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Original ArticlesMaintenance Dialysis
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Association between Duration of Predialysis Care and Mortality after Dialysis Start

Ping Liu, Robert R. Quinn, Matthew J. Oliver, Paul E. Ronksley, Brenda R. Hemmelgarn, Hude Quan, Swapnil Hiremath, Aminu K. Bello, Peter G. Blake, Amit X. Garg, John Johnson, Mauro Verrelli, James M. Zacharias, Samar Abd ElHafeez, Marcello Tonelli and Pietro Ravani
CJASN June 2018, 13 (6) 893-899; DOI: https://doi.org/10.2215/CJN.11951017
Ping Liu
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Robert R. Quinn
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Matthew J. Oliver
Department of Medicine, University of Toronto, Toronto, Ontario, Canada;
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Paul E. Ronksley
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Brenda R. Hemmelgarn
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Hude Quan
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Swapnil Hiremath
Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada;
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Aminu K. Bello
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada;
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Peter G. Blake
Division of Nephrology, Western University, London, Ontario, Canada;
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Amit X. Garg
Departments of Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada;
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John Johnson
London Health Sciences Centre, London, Ontario, Canada;
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Mauro Verrelli
Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada;
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James M. Zacharias
Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada;
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Samar Abd ElHafeez
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt
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Marcello Tonelli
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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Pietro Ravani
Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;
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    Figure 1.

    The course of disease may mediate (top diagram) or confound (bottom diagram) the association between duration of predialysis care and mortality after dialysis start. Causal diagrams representing two possible scenarios of the influence of the course of disease on the association between duration of predialysis care and mortality after dialysis start. (A) The course of disease is an effect mediator on the causal pathway between duration of predialysis care and mortality after dialysis start. Under this assumption, the total effect of duration of predialysis care is estimated ignoring the influence of markers of disease course. (B) The course of disease may be both a mediator and a confounder of the relationship of interest. Conditioning the analysis on markers of disease course (adjustment by regression or stratification) in these situations could introduce collider bias (course of disease is a collider on the causal path: duration of predialysis care → course of disease ← unknown factors → mortality after dialysis start). Marginal methods have been proposed to control for this form of confounding and minimize collider bias (21).

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    Figure 2.

    The association between duration of predialysis care and mortality after dialysis start differed by setting of dialysis start. Unadjusted mortality by duration of predialysis care and setting of dialysis start. The numbers of deaths for people with 0, 1–119, 120–364, and ≥365 days of predialysis care were 200, 76, 78, and 456, respectively. Error bars represent SEM.

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    Figure 3.

    The survival benefit associated with longer predialysis care was weaker and no longer significant after accounting for markers of disease course. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for mortality associated with duration of predialysis care. Models included all participants (A). Models included participants with predialysis care (B). (1) Standard Cox model adjusted for age at initiation of dialysis, sex, dialysis programs, the last available serum albumin before starting dialysis, and ten comorbidities (diabetes, congestive heart failure, cancer, other cardiac disease, cerebrovascular disease, coronary artery disease, peripheral vascular disease, chronic obstructive lung disease, polycystic kidney disease, and gastrointestinal bleeding). (2) Inverse probability of treatment weighted Cox model accounting for the same covariates as in the above Cox model and markers of disease course (inpatient or outpatient of dialysis start and the last available eGFR before starting dialysis). Analyses of inverse probabilities of treatment weighting are reported in Supplemental Figure 1 and Supplemental Tables 2 and 3.

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    Table 1.

