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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 4  |  Page : 743-750
A comparative study to evaluate factors that influence survival in multidisciplinary predialysis educated patients and “Crashlanders”

1 Institute of Health Sciences, Universiti Brunei Darussalam, Bandar Seri Begawan, Brunei Darussalam
2 Department of Nephrology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam
3 Department of Gastroenterology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam
4 Diaverum Prince Abdul Majeed Renal Center, Jeddah, Saudi Arabia
5 Institute of Health Sciences, Universiti Brunei Darussalam; Department of Nephrology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam

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Date of Web Publication21-Jul-2017


Integrated multidisciplinary predialysis education (MPE) is usually provided to support and prepare the pre-end-stage renal disease (ESRD) patients before the initiation of renal replacement therapy (RRT). However, the impact of MPE is not known in our population, which is comprised patients of Asian origins and recipients of a totally subsidized health-care system. This research compared the survival probability, sociodemographic, and clinical characteristics of MPE patients and non-MPE patients (or crashlanders). A retrospective cohort study was conducted to investigate ESRD patients who started RRT in Brunei Darussalam from January 2013 to December 2014. Data were extracted from the computerized clinical database and dialysis records. A total of 351 new cases of ESRD patients who started on hemodialysis during the study period were included in the study. The median age was 56.0 years, with a slight male preponderance (56.6%). The MPE group was significantly older (P = 0.001) and more likely to have a history of diabetes mellitus (P = 0.013), ischemic heart disease (P = 0.014), and hypertension (P = 0.016). Despite being older and having more comorbidities (P = 0.028), MPE patients have a better survival probability (P = 0.028) and a 34% decreased risk of dying. Of those who died, older age (P = 0.001), higher serum creatinine (P = 0.01), and lower hemoglobin level (P = 0.017) were significant prognostic indicators. MPE before the initiation of RRT contributed to greater survival probability in near ESRD patients. The survival benefits were evident despite the presence of inherent risks (older age and presence of comorbidities) in the MPE population in comparison with the non-MPE cohort.

How to cite this article:
Zukmin K, Ahmad I, Wynn AK, Lim YY, Naing L, Chong VH, Khalil MA, Tan J. A comparative study to evaluate factors that influence survival in multidisciplinary predialysis educated patients and “Crashlanders”. Saudi J Kidney Dis Transpl 2017;28:743-50

How to cite this URL:
Zukmin K, Ahmad I, Wynn AK, Lim YY, Naing L, Chong VH, Khalil MA, Tan J. A comparative study to evaluate factors that influence survival in multidisciplinary predialysis educated patients and “Crashlanders”. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2020 Aug 3];28:743-50. Available from: http://www.sjkdt.org/text.asp?2017/28/4/743/211343

   Introduction Top

According to Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation, stage 5 or end-stage renal disease (ESRD) can be deduced when the glomerular filtration rate (GFR) reduces to less than 15 mL/min/1.73 m2, and the initiation of renal replacement therapy (RRT) is required.[1] The incidence of ESRD is increasing world-wide.[2] In Brunei Darussalam, the incidence and prevalence of ESRD were 265 and 1250 per million populations, respectively, with >65 age group being the highest.[3] The annual death rate for the ESRD population was 11% with cardiovascular disease accounting for 43% of all deaths.[4]

Preparation for RRT from multidisciplinary predialysis education (MPE) is usually recommended in patients with chronic kidney disease (CKD) stage 4 with estimated GFR of <30 mL/min/1.73 m2.[1] An integrated care provided by a multidisciplinary team of professionals is needed to decrease the pathophysiological process of the disease and to provide supportive and palliative care as to increase disease control and quality of life of dialysis patients.[5] These preparations will usually include early referrals to vascular surgeons for fistula formation, comprehensive counseling by dieticians, and psychosocial evaluations by social workers. In addition, pre-ESRD care includes the early detection and prevention of CKD progression, prevention of uremic complication, and attenuation of comorbid conditions.[6] However, many CKD patients do not have the benefits of MPE, either through lack of awareness, undiagnosed kidney disease, or deliberate preference. For the purpose of this study, they are considered as the non-MPE patients or “crashlanders.”

