Comorbidity and other factors associated with modality selection in incident dialysis patients: The CHOICE study

doi:10.1053/ajkd.2002.30552

American Journal of Kidney Diseases

Volume 39, Issue 2, February 2002, Pages 324-336

Presented in part at the 30th Annual Meeting of the American Society of Nephrology, November 2-5, 1997, San Antonio, TX, and the 32nd Annual Meeting of the American Society of Nephrology, November 1-8, 1999, Miami Beach, FL.

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Abstract

Case-mix factors influence both the selection of dialysis modality and outcomes in end-stage renal disease (ESRD). A detailed characterization of the case-mix differences between peritoneal dialysis (PD) and hemodialysis (HD) patients at the onset of dialysis therapy has not been performed, despite the importance of accounting for baseline differences in future comparisons of outcomes across modality groups. We compared baseline characteristics of 279 PD and 759 HD patients enrolled in the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Cohort Study, a prospective study of incident dialysis patients. Comorbidity was assessed using the Index of Coexistent Diseases (ICED), consisting of a medical record review of 19 medical conditions and an observer-based assessment of 11 physical functions. ICED scores range from 0 to 3, with higher levels reflecting more severe comorbidity. Comorbidity was less severe in PD patients than in HD patients: the proportions of patients with ICED 0-1, ICED 2, and ICED 3 were 52%, 26%, and 22%, respectively, among the PD patients and 30%, 39%, and 31%, respectively, among the HD patients (P < 0.001). After controlling for all other factors, the differences in comorbidity remained significant. As compared with patients with ICED 0-1, the odds of being treated with PD for patients with ICED 2 and ICED 3 were less (odds ratio [OR] and 95% confidence intervals) 0.31 (0.17 to 0.56) and 0.50 (0.28 to 0.90), respectively. The number and severity of comorbid conditions at the onset of ESRD is significantly lower in patients choosing PD, independent of other factors influencing modality selection. The increased survival of PD patients reported in recent studies may simply reflect the self- or physician-directed selection of healthier patients to PD. Adjustment for case-mix differences in patients treated with PD versus HD is essential to the assessment of the independent effect of the dialysis modality on outcomes. © 2002 by the National Kidney Foundation, Inc.

Section snippets

Study design and patient eligibility

We conducted a cross-sectional analysis of baseline data on incident dialysis patients recruited from 81 dialysis units in 19 states of the US participating in the CHOICE Cohort Study. Patients were eligible if they had started chronic outpatient dialysis during the 3 months before enrollment, were 18 years or older, spoke English or Spanish, and gave informed consent. Home HD and hospice patients were excluded.

Patients were recruited from 79 dialysis units associated with Dialysis Clinic, Inc

Recruitment

Approximately two-thirds of eligible patients were enrolled from the participating dialysis units. Eligible patients enrolled were similar to eligible patients not enrolled with regard to gender and age. A total of 1,041 incident dialysis outpatients were enrolled from 81 dialysis centers; 279 PD dialysis (27%) and 762 HD patients (73%). Three HD patients did not have a completed ICED at baseline and were excluded from analyses in this report. Nine hundred and twenty-one patients (89%) were

Discussion

Within the US there is significant variation in PD utilization. Factors responsible for variation are not completely understood, but may include patients' clinical characteristics, medical judgement, physicians' and patients' preferences, and differences in physician and facility reimbursement.²⁴ A detailed characterization of differences in PD versus HD patients in the present study shows the extent by which these patient groups differ at the onset of chronic dialysis therapy.

We observed fewer

Acknowledgements

We thank the patients, staff, and physicians who participated in the CHOICE Study at Dialysis Clinic, Inc, St. Raphael's Hospital and New Haven CAPD. We also acknowledge and thank the CHOICE-DCI Clinical Liaison Committee (Thomas Depner, MD, H. Keith Johnson, MD, K Shashi Kant, MD, Klemens Meyer, MD, Richard Sherman, MD, Edward Schroeder, MD, Pradip Teredesai, MD, John Van Stone, MD, and Philip Zager, MD) and the New Haven CAPD Clinical Liaison Committee (Frederic Finkelstein, MD and Alan

