Among kidney disease patients, earlier care from a nephrologist is associated with a decreased likelihood of developing end-stage renal disease and a lower risk of death during the first year of dialysis, according to a study presented 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 (CKD) could have a substantial impact on the currently high U.S. ESRD rates as well as improve outcomes among those with ESRD, according to research by Elizabeth Hedgeman, MS, MPH (University of Michigan, Ann Arbor) and colleagues.
The researchers 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," says Hedgeman.
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. 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.
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."
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 ESRD. The new study provides "tantalizing" evidence that seeing a specialist earlier in the course of CKD 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. "It is imperative that we identify and implement measures to stop the development of CKD and its eventual progression to ESRD," says Hedgeman.
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," noted Hedgeman.
Study co-authors include Natalie Lueth, MPH, Tempie Shearon, MS, Brenda W. Gillespie, PhD, Rajiv Saran, MBBS, MD, MRCP, MS (Kidney Epidemiology and Cost Center, University of Michigan); Laura Plantinga, MS, Neil R. Powe, MD, MPH, MBA (San Francisco General Hospital and University of California San Francisco); and Nilka Rios Burrows, MPH, Desmond E. Williams, MD, PhD (US Centers for Disease Control and Prevention).
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