The objectives of the study were to compare the survival probability, sociodemographic, and clinical characteristics of MPE and non-MPE/crashlander patients during the study period. We hypothesized that there was a better survival probability among MPE group than non-MPE group.

   Methods Top

A retrospective cohort study was conducted to investigate all ESRD patients who started their first hemodialysis (HD) from January 2013 to December 2014.

The source population was all the new ESRD cases from Raja Isteri Pengiran Anak Saleha Hospital and all dialysis centers in Brunei Darussalam during the study period. All new ESRD cases were included in the study without sampling. Patients who had RRT for acute kidney injuries or acute on CKD and under the age of 18 were not included in the study.

Data were extracted from the computerized clinical registry and patients’ dialysis records. The data extracted included the sociodemographic information (age, sex, and race), clinical information (first date of dialysis, renal function at the time of initiation of dialysis treatment, cause of ESRD, comorbidities such as diabetes mellitus, ischemic heart disease, and hypertension), survival status, predialysis clinic referral, choice of RRT, and types of vascular access (for HD patients).

A structured data collection form was designed and pretested to check for suitability and validity of the data collection form.

The data were entered and processed using Statistical Package for the Social Sciences (SPSS) version 21.0 for Windows (SPSS Inc., Chicago, IL, USA). Patients’ estimated GFR was determined using a simplified modification of diet in renal disease equation. Descriptive statistics were used to describe categorical variable using frequency and percentage while mean with standard deviation and median with interquartile range (IQR) were used to describe numerical variable. Independent t-test was used to compare the means of two groups. On the other hand, Chi-square test and Fisher’s exact test were used to check for the association between two categorical variables for comparisons of proportions of two or more groups. Furthermore, Kaplan–Meier analysis was used to analyze the patient survival and Cox proportional hazards method was used to estimate hazard ratios and 95% confidence interval to identify the potential prognostic factors for survival probability. For all hypothesis tests, two-sided test and P <0.050 were considered statistically significant.

   Results Top

There were a total of 351 new cases of ESRD patients who started on HD in all dialysis centers in Brunei Darussalam through January 2013 to December 2014. The study population has a median (IQR) age of 56.0 (18.0) years. There were slightly more males than females, 198 (56.6%) and 152 (43.4%), respectively. Malays and non-Malays accounted for 86.6% and 13.4% of the study population, and diabetes mellitus was the cause for ESRD in 63% of cases. The renal functions of the kidney at the start of HD were as follow: mean serum creatinine 1020.0 (573.00) μmol/L, median estimated GFR 4.0 (3.00) mL/min/ 1.73 m2, mean serum urea 37.0 (15.00) mmol/L, and mean hemoglobin 9.0 (3.00) g/dL, respectively. The vascular access used at the start of HD was venous catheters 317 (92.7%) and arteriovenous fistula 25 (7.3.9%). One hundred and nineteen patients (34.6%) were deceased at the end of the study period. Details are summarized in [Table 1] and [Table 2].
Table 1: Comparison of sociodemographic and clinical characteristics (categorical variables) between multidisciplinary predialysis educated and non-multidisciplinary predialysis educated patients.

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Table 2: Comparison of sociodemographic and clinical characteristics (numerical variables) between multidisciplinary predialysis educated and non-multidisciplinary predialysis educated patients.

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The MPE groups were more likely to be older (P = 0.001), diabetics (P =0.013), and hypertensive (P = 0.016), have ischemic heart disease (P = 0.014), and to be using arteriovenous fistula (P <0.001).There was no significant association between the renal function (serum creatinine, serum urea, and hemoglobin) between the two groups. Details are presented in [Table 1] and [Table 2].

The 1-year survival rate was higher in the MPE group as compared to non-MPE (79.8% versus 66.2%). There was no significant difference after two years (57.7% and 60.1%) [Table 3]. MPE patients have 34% less risk of dying in comparison to non-MPE patients, and this was shown to be statistically significant (P = 0.028).
Table 3: Survival rates in multidisciplinary predialysis educated and non-multidisciplinary predialysis educated patients.