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Social determinants of health influencing the choice of dialysis modality in advanced chronic kidney disease: Need of an interdisciplinary approach
2024, Nefrologia
La influencia de los determinantes sociales de la salud en la elección de las técnicas de tratamiento renal sustitutivo (TRS) en la enfermedad renal crónica avanzada (ERCA) ha sido escasamente explorada, pudiendo generar problemas de inequidad, frecuentemente desapercibidos en la asistencia sanitaria. El objetivo de este estudio es identificar las desigualdades sociales y económicas que influyen en la elección de TRS en una consulta de ERCA en España.
Análisis retrospectivo incluyendo el total de pacientes atendidos en la consulta de ERCA en un hospital terciario desde 2009 a 2020. La inclusión en la consulta de ERCA comenzaba por un proceso de toma de decisiones, conducido por una enfermera específicamente instruida. Las variables consideradas para el estudio fueron: edad, sexo, etiología de la ERC, nivel de dependencia para las actividades básicas de la vida diaria (escala de Barthel) y actividades instrumentales de la vida diaria (escala de Lawton y Brody), nacionalidad española versus extranjera, nivel socioeconómico y barrera idiomática. El nivel socioeconómico se extrapoló según el domicilio y el distrito sanitario por centro de atención primaria al que pertenecían los pacientes.
Un total de 673 personas fueron atendidas en la consulta de ERCA en el periodo de estudio, de los cuales 400 (59,4%) optaron por la técnica de hemodiálisis (HD), 156 (23,1%) por diálisis peritoneal (DP), 4 (0,5%) por trasplante renal de donante vivo anticipado y 113 (16,7%) eligieron tratamiento conservador (TC). La elección de DP como técnica de TRS elegida (frente a HD) se asoció a personas con nivel socioeconómico alto (38,7 vs. 22,5%) (p = 0,002), a la nacionalidad española (91 vs. 77,7%) (p < 0,001), a una menor barrera idiomática (0,6 vs. 10,5%) (p < 0,001) y a mayores puntuaciones en la escala de Barthel (97,4 vs. 92,9) y la escala de Lawton y Brody (7 vs. 6,1) (p < 0,001). Ni la edad ni el sexo mostraron diferencias significativas en la elección de ambas técnicas. Los pacientes que optaron por TC eran significativamente de mayor edad (81,1 vs. 67,7 años; p < 0,001), más dependientes (p < 0,001), con una mayor proporción de mujeres (49,6 vs. 35,2%; p = 0,006) y de españoles (94,7 vs. 81%, p = 0,001) en relación con la elección de otras técnicas (DP y HD). El nivel socioeconómico no influyó en la elección de TC.
A pesar de que el proceso de toma de decisiones en la elección de TRS está reglado y estandarizado, existen factores como la situación socioeconómica, la migración, la barrera idiomática o la dependencia que influyen en el tipo de TRS elegido. Para abordar estos aspectos que pueden ser causa de inequidad se requiere de una intervención intersectorial y multinivel con equipos interdisciplinares que incluyan, entre otros, trabajadores sociales, para brindar una evaluación más holística y centrada en la persona.
The influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the “non-medical” barriers that influence the choice of RRT in an ACKD consultation in Spain.
Retrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel scale) and instrumental activities of daily living (Lawton and Brody scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged.
A total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7 vs. 22.5%) (p = 0.002), Spanish nationality (91 vs. 77.7%) (p < 0,001), to a lower language barrier (0.6 vs. 10.5%) (p < 0.001), and to a higher score on the Barthel scale (97.4 vs. 92.9) and on the Lawton and Brody scale (7 vs. 6.1) (p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs. 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6 vs. 35.2%; p = 0.006) and a higher proportion of Spaniards (94.7 vs. 81%, p = 0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC.
Despite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment.
Global coagulation assays in patients with chronic kidney disease and their role in predicting thrombotic risk
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Despite cardiovascular diseases and thrombosis being major causes of death in patients with chronic kidney disease (CKD), there remains no effective biomarker to predict thrombotic risk in this population.
To evaluate global coagulation assays in patients with CKD and correlate the biomarkers to clinical outcomes.
Patients with eGFR<30 mL/min/1.73m² were recruited (n = 90) in this prospective observational study. Blood samples were collected for global coagulation assays, including thromboelastography, calibrated automated thrombogram (CAT), overall hemostatic potential (OHP) and tissue factor pathway inhibitor (TFPI).
Following adjustment for age and gender, CKD subjects (mean age 66 years, 36 % female) had increased maximum amplitude on thromboelastography (70.1 vs 60.2 mm, p < 0.001), higher peak thrombin (233.2 vs 219.7 mm, p = 0.030) and increased OHP (16.1 vs 6.4 units, p < 0.001) compared to healthy controls (n = 153). TFPI was also increased in CKD patients (36.4 vs 14.5 ng/mL, p < 0.001). Compared to hemodialysis patients (n = 43), peritoneal-dialysis patients (n = 25) had more hypercoagulable parameters. Thirty-five CKD patients reported thrombotic complications – key predictors included dialysis, higher fibrinogen, reduced endogenous thrombin potential, elevated D-dimer and increased TFPI. Using the dialysis cohort, the predictive risk model based on the key predictors performed better than Framingham heart score and number of cardiovascular risk factors (Harrell's C-stat 0.862 vs 0.585 vs 0.565).
CKD appears to confer a hypercoagulable state compared to healthy controls. Interestingly, reduced thrombin generation and raised TFPI was paradoxically associated with increased thrombotic risks, highlighting possible complex compensatory mechanisms within the coagulation system, which may be important in predicting clinical outcomes.
Physical Resilience Phenotype Trajectories in Incident Hemodialysis: Characterization and Mortality Risk Assessment
2022, Kidney International Reports
Citation Excerpt :
Body mass index (in kg/m2) was based on height and weight reported on the Health Care Financing Administration Medical Evidence Report (HCFA Form 2728).17 Kidney disease specific markers selected included the following: (i) type of vascular access, by category: arteriovenous fistula or graft, or central venous catheter or unknown;25 (ii) predialysis initiation nephrology consult timing (early [>12 months], intermediate [4–12 months], late [<4 months], unclassified, or missing)26; (iii) laboratory values for serum albumin (g/dl) obtained from HCFA Form 2728;27 and (iv) estimated glomerular filtration rate, calculated using the 4-variable Modification of Diet in Renal Disease Study equation.28 We modeled comorbidities using the Index of Coexistent Disease (ICED), a validated index of presence and severity of comorbid conditions used extensively in mortality risk prediction in patients with kidney failure.
Although life-saving, the physiologic stress of hemodialysis initiation contributes to physical impairment in some patients. Mortality risk assessment following hemodialysis initiation is underdeveloped and does not account for change over time. Measures of physical resilience, the ability of a physiologic state to overcome physiologic stressors, may help identify patients at higher mortality risk and inform clinical management.
