Early nephrology care associated with lower mortality and incidence of end stage renal disease

Earlier care from a nephrologist reduces the chance of kidney patients developing end-stage renal disease and lowers their risk of death during the first year of dialysis, according to a study by the University of Michigan Kidney Epidemiology & Cost Center.

The study will be presented today at the American Society of Nephrology's 43rd Annual Meeting and Scientific Exposition.

Although confirmatory studies are needed, increasing the number of patients who receive nephrologist treatment for advanced chronic kidney disease could have a substantial impact on the increasing number of patients with kidney failure and improve outcomes among those with ESRD, says lead author Elizabeth Hedgeman, M.P.H., a research analyst at the U-M kidney epidemiology center.

National ESRD rates have risen steadily over the past two decades, and recent data suggest that 25 to 30 million Americans may have CKD—some of whom will eventually develop kidney failure and require dialysis or a transplant to live.

Hedgeman and colleagues analyzed Medicare data on more than 260,000 patients who started treatment for ESRD from 2005 to 2007. Just under one-fourth of patients were treated by a nephrologist for at least twelve months before their kidney disease progressed to ESRD, as recommended by the U.S. Department of Health and Human Service's Healthy People guidelines.

"We already know that nephrology care improves patient preparedness for ESRD onset, and is associated with lower first-year mortality in those who already have ESRD," says Hedgeman.

"In our new study, we wanted to view the state of affairs for the nation as a whole. Patients who had been treated by a nephrologist for at least twelve months were in better health, more prepared for dialysis and better informed about their transplant options," she explains.

"In the first year after developing ESRD, the risk of death was about 40 percent lower for patients who had received the recommended nephrology care," says Hedgeman.

States varied widely in terms of the proportion of patients receiving recommended nephrology care.

"On a national level, states with larger percentages of patients receiving twelve or more months of nephrology care had correspondingly decreased rates of ESRD incidence and first-year mortality after ESRD onset," says Hedgeman.

"Six months of care was better than no care, and twelve months of care was still better than six months," according to Hedgeman. "There was no indication that that the benefits of nephrologist involvement waned."

The new study provides "tantalizing" evidence that seeing a specialist earlier in the course of chronic kidney disease could have a significant impact on patients' health—not only improving outcomes for patients with ESRD, but also reducing the number of patients who progress to ESRD in the first place.

"Patients who know they have chronic kidney disease should insist on seeing a nephrologist early on before kidney function dwindles to the point that nothing can be done to reduce complications," says study co-author Rajiv Saran, M.B.B.S, M.D., MRCP, MS, associate professor of internal medicine at the U-M and associate director of the U-M Kidney Epidemiology and Cost Center.

"Nephrologists can systematically focus on the complications of kidney disease more so than a primary care doctor would have time for. It's a partnership between primary care and nephrology care that's critical for improving the outcomes of our patients," he says.

Because of its observational nature, the study does not prove that longer duration of nephrology care leads to better patient outcomes, nor does it link duration of nephrology care to the level of kidney function at the time of referral to the nephrologist.

"Our snapshot of referral practices within the United States is incomplete without this information," says Hedgeman.

SOURCE University of Michigan Kidney Epidemiology & Cost Center