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Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease.
JAMA Intern Med. 2020 12 01; 180(12):1647-1654.JIM

Abstract

Importance

In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined.

Objective

To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD.

Design, Setting, and Participants

Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year.

Main Outcomes and Measures

One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort.

Results

In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study.

Conclusions and Relevance

The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD.

Authors+Show Affiliations

Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco. Division of Research, Kaiser Permanente Northern California, Oakland.Division of Research, Kaiser Permanente Northern California, Oakland.Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California.Division of Research, Kaiser Permanente Northern California, Oakland. Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California. Division of Medical Education, Department of Medicine, University of California, San Francisco, San Francisco.Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.Division of Research, Kaiser Permanente Northern California, Oakland.Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco. Division of Research, Kaiser Permanente Northern California, Oakland. Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco. Department of Medicine, Stanford University, Stanford, California. Department of Health Research and Policy, Stanford University, Stanford, California.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

33044519

Citation

Hsu, Chi-Yuan, et al. "Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease." JAMA Internal Medicine, vol. 180, no. 12, 2020, pp. 1647-1654.
Hsu CY, Parikh RV, Pravoverov LN, et al. Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. JAMA Intern Med. 2020;180(12):1647-1654.
Hsu, C. Y., Parikh, R. V., Pravoverov, L. N., Zheng, S., Glidden, D. V., Tan, T. C., & Go, A. S. (2020). Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. JAMA Internal Medicine, 180(12), 1647-1654. https://doi.org/10.1001/jamainternmed.2020.5009
Hsu CY, et al. Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. JAMA Intern Med. 2020 12 1;180(12):1647-1654. PubMed PMID: 33044519.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Implication of Trends in Timing of Dialysis Initiation for Incidence of End-stage Kidney Disease. AU - Hsu,Chi-Yuan, AU - Parikh,Rishi V, AU - Pravoverov,Leonid N, AU - Zheng,Sijie, AU - Glidden,David V, AU - Tan,Thida C, AU - Go,Alan S, PY - 2020/10/13/pubmed PY - 2021/4/15/medline PY - 2020/10/12/entrez SP - 1647 EP - 1654 JF - JAMA internal medicine JO - JAMA Intern Med VL - 180 IS - 12 N2 - Importance: In the last 2 decades, there have been notable changes in the level of estimated glomerular filtration rate (eGFR) at which patients initiate long-term dialysis in the US and around the world. How changes over time in the likelihood of dialysis initiation at any given eGFR level in at-risk patients are associated with the population burden of end-stage kidney disease (ESKD) has not been not well defined. Objective: To examine temporal trends in long-term dialysis initiation by level of eGFR and to quantify how these patterns are associated with the number of patients with ESKD. Design, Setting, and Participants: Retrospective cohort study analyzing data obtained from a large, integrated health care delivery system in Northern California from 2001 to 2018 in successive 3-year intervals. Included individuals, ranging in number from as few as 983 122 (2001-2003) to as many as 1 844 317 (2016-2018), were adult members with 1 or more outpatient serum creatinine levels determined in the prior year. Main Outcomes and Measures: One-year risk of initiating long-term dialysis stratified by eGFR levels. Multivariable logistic regression was performed to assess temporal trends in each 3-year cohort with adjustment for age, sex, race, and diabetes status. The potential change in dialysis initiation in the final cohort (2016-2018) was estimated using the relative difference between the standardized risks in the initial cohort (2001-2003) and the final cohort. Results: In the initial 3-year cohort, the mean (SD) age was 55.4 (16.3) years, 55.0% were women, and the prevalence of diabetes was 14.9%. These characteristics, as well as the distribution of index eGFR, were stable across the study period. The likelihood of receiving dialysis at eGFR levels of 10 to 24 mL/min/1.73 m2 generally increased over time. For example, the 1-year odds of initiating dialysis increased for every 3-year interval by 5.2% (adjusted odds ratio, 1.052; 95% CI, 1.004-1.102) among adults with an index eGFR of 20 to 24 mL/min/1.73 m2, by 6.6% (adjusted odds ratio, 1.066; 95% CI, 1.007-1.130) among adults with an eGFR of 16 to 17 mL/min/1.73 m2, and by 5.3% (adjusted odds ratio, 1.053; 95% CI, 1.008-1.100) among adults with an eGFR of 10 to 13 mL/min/1.73 m2, adjusting for age, sex, race, and diabetes. The incidence of new cases of ESKD was estimated to have potentially been 16% (95% CI, 13%-18%) lower if there were no changes in system-level practice patterns or other factors besides timing of initiating long-term dialysis from the initial 3-year interval (2001-2003) to the final interval (2016-2018) assessed in this study. Conclusions and Relevance: The present results underscore the importance the timing of initiating long-term dialysis has on the size of the population of individuals with ESKD. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/33044519/Implication_of_Trends_in_Timing_of_Dialysis_Initiation_for_Incidence_of_End_stage_Kidney_Disease_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2020.5009 DB - PRIME DP - Unbound Medicine ER -