transition, the crude all-cause mortality rate was 0.32 person-year for those screened and 0.35 person-year for those not screened, while the median (interquartile range) hospitalizations were 2 (2, 2) per year for both groups. In fully adjusted models, pre-ESRD depression screening was associated with a lower risk of mortality [hazard ratio (95% confidence interval): 0.94 (0.90-0.99)] and hospitalization [incidence rate ratio (95% confidence interval): 0.97 (0.9-0.99)].

Conclusion

Depression screening among adults prior to maintenance HD transition may be associated with better outcomes during the following year.

Background and objectives

Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease.

Design, setting, participants, & measurements

As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes.

Results

The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient.

Conclusions

Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.

Abstract: BACKGROUND AND AIMS: Within the Veterans Health Administration, the largest integrated healthcare system in the USA, 1.1 million Veterans (16.4%) have been identified as having chronic kidney disease (CKD). Annual spending on US Veterans with non-dialysis dependent CKD is estimated at $19 billion/year, and each year ∼10% of US Veterans with advanced CKD progress to end-stage renal disease (ESRD) requiring renal replacement therapy in the form of dialysis or kidney transplantation. While dialysis has been the dominant treatment paradigm in this population, with ∼22 000 enrolled Veterans receiving dialysis from VA-based dialysis facilities or from VA-contracted community providers, this treatment approach may not offer survival benefit nor improved quality of life in certain subgroups (elderly, multi-morbid). We sought to examine the clinical characteristics of a contemporary cohort of US Veterans with advanced CKD treated with conservative non-dialytic management versus dialysis. METHOD: In a national cohort of US Veterans receiving care from the VA healthcare system, we identified patients with advanced CKD, identified as those with ≥ 2 eGFR measurements < 25 mL/min/1.73 m2 separated by ≥ 90 days over the period of 1 October 2010–30 September 2019. Used linked United States Renal Data System and Medicare data, patients were categorized according to (1) receipt of conservative management (CM), defined as those who did not receive dialysis within 2 years of the index eGFR (first eGFR < 25 mL/min/1.73 m2) and (2) receipt of dialysis within 2 years of the index eGFR. We then examined the clinical characteristics and outcome trajectory of those treated with CM versus dialysis, with follow-up through 30 September 2021. RESULTS: Among 106 089 advanced CKD patients who met eligibility criteria, 24.6% (N = 26 113) and 75.4% (N = 79 956) were treated with dialysis versus CM, respectively (index eGFR distribution shown in Fig. 1, left panel). In the overall cohort, the mean ± SD age was 73 ± 12 years and 97.4% were men, with a younger age distribution seen in those receiving dialysis versus CM, yet a similar sex distribution across the two treatment groups (Table 1). Across racial groups, there was a greater tendency for Black, Asian, Pacific Islander and Native American Veterans to undergo dialysis versus CM as compared with Veterans of White race. A greater proportion of deaths were observed among Veterans treated with dialysis versus CM (73.2% versus 70.3%, respectively; available follow-up time to censoring or death is shown in Fig. 1, right panel). CONCLUSION: In a nationally representative CKD cohort, we observed differences in socio-demographics, including racial background, among patients who were treated with CM versus dialysis. Additionally, death was more frequently observed in those who underwent dialysis versus CM. Further studies are needed to examine the comparative effectiveness of CM versus dialysis transition on CKD outcomes.

