Inadequate predialysis care and mortality after initiation of renal replacement therapy  Rajni Singhal, Janet E. Hux, Shabbir M H Alibhai, Matthew J. Oliver  Kidney International  Volume 86, Issue 2, Pages 399-406 (August 2014) DOI: 10.1038/ki.2014.16 Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 1 Relationship between traditional and alternate measures of chronic kidney disease care. Many patients with ‘early’ care had low cumulative care and inconsistent critical period care. About 19.1% of patients had low cumulative care (≤5 visits) and 39.7% had inconsistent critical period care (seen in only 1 or 2 of the 6 months prior to start of renal replacement therapy). Overall, 15.0% of patients with early care had both low cumulative care and inconsistent critical period care. Likelihood of consistent critical period care relative to inconsistent care increased when patients had high cumulative care. Overall, only 38.3% of patients with early care had both high cumulative care and consistent critical period care. Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 2 Mortality by measures of chronic kidney disease care. Mortality at 1 year after start of renal replacement therapy was higher in patients with late care, lower cumulative care, and inconsistent critical period care. Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 3 Secondary outcomes by measures of chronic kidney disease (CKD) care. (a) Inpatient start of renal replacement therapy (RRT) by measures of CKD care. (b) Prior access creation by measures of CKD care. (a) Incidence of inpatient start was higher in patients with late care, lower cumulative care, and inconsistent critical period care. (b) Attempts at prior access creation were higher in patients with early care, higher cumulative care, and consistent critical period care. Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 4 Population selection process. The study population is intended to consist of adults with chronic kidney disease (CKD) who started renal replacement therapy (RRT) in Ontario between 1 July 1998 and 31 March 2008 with prior outpatient CKD care. The likelihood of acute kidney injury in the cohort was reduced by excluding individuals (1) with no CKD care, (2) who started on continuous RRT modalities, and (3) who recovered renal function. Individuals residing in long-term care facilities prior to start of RRT were also excluded. HD, hemodialysis; OHIP, Ontario Health Insurance Plan database; PD, peritoneal dialysis. Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 5 Study timelines. CKD, chronic kidney disease; RRT, renal replacement therapy. Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions

Figure 6 Measures used to capture chronic kidney disease (CKD) care. (1) A cutoff of 6 months was used to define late versus early start of care. (2) Cumulative care was defined as low (≤5), moderate (6–10), and high (>10) according to the sum of outpatient nephrology visits in the 36 months prior to start of RRT. (3) Consistent critical period care required individuals to be seen in 3 or more of the 6 months prior to start of renal replacement therapy (RRT; critical period). In the example, the patient would be considered to have started CKD care early (first outpatient nephrology visit 20 months prior to start of RRT), have low cumulative care (five visits), and have inconsistent critical period care (visits in only 2 of the 6 months prior to start of RRT). Kidney International 2014 86, 399-406DOI: (10.1038/ki.2014.16) Copyright © 2014 International Society of Nephrology Terms and Conditions