Nephrology consultation and kidney failure in people with stage 4 chronic kidney disease: a population-based cohort stud
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ORIGINAL ARTICLE
Nephrology consultation and kidney failure in people with stage 4 chronic kidney disease: a population‑based cohort study Ping Liu1 · Robert R. Quinn1 · Giuliana Cortese2 · Mohamed Mahsin1 · Matthew T. James1 · Paul E. Ronksley1 · Hude Quan1 · Braden Manns1 · Brenda R. Hemmelgarn1 · Marcello Tonelli1 · Pietro Ravani1 Received: 18 August 2020 / Accepted: 21 October 2020 © Italian Society of Nephrology 2020
Abstract Background Guidelines recommend referral for nephrology consultation for people with severe chronic kidney disease (CKD) to improve care and renal outcomes, yet the advocated benefits of nephrology referral on CKD progression in this patient population are unclear. Methods We linked laboratory and administrative data in Alberta, Canada to identify adults with stage 4 CKD between 2002 and 2014 (follow-up end on March 31, 2017). We studied the association between time-varying receipt of outpatient nephrology consultation and kidney failure (the earlier of renal replacement initiation or eGFR 28 Drugs dispensed ACEI or ARBs No Yes Data missing Statins No Yes Data missing NSAIDs No Yes Data missing
2404 (51.2) 4336 (92.4) 573 (12.2) 369 (7.9) 1100 (23.4) 2262 (23.4)
3684 (38.0) 8909 (92.0) 1278 (13.2) 694 (7.0) 2975 (30.7) 354 (7.5)
0.27 0.01 − 0.03 0.03 − 0.16 − 0.45
3120 (66.5) 598 (12.7) 353 (7.5) 295 (6.3) 329 (7)
5911 (61.0) 1186 (12.2) 728 (7.5) 720 (7.4) 1142 (11.8)
0.11 0.02 0.00 − 0.05 − 0.16
811 (17.3) 3622 (77.1) 262 (5.6)
2849 (29.4) 6696 (69.1) 142 (1.5)
− 0.29 0.18 0.23
2102 (44.8) 2294 (48.9) 299 (6.4)
6251 (64.5) 3274 (33.8) 162 (1.7)
− 0.41 0.31 0.24
3338 (71.1) 1000 (21.3) 357 (7.6)
7563 (78.1) 1940 (20.0) 184 (1.9)
− 0.16 0.03 0.27
Values are number (%), otherwise stated ACEI/ARBs angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, eGFR estimated glomerular filtration rate, IQR inter quartile range, NSAIDs nonsteroidal anti-inflammatory drugs, SD standard deviation, exposed nephrology consultation present, unexposed nephrology consultation absent
Over a median follow-up of 2.6 (IQR 1.2–4.6) years, 1277 (9%) patients progressed to kidney failure (963 treated with renal replacement), 7635 (53%) died without kidney failure, and 5470 (38%) were censored (1362 were event-free 1.5-year following the last eGFR measurement and 95 outmigrated from Alberta). The proportion of kidney failure with renal replacement was higher among those who saw a nephrologist (15.3%, 720/4695) than among those who did not (2.5%, 243/9687).
vs 0.57 (0.56–0.58). This pattern was consistent across all categories defined by baseline age and eGFR. However, with advancing age or higher eGFR, the risk of kidney failure became progressively smaller and the risk of death became progressively larger regardless of nephrology consultation. The probability of being event-free at 5 years was comparable between the exposure groups across all age and eGFR categories, except for those aged ≥ 85 years who had the lowest absolute risk of kidney failure but a higher
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