Abstract: BACKGROUND AND AIMS: While dialysis has been the prevailing treatment paradigm in advanced CKD patients progressing to ESRD, this treatment approach may lead to a decline in physical function, loss of independence, and greater healthcare utilization among certain subgroups. We sought to compare the impact of dialysis versus conservative dialysis-free management on hospitalization lengths of stay (LOS) in advanced CKD patients. METHOD: We examined a national cohort of advanced CKD patients (≥2 eGFRs <25 mL/min/1.73 m2 separated by ≥90 days) treated with conservative management (CM) versus dialysis over 1 January 2007—30 June 2020 from the OptumLabs® Data Warehouse (OLDW), which contains de-identified administrative claims, including medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, as well as electronic health record data. In primary analyses, patients were categorized according to receipt of CM, defined as those who did not receive dialysis within 2-years of the index eGFR (1st eGFR <25 mL/min/1.73 m2), versus receipt of dialysis. In secondary analyses, we examined finer gradations of the timing of dialysis, defined as late versus early transition (eGFRs <15 versus ≥15 mL/min/1.73 m2 respectively, at the time of dialysis initiation). We compared LOS among patients treated with CM versus dialysis who were hospitalized within 2 years of their index eGFR using linear mixed effects models that separately considered a fixed age of the cohort (65-years old), with varying times of hospitalization from the index eGFR date, as well as a fixed time of hospitalization from the index eGFR date (12 months) with varying age. RESULTS: Among 169 479 advanced CKD patients who were hospitalized within 2-years of their index eGFR, there were a total of 620 168 hospitalizations over this time period. In primary analyses that considered a fixed age of the cohort, dialysis patients experienced longer average LOS versus those treated with CM, with differences attenuating over time (∆ of + 1.5-days for hospitalizations 1-month from the index eGFR; Fig. 1A, upper panel). In secondary analyses, differences in average LOS were even greater for those treated with early dialysis versus CM (∆ of + 2-days for hospitalizations 1-month from the index eGFR, Fig. A, lower panel). In primary analyses that considered a fixed time of hospitalization from the index eGFR, dialysis patients >20-years old had longer average LOS versus those treated with CM, with differences increasing with older age (∆ of + 1.25-days for hospitalizations for patients 70-years old; Fig. 1B, upper panel). In secondary analyses, differences in average LOS were even greater for those treated with early dialysis versus CM (∆ of + 1.87-days for patients 70-years old, Fig. 1B, lower panel). CONCLUSION: In a nationally representative CKD cohort, compared with dialysis, those treated with CM as an alternative patient-centered treatment strategy had shorter LOS across varying time points and age groups. Further studies are needed to examine the comparative effectiveness of CM versus dialysis transition on CKD outcomes.

Background and objectives

The highly specialized and technologically focused approach to care inherent to many health systems can adversely affect patients' emotional experiences of illness, while also obscuring these effects from the clinician's view. We describe what we learned from patients with advanced kidney disease about the emotional impact of illness and care.

Design, setting, participants, & measurements

As part of an ongoing study on advance care planning, we conducted semistructured interviews at the VA Puget Sound Healthcare System in Seattle, Washington, with 27 patients with advanced kidney disease between April of 2014 and May of 2016. Of these, ten (37%) were receiving center hemodialysis, five (19%) were receiving peritoneal dialysis, and 12 (44%) had an eGFR≤20 ml/min per 1.73 m² and had not started dialysis. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory methods.

Results

We here describe three emergent themes related to patients' emotional experiences of care and illness: (1) emotional impact of interactions with individual providers: when providers seemed to lack insight into the patient's experience of illness and treatment, this could engender a sense of mistrust, abandonment, isolation, and/or alienation; (2) emotional impact of encounters with the health care system: just as they could be affected emotionally by interactions with individual providers, patients could also be affected by how care was organized, which could similarly lead to feelings of mistrust, abandonment, isolation, and/or alienation; and (3) emotional impact of meaning-making: patients struggled to make sense of their illness experience, worked to apportion blame, and were often quick to blame themselves and to assume that their illness could have been prevented.

Conclusions

Interactions with individual providers and with the wider health system coupled with patients' own struggles to make meaning of their illness can take a large emotional toll. A deeper appreciation of patients' emotional experiences may offer important opportunities to improve care.

Whereas in many parts of the world a low protein diet (LPD, 0.6-0.8 g/kg/day) is routinely prescribed for the management of patients with non-dialysis-dependent chronic kidney disease (CKD), this practice is infrequent in North America. The historical underpinnings related to LPD in the USA including the non-conclusive results of the Modification of Diet in Renal Disease Study may have played a role. Overall trends to initiate dialysis earlier in the course of CKD in the US allowed less time for LPD prescription. The usual dietary intake in the US includes high dietary protein content, which is in sharp contradistinction to that of a LPD. The fear of engendering or worsening protein-energy wasting may be an important handicap as suggested by a pilot survey of US nephrologists; nevertheless, there is also potential interest and enthusiasm in gaining further insight regarding LPD's utility in both research and in practice. Racial/ethnic disparities in the US and patients' adherence are additional challenges. Adherence should be monitored by well-trained dietitians by means of both dietary assessment techniques and 24-h urine collections to estimate dietary protein intake using urinary urea nitrogen (UUN). While keto-analogues are not currently available in the USA, there are other oral nutritional supplements for the provision of high-biologic-value proteins along with dietary energy intake of 30-35 Cal/kg/day available. Different treatment strategies related to dietary intake may help circumvent the protein- energy wasting apprehension and offer novel conservative approaches for CKD management in North America.