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Older age (P = 0.001), high serum creatinine level (P <0.001), lower estimated GFR (P <0.001), and lower hemoglobin level (P = 0.017) were associated with the reduction in the survival probability. [Table 4] shows the prognostics factors for survival probability. As shown in [Figure 1], the survival was higher in MPE group as in comparison to non-MPE group (Cox-Mantel log-rank test, χ2 = 4.89, df = 1, P = 0.027).
Table 4: Prognostics factors for survival probability.

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Figure 1: Survival curve of multidisciplinary predialysis educated patients and nonmultidisciplinary predialysis educated patients.

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   Discussion Top

In this retrospective study, we have demonstrated that the 1-year survival rate was higher in the MPE group than the non-MPE group or “crashlanders”. The two groups of patients were not matched for age and comorbidities. MPE patients were more likely to be older and have diabetes, hypertension, and ischemic heart disease. Not withstanding these obvious disadvantages, our data have shown that they have a 34% reduction in risk of dying. We believe that this has accentuated and emphasized the importance of MPE in avoiding mortal complications in new ESRD patients because it implied that MPE patients have derived direct benefits from counseling, early preparatory, and preventative work. Both groups were not matched in their basic demographics due to the peculiar characteristics of the health-care system and patient population. The health-care system in Brunei is fully subsidized by the government. This means that all patients are entitled to free health care and have easy access to specialist clinics. Therefore, older and chronic disease patients are often captured and followed up by the system. Younger patients, on the other hand, are less likely to be aware of their medical conditions, often through ignorance or denials, and are also more likely to default treatment or to be noncompliant. Of particular relevance to our population, Tong et al reported that young patients with CKD have a tendency to dissociate themselves from the disease resulting in higher rates of nonadherence.[7] Different studies appear to have different patient demographics in their non-MPE cohort. Some studies have reported a greater frequency of patients with diabetes mellitus, ischemic heart disease, and congestive heart failure in patients who have unplanned start in dialysis.[8] Another study has shown that older patients were more likely to have acute start due to probable likelihood of intercurrent illness and comorbidities.[9] We believe that our study is unique in that it can provide direct evidence for the value of MPE toward survival, without being confounded by other mitigating factors such as age and comorbidities that were often found in other studies.

First-year death rate for MPE and non-MPE patients was 21.2% and 33.8%. The Brunei dialysis and transplant registry from the same population reported an annual death rate of between 11% and 15% for all dialysis patients,[3] which suggest the petering of death rates after the 1st-year. High 1st-year death rate is not unusual and has been attributed to a number of factors. Older age, catheter vascular usage, hypoalbuminemia, cancer, and congestive heart failure have been implicated.[3] Vitamin D deficiency,[10] late referrals,[11] mental health, and self-care knowledge[12] were less commonly reported causes. The US Renal Data System reported a 1st-year death of 24%, with a peak at month 3.[13] The United Kingdom reported similar high 1st-year mortality rates at 23.4%, increasing to 28.1% for patients over 65 years of age.[14] There was no significant difference between serum creatinine, urea, creatinine, and estimated GFR between MPE and non-MPE groups. However, more importantly, for patients who died, older age, high serum creatinine, lower estimated GFR, and serum hemoglobin were significant negative prognostic markers. This is not entirely surprising because the presence of these factors would have meant that the individuals were more physically and metabolically compromised and hence, more likely to suffer from complications.

