Inadequate predialysis care and mortality after initiation of renal replacement therapy.

Adequacy of chronic kidney disease (CKD) care is traditionally measured as early or late, but this does not reflect the effect of cumulative or consistent care. Here we relate alternate measures of CKD care to mortality and other outcomes in patients with end-stage renal disease (ESRD) who started renal replacement therapy (RRT) between 1998 and 2008. CKD care was defined traditionally as early or late, and alternatively as cumulative care (total visits) and consistency of care in the critical period immediately prior to start of RRT (consistent critical period care required visits in 3 or more of the 6 months prior to RRT start). The primary outcome was 1-year mortality, with secondary outcomes of inpatient start and access creation. Of 12,143 patients aged 18-97 years at the start of RRT, 75.9% had early CKD care. Only 38.3% of the early group had high cumulative (over 10 visits) and consistent critical period care. The 1-year mortality of 15.8% was more likely with late care, lower cumulative care, and inconsistent critical period care. Both cumulative care and consistent critical period care independently predicted mortality, as well as secondary outcomes. Alternate measures of CKD care are important predictors of outcomes in ESRD and should be considered when reporting adequacy of care. Thus, patients traditionally classified as receiving early CKD care often do not receive adequate care immediately prior to initiating RRT.

Thromboembolic complications in the nephrotic syndrome: pathophysiology and clinical management.

Patients with the nephrotic syndrome are at increased risk of developing venous and arterial thromboembolism, the most common of which is renal vein thrombosis. There are several unanswered or controversial issues relating to the nephrotic syndrome and thromboembolism, which include the mechanism of thromboembolism, and optimal diagnostic and anticoagulant management strategies. This review will discuss several of these issues: the epidemiology and clinical spectrum of thromboembolic disease occurring in patients with the nephrotic syndrome; the pathophysiology of the hypercoagulable state associated with the nephrotic syndrome; the diagnosis of renal vein thrombosis in the nephrotic syndrome; and the evidence for prophylactic and therapeutic anticoagulation strategies in such patients.