    Participant characteristics by duration of predialysis care

    CharacteristicOverall, n=3152Predialysis CareAny Predialysis Care, d
    No, n=738Any, n=24141–119, n=264120–364, n=305≥365, n=1845
    Demographics
     Age, yr64±1563±1665±1563±1664±1665±15
     Age ≥65 yr1726 (55)377 (51)1349 (56)140 (53)153 (50)1056 (57)
     Men1928 (61)472 (64)1456 (60)152 (58)195 (64)1109 (60)
    BMI, kg/m228.4±7.228.3±7.728.4±7.027.7±7.427.5±6.428.6±7.1
    Presence of comorbidities
     Diabetes1656 (53)292 (40)1364 (57)135 (51)174 (57)1055 (57)
     Coronary artery disease1067 (34)251 (34)816 (34)77 (29)95 (31)644 (35)
     Congestive heart failure937 (30)248 (34)689 (29)72 (27)87 (29)530 (29)
     Other cardiac disease907 (29)273 (37)634 (26)58 (22)85 (28)491 (27)
     Cerebrovascular disease490 (16)100 (14)390 (16)32 (12)45 (15)313 (17)
     Peripheral vascular disease532 (17)121 (16)411 (17)42 (16)49 (16)320 (17)
     Cancer633 (20)173 (23)460 (19)74 (28)63 (21)323 (18)
     Chronic obstructive lung disease215 (7)60 (8)155 (6)15 (6)14 (5)126 (7)
     Polycystic kidney disease111 (4)3 (0.4)108 (4)4 (2)5 (2)99 (5)
     Gastrointestinal bleeding299 (9)91 (12)208 (9)20 (8)20 (7)168 (9)
    Setting of dialysis starts
     Outpatient1400 (44)15 (2)a1385 (57)111 (42)169 (55)1105 (60)
     Inpatient1752 (56)723 (98)1029 (43)153 (58)136 (45)740 (40)
    Modality of dialysis initiation
     CRRT228 (7)182 (25)46 (2)5 (2)5 (2)36 (2)
     HD2302 (73)543(74)1759 (73)234 (89)237 (78)1288 (70)
     PD622 (20)13 (2)609 (25)25 (9)63 (21)521 (28)
    Laboratory measurements
     eGFR, ml/min per 1.73 m27.5 [5.6–10.2]8.2 [5.2–14.7]7.3 [5.7–9.6]7.2 [5.5–9.7]7.3 [5.6–9.6]7.4 [5.7–9.6]
     eGFR, ml/min per 1.73 m2, categoryb
      <102310 (74)430 (59)1880 (78)201 (76)237 (78)1442 (78)
      10–15532 (17)121 (17)411 (17)41 (16)47 (15)323 (18)
      >15296 (9)178 (24)118 (5)21 (8)20 (7)77 (4)
      Missing1495113
     Serum albumin, g/dl3.2±0.72.7±0.73.3±0.73.1±0.73.2±0.73.3±0.7
     Serum albuminb
      <3.6 g/dl2070 (67)613 (88)1457 (61)181 (71)197 (65)1079 (59)
      Missing7842368424
     Hemoglobin, g/dl9.7±1.69.3±1.79.8±1.69.3±1.79.7±1.69.9±1.5
    • Values for categorical variables are given as count (percentage); values for continuous variables are given as mean±SD or median [interquartile range]. BMI, body mass index; CRRT, continuous RRT; HD, hemodialysis; PD, peritoneal dialysis.

    • ↵a These 15 patients had no outpatient nephrology care before starting dialysis, but they were seen by a nephrologist in an emergency department and stable enough to start dialysis in an outpatient setting without being admitted to hospital.

    • ↵b Values do not sum up to subtotal due to missing data.

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Clinical Journal of the American Society of Nephrology: 13 (6)
Clinical Journal of the American Society of Nephrology
Vol. 13, Issue 6
June 07, 2018
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Association between Duration of Predialysis Care and Mortality after Dialysis Start
Ping Liu, Robert R. Quinn, Matthew J. Oliver, Paul E. Ronksley, Brenda R. Hemmelgarn, Hude Quan, Swapnil Hiremath, Aminu K. Bello, Peter G. Blake, Amit X. Garg, John Johnson, Mauro Verrelli, James M. Zacharias, Samar Abd ElHafeez, Marcello Tonelli, Pietro Ravani
CJASN Jun 2018, 13 (6) 893-899; DOI: 10.2215/CJN.11951017

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Association between Duration of Predialysis Care and Mortality after Dialysis Start
Ping Liu, Robert R. Quinn, Matthew J. Oliver, Paul E. Ronksley, Brenda R. Hemmelgarn, Hude Quan, Swapnil Hiremath, Aminu K. Bello, Peter G. Blake, Amit X. Garg, John Johnson, Mauro Verrelli, James M. Zacharias, Samar Abd ElHafeez, Marcello Tonelli, Pietro Ravani
CJASN Jun 2018, 13 (6) 893-899; DOI: 10.2215/CJN.11951017
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Keywords

  • kidney failure
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  • mortality risk
  • nephrology
  • Inpatients
  • proportional hazards models
  • retrospective studies
  • Outpatients
  • Canada
  • Renal Insufficiency, Chronic
  • peritoneal dialysis
  • disease progression
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