MPE in our setting is provided by a multi-disciplinary team of professionals which includes nephrologists, nurse practitioners, dieticians, and medical social workers. Nurse practitioners comprise specific nurses that specialize in vascular access, HD and peritoneal dialysis, and transplantation. We occasionally involve geriatricians and palliative care team if patients have preemptively decided to not to undergo RRT. The clinic focuses on the strategies to maintain a target blood pressure of 130/80 mm Hg, improve patient compliance with hypertensive medications, tailor nutritional needs with a particular emphasis on low potassium, phosphate, and protein diet, and avoid the use of nephrotoxins and alternative remedies. Fast track vascular services for fistula formations and early commencement of RRT are also among the chief goals although patients tend to defer these until they become severely symptomatic. Cultural acceptance and religious counseling were also covered in this clinic to overcome social stigmatization and improve psychological acceptance. Many studies have demonstrated the benefits of MPE. MPE in predialysis period was independently associated with in-patient and total medical expenditures of the first six-month postdialysis owing.[15] MPE can also offer advantages in cardiovascular events and infections.[16] Furthermore, MPE can decrease the incidence of dialysis and reduce the mortality in late-stage CKD patients.[8],[17],[18] Late referrals to nephrologists have often been identified as a negative prognostic marker with an increase in mortality and morbidity.[9],[19]

We acknowledged that patients in this study started RRT at a late stage. Even MPE patients who were extensively counseled were reluctant to start RRT unless they start having uremic or fluid overload symptoms. However, the main advantage gained by MPE patients is that they were able to be regularly captured at fixed interval clinics by the nephrology team, and some emergency presentations may have been averted. Non-MPE patients usually present in a critical stage and often require intensive care admissions for hemodynamical and ventilatory support which could worsen their overall outcome. Interestingly, non-MPE patients do not have significantly higher creatinine level at the time of commencement of dialysis suggesting that they primarily suffered from symptoms of fluid overload and hyperkalemia. This is not entirely surprising as they will not have had the benefits of fluid restriction, dietary counseling, and diuretics therapy that MPE patients usually have. Even so, there is confusing evidence regarding the benefits of early dialysis start. A recent systemic review for KDOQI indicated that early dialysis start (at estimated creatinine clearance of 10–14 mL/min) did not reduce mortality compared to later initiation (creatinine clearance of 5–7 mL/min).[20] Based on these evidence, we feel that the optimal timing for dialysis start in our population should be symptom based rather than eGFR based. Through our experience with the local population, coercing patients to start dialysis before symptoms have arisen may alienate them from the team resulting in them defaulting clinics and seeking alternative treatments.

There are several limitations in this study. The duration and the consistency of the pre-dialysis care were not assessed to determine the degree of effectiveness correlating to how much care they received. A longer duration[21] and consistent nephrological care[22] before the initiation of dialysis have been associated with a better survival probability. We would also have liked to assess morbidity data such as length of hospital stay and infectious (access-related and endocarditis) and cardiovascular complications (myocardial infection and cerebrovascular accidents), but the retrospective nature of this study made it difficult to gather these information as medical case notes were not consistently available for reviews. We were not able to obtain or verify reliable renal history for some non-MPE patients who presented with ESRD resulting in us making clinical judgments on whether there had been existing renal impairment through data such as ultrasonography and medical history.

In conclusion, multidisciplinary predialysis care before the initiation of HD contributed to a greater survival probability in pre-ESRD patients. Age and presence of diabetes mellitus, hypertension, and ischemic heart disease were shown to be some of the factors which would incline patients toward receiving multidisciplinary predialysis care. While increasing age, serum creatinine and increasing estimated GFR were identified as factors associated with the reduction in survival probability. This study has allowed us to evaluate our practice and rectify some of the deficiencies that existed within our services. We have addressed pathways for primary care and other allied health specialties (especially, endocrinology and cardiology) to simplify and facilitate referrals. Additional attention is given to our outpatient system to ensure that existing patients remained in the loop and do not fall through the net. Health promotion exercises have also been ramped up to improve public knowledge about renal disease and the value of early screening for high-risk patients. We have also made conscious efforts to strengthen rapport and to destigmatize CKD to enhance adherence and compliance to treatment, particularly in the younger population. We hope to achieve better long-term survival outcomes through these endeavors.

Conflict of interest. None declared.

