Original Investigation
Pathogenesis and Treatment of Kidney Disease
Trajectories of Kidney Function Decline in the 2 Years Before Initiation of Long-term Dialysis

https://doi.org/10.1053/j.ajkd.2011.11.044Get rights and content

Background

Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis.

Setting & Participants

5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003.

Predictor

Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis.

Outcomes & Measurements

Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation.

Results

We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR <30 mL/min/1.73 m2 (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m2 per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m2 (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m2 per year), 9.5% had accelerated loss of eGFR from levels >60 mL/min/1.73 m2 (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m2 per year), and 3.1% experienced catastrophic loss of eGFR from levels >60 mL/min/1.73 m2 within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation.

Conclusions

There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.

Section snippets

Patients and Data Sources

We used data from the Veterans Affairs (VA) and the US Renal Data System (USRDS)16 to identify 6,253 patients 18 years and older who initiated long-term dialysis between October 1, 2001, and December 31, 2003 (more recent USRDS data are not currently available for veteran cohorts) and had at least one serum creatinine measurement at a VA medical center within 45 days of dialysis initiation. Of these, we identified a subset of 5,742 (87%) patients with at least 2 serum creatinine measurements

Results

For the 5,606 cohort members, there were a median of 20 (25th-75th percentile, 12-34) serum creatinine measurements during the 2-year period before dialysis initiation. On average, patients had at least one serum creatinine measurement in 5 of the 8 quarters before initiation. The median eGFR slope for all cohort members was 10 (25th-75th percentiles, 5.8 to 16.6) mL/min/1.73 m2 per year. We identified 4 distinct trajectories of eGFR among members of this cohort (Fig 1; Table 1). Most patients

Discussion

Among members of a large integrated health system, there was a substantial degree of heterogeneity in patterns of eGFR loss during the 2-year period leading to the initiation of long-term dialysis. Trajectories of eGFR before dialysis initiation were associated strongly with care practices at and before the time of initiation and with mortality during the first year after initiation.

To our knowledge, this is the first study to comprehensively describe patterns of eGFR loss preceding the

Acknowledgements

We thank Ms Whitney Showalter of the VA Puget Sound Healthcare System (VAPSHCS) for providing study coordination and administrative support for this project.

Support: This work was supported by an Interagency Agreement between the Centers for Disease Control and Prevention (CDC) and VAPSHCS (07FED69212), the VA Puget Sound Health Services Research and Development Center of Excellence, and a Beeson Career Development Award from the National Institute on Aging to Dr O'Hare (K 1K23AG28980). The

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    Originally published online February 10, 2012.

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