More intense predialysis nephrology care is associated with better outcomes among older adults starting dialysis, a new study suggests.

Nephrology care before Dialysis

In a retrospective study, patients who made more frequent visits to a nephrologist in the 12 months prior to dialysis had a lower risk of severe anemia and greater likelihood of having a permanent vascular access at dialysis initiation, data show.

Patients who made more frequent predialysis visits to a nephrologist had a lower risk of severe anemia at dialysis initiation.

The study, by Michael J. Fischer, MD, of the University of Illinois Medical Center in Chicago, and colleagues, included 58,014 patients aged 66 years or older (mean 75.7 years) who initiated chronic dialysis in 2000–2001. All were eligible for Veterans Affairs and/or Medicare-covered services.

Low, moderate and high intensity dialysis

The investigators grouped patients according to intensity of nephrology visits during the 12 months prior to dialysis initiation: low intensity (fewer than 3 visits), moderate intensity (3–6 visits), and high intensity (more than 6 visits).

During the 12 months prior to starting dialysis, 22%, 13%, and 19% of patients received low-, moderate-, and high-intensity predialysis nephrology care, respectively, and 46% received no predialysis nephrology care, and these patients served as a reference group, Dr. Fischer's team reported online in BMC Nephrology.

After adjustment for confounders, patients with high-intensity care had a 30% decreased risk of severe anemia, 34% decreased risk of having a very low estimated glomerular filtration rate (eGFR), and 3.6 times increased likelihood of having a permanent vascular access at dialysis initiation compared with the reference group.
The high-intensity group also had a 20% decreased mortality risk at 2 years following dialysis initiation.

Patients in the moderate-intensity and low-intensity groups had a 16% and 4% decreased risk of severe anemia, respectively, and a 33% and 28% decreased risk of having a very low eGFR. They were 2.61 times and 1.57 times more likely to start dialysis with a permanent vascular access, and they had a 13% and 6% decreased mortality risk at 2 years.


“These findings suggest that in older patients expected to initiate chronic dialysis, more frequent nephrology care beforehand may translate into more favorable outcomes at the time of and within two years following dialysis initiation,” the investigators concluded.

Dr. Fischer and his colleagues noted that they are not advocating broad nephrology referral for all older patients with severe chronic kidney disease.

“Decisions regarding implementing guideline recommendations and dialysis preparations for older patients are often particularly complex and challenging because of the burden of disability and functional compromise,” they stated.

In pointing out study limitations, the investigators noted that selection bias could impact their findings because predialysis nephrology care was not allocated randomly. “Patients with more rapid loss of kidney function might be both more ill and less likely to see a nephrologist.”

The researchers also noted that lead time bias could affect their findings “because patients with higher intensity nephrology care initiated dialysis at higher eGFR values, and may possibly have less severe disease.”