Hospitalization during advancing chronic kidney disease.

BACKGROUND: The care of patients with end-stage renal disease (ESRD) is associated with substantial costs to society, much of which is accounted for by a high rate of hospitalization. However, the influence of declining kidney function on hospitalization as ESRD approaches is not well understood. METHODS: We performed a retrospective cohort study of national data to evaluate the frequency of hospitalizations among patients with chronic kidney disease (CKD) who reached ESRD and had at least 2 years of Medicare eligibility before initiation of dialysis therapy. The study period for each patient extended from 2 years before to 6 months after the initiation of dialysis therapy. RESULTS: The study cohort was composed of 109,321 patients with a mean age of 75 years, all of whom initiated long-term dialysis therapy between 1995 and 1998. Mean hospitalization rate was 134 hospitalizations/1,000 patient-months at risk (PMAR). Hospitalization rates gradually increased as ESRD approached, peaking in the 3 months immediately after the initiation of dialysis therapy at 487 hospitalizations/1,000 PMAR. Cause-specific hospitalization rates mirrored this trend and were greatest for placement of vascular access and diagnoses related to cardiovascular (CVD) and infectious disease. CONCLUSION: Hospitalizations during CKD become more frequent with the approach of ESRD. The majority of these hospitalizations, both before and after the initiation of dialysis therapy, are caused by comorbidity related to CKD. These hospitalizations may be favorably impacted on by heightened attention to the prevention and management of CVD and timely placement of vascular access during CKD.

United States Renal Data System assessment of the impact of the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines.

Since 1989, significant efforts have focused on improving the care of dialysis patients in the United States. Numerous organizations have developed clinical practice guidelines; however, few guidelines have received the broad support given to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI). These guidelines, independently developed from an extensive review of the literature, include sections on dialysis adequacy, anemia treatment, and vascular access. To assess the impact of these guidelines on clinical practice, we evaluated data on hematocrits, recombinant human erythropoietin dosing, hemodialysis adequacy, and simple fistula and dialysis catheter utilization using Medicare dialysis provider claims and Medicare Part B physician services. Hematocrits have increased steadily, with the exception of the period when the Hematocrit Measurement Audit was in effect. After cancellation of the policy, hematocrits increased to the midpoint of the DOQI target range (34.4%). Although the level of dialysis therapy has stabilized, with the average urea reduction rate of 68% to 69.9% in 1997 to 1999 being slightly greater than the DOQI target of 65% or greater, geographic variability is apparent. Simple fistula placement rates increased by 45% during the pre-DOQI and post-DOQI period from 1994 to 1999. The use of temporary catheters decreased, whereas placement of permanent catheters has increased, which may reflect recommended practice guidelines. Although it appears that clinical practice guidelines have improved the clinical care of dialysis patients, considerable regional variations in care across the country should be given significant attention.

Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%.

Anemia treatment with epoetin has led to dramatic increases in hematocrit levels since 1989. Studies have demonstrated that morbidity and mortality rates are lower when hematocrit values are within the Disease Outcomes Quality Initiative (DOQI) target range (33 to 36%). Recently, clinical studies demonstrated that patients without cardiovascular disease exhibited lower morbidity rates and improved cognitive function with hematocrit values of >36%. One prospective trial, in contrast, demonstrated that normal hematocrit values among patients with cardiac disease were associated with higher mortality rates. These conflicting results have led to concerns regarding the risks and benefits associated with hematocrit values between 36 and 42%. To address these concerns, a recent cohort of 1996 to 1998 incident hemodialysis patients was studied, with assessments of the risks of death and hospitalization and the medical costs associated with hematocrit values of >36%. Patients survived at least 9 mo after dialysis initiation, and comorbidity, disease severity, and hematocrit levels were determined for months 4 to 9. Patients were grouped on the basis of hematocrit values, i.e., <30, 30 to <33, 33 to <36, 36 to <39, or > or =39%, with 1 yr of follow-up monitoring. A Cox regression model was used to evaluate all-cause and cause-specific mortality and hospitalization rates. The economic evaluations included analyses with Medicare Parts A and B allowable expenditures as the dependent variable and the same clinical characteristics as independent variables. For patients with hematocrit values of > or =36%, mortality rates were not different, hospitalization rates were 16 to 22% lower, and expenditures were 8.3 to 8.5% less, compared with patients with hematocrit values of 33 to <36%. These observations do not demonstrate causality. Additional long-term studies are needed to assess the risks of higher hematocrit values among all patients and patients with cardiovascular disease.