We created 3 resilience categories (improving, stable, and declining) for trajectories of 4 phenotypes (physical function [PF], mental health [MH], vitality [VT], and general health [GH]) using SF-36 data collected the first year after hemodialysis initiation in the Choices for Healthy Outcomes in Caring for ESKD (CHOICE) study on 394 adults aged more than 55 years. Using mixed effects and Cox proportional hazard modeling, we assessed mortality following the first year on dialysis by resilience categories for each phenotype, adjusting for baseline phenotype and other confounders defined a priori over 4 years average follow-up.
Based on global Wald tests, statistically significant associations of PF (P = 0.03) and VT (P = 0.0004) resilience categories with mortality were found independent of covariates. Declining PF trajectory was associated with higher mortality risk (hazard ratio [HR] = 1.32; 95% confidence interval [CI], 1.05–1.66), whereas improving VT trajectory was associated with lower mortality risk (HR= 0.73; 95% CI, 0.53 to 1.00), each as compared to stable trajectory.
Decreased resilience in PF and VT was independently associated with mortality. Phenotypic trajectories provide added value to baseline markers and patient characteristics when evaluating mortality. Hence, resilience measures hold promise for targeting population health interventions to the highest risk patients.
Cohort Study of Outpatient Hemodialysis Management Strategies for COVID-19 in North-West London
2020, Kidney International Reports
Dialysis patients are at risk of severe coronavirus disease 2019 (COVID-19). We managed COVID-19 hemodialysis outpatients in dedicated satellite dialysis units. This provided rare opportunity to study early disease progress in community-based patients. We aimed to (i) understand COVID-19 progression, (ii) identify markers of future clinical severity, and (iii) assess associations between dialysis management strategies and COVID-19 clinical outcomes.
We conducted a cohort study of all outpatients managed at a COVID-19 hemodialysis unit. We analyzed data recorded as part of providing COVID-19 clinical care. We analyzed associations between features at diagnosis and the first 3 consecutive hemodialysis sessions in patients who required future hospital admission, and those who had died at 28 days.
Isolated outpatient hemodialysis was provided to 106 patients over 8 weeks. No patients received antiviral medication or hydroxychloroquine. Twenty-one patients (20%) were admitted at COVID-19 diagnosis; 29 of 85 patients (34%) were admitted after initial outpatient management; 16 patients (15%) died. By multivariate analysis, nonactive transplant list status, use of institutional transport, and increased white cell count associated with future hospitalization and increased age associated with death. Oxygen saturations progressively decreased over the first 3 dialysis sessions in the cohorts that progressed to future hospital admission or death. Mean ultrafiltration volume of the first 3 hemodialysis sessions was reduced in the same cohorts.
Outpatient hemodialysis in patients with COVID-19 is safe for patients and staff. Features at the first 3 dialysis sessions can identify individuals at risk of future hospitalization and death from COVID-19.
The Role of the Chronic Kidney Disease Clinic and Multidisciplinary Team Care
2018, Chronic Kidney Disease, Dialysis, and Transplantation: A Companion to Brenner and Rector’s The Kidney
Chronic kidney disease (CKD) is a growing global issue, currently affecting approximately 10% of the population. Optimal care of these patients must encompass their complex medical issues, aiming not only to delay progression of disease but also to manage symptoms and complications of their CKD and comorbidities, facilitate timely and smooth transition to renal replacement therapy, and support conservative management choice in patients who opt for this. Furthermore, care should include advocacy for the patient and support of their social and psychological needs. Due to the complex and multifaceted needs of patients with CKD, a multidisciplinary clinic allows longitudinal follow-up of these patients, allowing continuity of care and utilization of the skills of multiple team members including doctors, nurses, social workers, pharmacists, and other allied health members. Patients with CKD come from varied socioeconomic and educational backgrounds, with variable health literacy and educational needs, and a team approach with well-defined roles, responsibilities, and objectives is a logical and effective way of caring for these patients. Through this approach, it is hoped that improved outcomes for patients with CKD may be achieved.
Factors affecting the choice of peritoneal dialysis: Perspective of patients and nephrologists
2017, Nephrologie et Therapeutique
Identifier les facteurs liés au choix de la dialyse péritonéale (DP) comme première technique de dialyse selon le point de vue des patients et celui des néphrologues.
Il s’agit d’une étude multicentrique rétrospective, de type cas-témoins, qui a été réalisée auprès de patients ayant démarré la dialyse entre 2010 et 2014 dans quatre établissements de la région Provence-Alpes-Côte d’Azur. Les néphrologues prenant en charge les patients inclus et acceptant de participer ont également été interrogés. Les données ont été recueillies à l’aide de deux questionnaires standardisés : un destiné aux patients et un destiné aux néphrologues. Les données démographiques et cliniques à l’initiation de la dialyse sont issues du registre Rein.
Au total, 150 patients ont été interrogés, ils avaient en moyenne 63,7 ans. La DP était contre-indiquée pour 26,7 % d’entre eux. Pour les patients éligibles aux deux techniques de dialyse, 46,7 % avaient exprimé une préférence pour la DP, 31,8 % pour l’HD et 21,5 % n’avaient exprimé aucune préférence. La préférence était influencée fortement par l’information et l’ancienneté du suivi néphrologique. Les principaux facteurs liés au choix personnel de la DP étaient l’autonomie et le désir d’autonomie. La mise en dialyse en urgence influençait négativement le choix de la DP.
Un tiers des patients éligibles aux deux techniques pouvaient et voulaient être sous DP. Les freins étaient essentiellement liés aux pratiques professionnelles. Une meilleure information pourrait augmenter ce potentiel de patients.
To identify factors related to the choice of peritoneal dialysis as a first dialysis technique: the viewpoint of patients and viewpoint of nephrologists.
A retrospective multicenter study, type case-control was conducted in patients starting dialysis between 2010 and 2014 in 4 dialysis facilities in the PACA region. Nephrologists take care of patients included in the study were also interviewed. Data were collected using two standardized questionnaires: One for the patient and one for the nephrologists and using the French REIN registry.
One hundred and fifty patients were interviewed, the average age was 63.7 years. The medical contraindication for PD was present in 26.7%. Among patients eligible for both dialysis techniques, 46.7% had a preference for DP, 31.8% for HD and 21.5% did not have any preference. Patient preference is strongly influenced by information and the duration of predialysis nephrologist care (referral of nephrologist). The main factors related to personal choice of peritoneal dialysis are autonomy and desire for autonomy. Emergency dialysis influences negatively the choice of the PD.
A third of eligible patients for the 2 techniques could and wanted to be on PD. The limitations for PD are mainly related to professional practices. Better information could increase the utilization of PD to 32%.

