title: Abrupt Decline in Kidney Function Before Initiating Hemodialysis and All-Cause Mortality: The Chronic Renal Insufficiency Cohort (CRIC) Study.
abstract: It is not clear whether the pattern of kidney function decline in patients with chronic kidney disease (CKD) may relate to outcomes after reaching end-stage renal disease (ESRD). We hypothesize that an abrupt decline in kidney function prior to ESRD predicts early death after initiating maintenance hemodialysis therapy.
  
  
  
  Prospective cohort study.
  
  
  
  The Chronic Renal Insufficiency Cohort (CRIC) Study enrolled men and women with mild to moderate CKD. For this study, we studied 661 individuals who developed chronic kidney failure that required hemodialysis therapy initiation.
  
  
  
  The primary predictor was the presence of an abrupt decline in kidney function prior to ESRD. We incorporated annual estimated glomerular filtration rates (eGFRs) into a mixed-effects model to estimate patient-specific eGFRs at 3 months prior to initiation of hemodialysis therapy. Abrupt decline was defined as having an extrapolated eGFR≥30mL/min/1.73m(2) at that time point.
  
  
  
  All-cause mortality within 1 year after initiating hemodialysis therapy.
  
  
  
  Multivariable Cox proportional hazards.
  
  
  
  Among 661 patients with CKD initiating hemodialysis therapy, 56 (8.5%) had an abrupt predialysis decline in kidney function and 69 died within 1 year after initiating hemodialysis therapy. After adjustment for demographics, cardiovascular disease, diabetes, and cancer, abrupt decline in kidney function was associated with a 3-fold higher risk for death within the first year of ESRD (adjusted HR, 3.09; 95% CI, 1.65-5.76).
  
  
  
  Relatively small number of outcomes; infrequent (yearly) eGFR determinations; lack of more granular clinical data.
  
  
  
  Abrupt decline in kidney function prior to ESRD occurred in a significant minority of incident hemodialysis patients and predicted early death in ESRD.
authors.affiliation: University of California, San Francisco, San Francisco, CA. Electronic address: raymond.hsu@ucsf.edu.
authors.forename: Raymond K
authors.initials: RK
authors.lastname: Hsu
authors.affiliation: University of Pennsylvania, Philadelphia, PA.
authors.forename: Boyang
authors.initials: B
authors.lastname: Chai
authors.affiliation: University of Pennsylvania, Philadelphia, PA.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Roy
authors.affiliation: University of Pennsylvania, Philadelphia, PA.
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Anderson
authors.affiliation: University of Washington, Seattle, WA.
authors.forename: Nisha
authors.initials: N
authors.lastname: Bansal
authors.affiliation: University of Pennsylvania, Philadelphia, PA.
authors.forename: Harold I
authors.initials: HI
authors.lastname: Feldman
authors.affiliation: University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA; Stanford University, Stanford, CA.
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.affiliation: Tulane University, New Orleans, LA.
authors.forename: Jiang
authors.initials: J
authors.lastname: He
authors.affiliation: Case Western Reserve University, Cleveland, OH.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Horwitz
authors.affiliation: National Institutes of Health, Bethesda, MD.
authors.forename: John W
authors.initials: JW
authors.lastname: Kusek
authors.affiliation: University of Illinois, Chicago, IL.
authors.forename: James P
authors.initials: JP
authors.lastname: Lash
authors.affiliation: University of Michigan, Ann Arbor, MI.
authors.forename: Akinlolu
authors.initials: A
authors.lastname: Ojo
authors.affiliation: Wayne State University, Detroit, MI.
authors.forename: James H
authors.initials: JH
authors.lastname: Sondheimer
authors.affiliation: University of Pennsylvania, Philadelphia, PA.
authors.forename: Raymond R
authors.initials: RR
authors.lastname: Townsend
authors.affiliation: University of Maryland, Baltimore, MD.
authors.forename: Min
authors.initials: M
authors.lastname: Zhan
authors.affiliation: University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
authors.forename: Chi-Yuan
authors.initials: CY
authors.lastname: Hsu
mesh_terms: D002423:Cause of Death; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000503:physiopathology* / Q000628:therapy; D013997:Time Factors
keywords: Chronic Renal Insufficiency Cohort (CRIC); Kidney function; disease trajectory; eGFR decline; end-stage renal disease (ESRD); estimated glomerular filtration rate (eGFR); hemodialysis; mortality; renal replacement therapy (RRT) initiation; transition to ESRD
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