   References Top

National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39 2 Suppl 1:S1-266.  Back to cited text no. 1
Levin A. The advantage of a uniform terminology and staging system for chronic kidney disease (CKD). Nephrol Dial Transplant 2003; 18:1446-51.  Back to cited text no. 2
Tan J. End stage renal disease in Brunei Darussalam – Report from the first Brunei Dialysis Transplant Registry (BDTR). Ren Fail 2013;35:1101-4.  Back to cited text no. 3
Tan J. Renal replacement therapy in Brunei Darussalam: Comparing standards with international renal registries. Nephrology (Carlton) 2014;19:288-95.  Back to cited text no. 4
Sijpkens YW, Berkhout-Byrne NC, Rabelink TJ. Optimal predialysis care. NDT Plus 2008;1 Suppl 4:iv7-13.  Back to cited text no. 5
Obrador GT, Ruthazer R, Arora P, Kausz AT, Pereira BJ. Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol 1999;10:1793-800.  Back to cited text no. 6
Tong A, Gow K, Wong G, Henning P, Carroll R. Patient perspectives of a young adult renal clinic: A mixed-methods evaluation. Nephrology (Carlton) 2015;20:352-9.  Back to cited text no. 7
Brown PA, Akbari A, Molnar AO, et al. Factors associated with unplanned dialysis starts in patients followed by nephrologists: A retropective cohort study. PLoS One 2015;10: e0130080.  Back to cited text no. 8
Buck J, Baker R, Cannaby AM, Nicholson S, Peters J, Warwick G. Why do patients known to renal services still undergo urgent dialysis initiation? A cross-sectional survey. Nephrol Dial Transplant 2007;22:3240-5.  Back to cited text no. 9
Wolf M, Shah A, Gutierrez O, et al. Vitamin D levels and early mortality among incident hemodialysis patients. Kidney Int 2007;72: 1004-13.  Back to cited text no. 10
Kazmi WH, Obrador GT, Khan SS, Pereira BJ, Kausz AT. Late nephrology referral and mortality among patients with end-stage renal disease: A propensity score analysis. Nephrol Dial Transplant 2004;19:1808-14.  Back to cited text no. 11
Curtin RB, Sitter DC, Schatell D, Chewning BA. Self-management, knowledge, and functioning and well-being of patients on hemodialysis. Nephrol Nurs J 2004;31:378-86, 396.  Back to cited text no. 12
Wingard RL, Chan KE, Lazarus JM, Hakim RM. The “right” of passage: Surviving the first year of dialysis. Clin J Am Soc Nephrol 2009; 4 Suppl 1:S114-20.  Back to cited text no. 13
Cherukuri A, Bhandari S. Analysis of risk factors for mortality of incident patients commencing dialysis in East Yorkshire, UK. QJM 2010;103:41-8.  Back to cited text no. 14
Yu YJ, Wu IW, Huang CY, et al. Multi-disciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS One 2014;9:e112820.  Back to cited text no. 15
Cho EJ, Park HC, Yoon HB, et al. Effect of multidisciplinary pre-dialysis education in advanced chronic kidney disease: Propensity score matched cohort analysis. Nephrology (Carlton) 2012;17:472-9.  Back to cited text no. 16
Bradbury BD, Fissell RB, Albert JM, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2007;2:89-99.  Back to cited text no. 17
Wu IW, Wang SY, Hsu KH, et al. Multi-disciplinary predialysis education decreases the incidence of dialysis and reduces mortality – A controlled cohort study based on the NKF/ DOQI guidelines. Nephrol Dial Transplant 2009;24:3426-33.  Back to cited text no. 18
Roubicek C, Brunet P, Huiart L, et al. Timing of nephrology referral: Influence on mortality and morbidity. Am J Kidney Dis 2000;36:35-41.  Back to cited text no. 19
Slinin Y, Greer N, Ishani A, et al. Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: A systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis 2015;66:823-36.  Back to cited text no. 20
Jungers P, Massy ZA, Nguyen-Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 2001;16:2357-64.  Back to cited text no. 21
Khan SS, Xue JL, Kazmi WH, et al. Does predialysis nephrology care influence patient survival after initiation of dialysis? Kidney Int 2005;67:1038-46.  Back to cited text no. 22

Correspondence Address:
Jackson Tan
Institute of Health Sciences, Universiti Brunei Darussalam, Bandar Seri Begawan
Brunei Darussalam
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