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^☆: Supported in part by a grant from the Agency for Healthcare Research and Quality (AHRQ) (formerly Agency for Health Care Policy Research [AHCPR] HS08365 to N.R.P.) and a Clinical Research Fellowship from the Alberta Heritage Foundation for Medical Research (to D.C.M.).

^☆☆: Address reprint requests to Andrew S. Levey, MD, New England Medical Center, Division of Nephrology, Box 391, Boston, MA 02111. E-mail: [email protected]

^★: 0272-6386/02/3902-0011$35.00/0

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Original InvestigationsComorbidity and other factors associated with modality selection in incident dialysis patients: The CHOICE study☆,☆☆,★

Abstract

Section snippets

Study design and patient eligibility

Recruitment

Discussion

Acknowledgements

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

J Chron Dis

Kidney Int

J Clin Epidemiol

Kidney Int

The impact of comorbid risk factors at the start of dialysis upon the survival of ESRD patients

ASAIO J

The Index of Coexistent Disease (ICED) is an independent predictor of death in a prospective ESRD cohort

J Am Soc Nephrol

The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis

N Engl J Med

Risk factors for hospital utilization in chronic dialysis patients

J Am Soc Nephrol

US Renal Data System: Excerpts From the USRDS 1999 Annual Data Report

Am J Kidney Dis

Original Investigations
Comorbidity and other factors associated with modality selection in incident dialysis patients: The CHOICE study☆,☆☆,★