Characteristics of patients Without renal recovery

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Presentation transcript:

Characteristics of patients Without renal recovery Cessation of Renal Replacement Therapies with Improved Kidney Function in the ESRD Medicare Program The Fistula First Breakthrough Initiative Data Committee Background Results ESRD has meant “Loss of kidney function, with need for kidney replacement treatments”, however, as evidence will show, some patients may not actually be afflicted with ESRD in the first place, and may instead be individuals suffering from types of acute kidney injury. Characteristics of patients Without Renal Recovery With Renal Recovery p value No restart Restart N 181,037 (94.25%) 11,054 (5.75%) 0.010 11,053 (99.03%) 1916 (0.97%) Age (years) 63.9 ± 15.6 62.3 ± 15.6 <0.001 Male (%) 56.5 58.3 58.6 57.7 0.425 Access (%) AV Fistula (%) 14.79 1.86 7.41 AV graft (%) 3.39 0.89 1.25 Catheter (%) 80.92 96.41 90.08 Other (%) 0.90 0.84 Insurance coverage Employer (%) 93.2 6.8 Medicare Adv. (%) 94.5 5.5 0.168 Medicare (%) 94.6 5.4 48.11 55.17 Medicaid (%) 95.2 4.8 21.49 25.21 None (%) 93.9 6.1 0.087 8.21 5.17 Prior Nephrology care 56.91 24.19% 24.19 46.09 < 6months (%) 21.11 26.69 29.69 22.42 6 – 12 months (%) 36.37 40.65 38.05 > 12 months (%) 42.52 29.66 39.52 Primary diagnosis Diabetes (%) 42.94 21.38 41.54 Hypertension (%) 27.80 19.07 21.092 0.004 AIN (%) 0.17 2.02 0.26 ATN (%) 2.29 22.05 6.84 Other toxic agents (%) 0.39 1.51 0.63 0.002 Cholesterol emboli (%) 0.33 1.01 0.42 0.012 Multiple myeloma (%) 0.93 2.48 1.36 0.003 Unknown Etiology (%) 3.87 7.34 3.6 Comorbids 33.57 23.43 41.39 76.34 65.26 76.93 CHF (%) 29.78 22.08 36.95 CVA (%) 8.5 6.59 9.19 No Comorbids (%) 0.02 0.1 0.167 Multivariate model for persistent recovery of renal function Recovery Odds Ratio Std Error z P value 95% CI Age < 65 Reference Age > 65 0.870 0.023 -5.160 0.000 0.825 0.917 Male Female 0.977 0.021 -1.090 0.275 0.937 1.019 Access AV Fistula AV graft 1.847 0.232 4.890 1.444 2.361 Catheter 4.545 0.329 20.940 3.944 5.237 Other 3.535 0.473 9.430 2.719 4.596 Race White Black 0.530 0.015 -22.410 0.501 0.560 0.562 0.034 -9.520 0.499 0.633 ESRD Network ESRD Network 1 1.252 0.112 2.510 0.012 1.051 1.491 ESRD Network 2 1.151 0.091 1.770 0.076 0.985 1.345 ESRD Network 3 ESRD Network 4 1.653 0.130 6.400 1.417 1.929 ESRD Network 5 2.237 0.167 10.760 1.932 2.590 ESRD Network 6 2.298 11.460 1.993 2.649 ESRD Network 7 2.525 0.180 12.970 2.195 2.904 ESRD Network 8 0.190 12.310 2.179 2.926 ESRD Network 9 2.015 0.143 9.850 1.753 2.317 ESRD Network 10 1.673 0.138 6.250 1.424 1.965 ESRD Network 11 1.664 0.122 6.920 1.440 1.922 ESRD Network 12 2.211 0.173 10.150 1.897 2.578 ESRD Network 13 2.595 0.200 12.400 2.232 3.017 ESRD Network 14 1.502 0.111 5.510 1.300 1.737 ESRD Network 15 1.981 0.152 8.880 1.704 2.304 ESRD Network 16 1.610 5.350 1.353 1.917 ESRD Network 17 1.539 0.127 5.220 1.309 1.809 ESRD Network 18 2.037 0.146 9.940 2.344 Comorbid Hypertension 0.849 0.020 -6.890 0.811 0.890 Diabetes 0.927 0.025 -2.780 0.005 0.879 0.978 Cardiac Disease 0.812 0.019 -8.730 0.775 0.851 Insurance Medicare 0.916 0.024 -3.310 0.001 0.965 Medicaid 0.813 0.022 -7.780 0.772 0.856 No Medical coverage 0.705 0.029 -8.520 0.651 0.764 Diagnosis Unknown Etiology 1.462 0.064 8.610 1.341 1.594 Hypertensive Nephropathy 0.687 -11.730 0.645 0.732 Diabetic glomerulosclerosis 0.551 0.018 -18.700 0.517 0.586 Acute Injury 5.136 0.168 50.090 4.818 5.476 Other nephrotoxic agents 3.339 0.311 12.930 2.781 4.009 Multiple Myeloma 1.683 0.119 7.370 1.465 1.933 Methods A total of 205,399 incident ESRD hemodialysis patients from 2008 & 2009 were tracked over two years in the CMS SIMS registry. Start dates were initialized with incident dialysis. Recovery, if reported, was marked from dialysis facility updates transmitted through ESRD Networks and entered into the SIMs central repository on a daily basis. Patients who were restarted on dialysis during the period were excluded from our primary analysis. Diagnoses with highest rates of recovery of renal function   With renal recovery Without renal recovery Acute interstitial nephritis 42.7% (223) 57.8% (299) Tubular necrosis 37% (2,437) 63% (4,144) Nephropathy caused by other agents 19.1% (167) 80.9% (709) Cholesterol emboli, renal emboli 15.9% (112) 84.1% (594) Other renal disorders 15.5% (409) 84.5% (594) Multiple Myeloma 14% (274) 86% (1,688) Hepatorenal syndrome 12.8% (127) 87.2% (865) Etiology uncertain 10.4% (811) 89.6% (7,001) Overall 5.8% (11,032) 94.2% (180,887) Geographical Variation in rates of Renal Recovery Discussion Conclusions In the US ESRD program 6.6% of patients experienced renal recovery with a median time to recovery of 74 days. Approx 14.5% of patients subsequently were restarted on dialysis. Patients with persistent recovery of renal function, tended to be white, below 65 years of age, with temporary accesses (catheters or other) and the etiology of their kidney disease was acute injury (AIN, ATN, cholesterol emboli or hepatorenal syndrome) or exposure to a nephrotoxic agent.