Decisions about Renal Replacement Therapy in Patients with Advanced Kidney Disease in the US Department of Veterans Affairs, 2000-2011

Abstract

Background and objectives: It is not known what proportion of United States patients with advanced CKD go on to receive RRT. In other developed countries, receipt of RRT is highly age dependent and the exception rather than the rule at older ages.

Design, setting, participants, & measurements: We conducted a retrospective study of a national cohort of 28,568 adults who were receiving care within the US Department of Veteran Affairs and had a sustained eGFR <15 ml/min per 1.73 m2 between January 1, 2000 to December 31, 2009. We used linked administrative data from the US Renal Data System, US Department of Veteran Affairs, and Medicare to identify cohort members who received RRT during follow-up through October 1, 2011 (n=19,165). For a random 25% sample of the remaining 9403 patients, we performed an in-depth review of their VA-wide electronic medical records to determine the treatment status of their CKD.

Results: Two thirds (67.1%) of cohort members received RRT on the basis of administrative data. On the basis of the results of chart review, we estimate that an additional 7.5% (95% confidence interval, 7.2% to 7.8%) of cohort members had, in fact, received dialysis, that 10.9% (95% confidence interval, 10.6% to 11.3%) were preparing for and/or discussing dialysis but had not started dialysis at most recent follow-up, and that a decision had been made not to pursue dialysis in 14.5% (95% confidence interval, 14.1% to 14.9%). The percentage of cohort members who received or were preparing to receive RRT ranged from 96.2% (95% confidence interval, 94.4% to 97.4%) for those <45 years old to 53.3% (95% confidence interval, 50.7% to 55.9%) for those aged ≥85 years old. Results were similar after stratification by tertile of Gagne comorbidity score.

Conclusions: In this large United States cohort of patients with advanced CKD, the majority received or were preparing to receive RRT. This was true even among the oldest patients with the highest burden of comorbidity.

Keywords: Adult; Comorbidity; Developed Countries; Electronic Health Records; Follow-Up Studies; Humans; Medicare; Renal Insufficiency, Chronic; Renal Replacement Therapy; Retrospective Studies; United States; Veterans; clinical epidemiology; dialysis; end-stage renal disease; glomerular filtration rate; kidney; renal dialysis.

Copyright © 2016 by the American Society of Nephrology.

Figures

Figure 1.

Cohort derivation. USRDS, US Renal Data System; VA, Department of Veteran Affairs.

Figure 2.

Age differences in treatment decisions and practices for advanced kidney disease. *On the basis of chart review of a random sample of patients who were not enrolled in the US Renal Data System (USRDS) and did not have a dialysis procedure code in Medicare or Department of Veteran Affairs (VA) administrative files during follow-up.

Figure 3.

Age differences in treatment decisions and practices for advanced kidney disease stratified by comorbidity score. (A) Low comorbidity. (B) Moderate comorbidity. (C) High comorbidity. *On the basis of chart review of a random sample of patients who were not enrolled in the US Renal Data System (USRDS) and did not have a dialysis procedure code in Medicare or Department of Veteran Affairs (VA) administrative files during follow-up.

Figure 4.

International differences in use of RRT among patients with advanced CKD. Hemmelgarn et al. and Sparke et al. include the original data for Canada and Australia/New Zealand, respectively (7,8).