Facility-level CKD-MBD composite score and risk of adverse clinical outcomes among patients on hemodialysis.
Patients receiving hemodialysis with values outside of target levels for parathyroid hormone (PTH: 150-600 pg/mL), calcium (Ca: 8.4-10.2 mg/dL), and phosphate (P: 3.5-5.5 mg/dL) are at elevated morbidity and mortality risk. We examined whether patients receiving care in dialysis facilities where greater proportions of patients have at least two values out of target have a higher risk of adverse clinical outcomes.



The study cohort consisted of 39,085 prevalent hemodialysis patients in 1298 DaVita dialysis facilities as of September 1, 2009, followed from January 1, 2010, until an outcome, a censoring event, or December 31, 2010. We determined the quintile of the distribution across facilities of the proportion of patients with at least two of three parameters out of, or above, target over a 4-month baseline period. The primary composite outcome was cardiovascular hospitalization or death. Secondary outcomes included death, cardiovascular hospitalization, and parathyroidectomy. Poisson regression models were used to estimate the association of facility quintile with outcomes.



Facility quintile was associated with a 7 % increased risk of cardiovascular hospitalization or death (quintile 5 versus 1, RR 1.07, 95 % CI 1.01-1.13) using the out-of-target measure of exposure and a 12 % increased risk (RR 1.12, 95 % CI 1.06-1.19) using the above-target measure. No association was seen for death using either measure. Patients in facility quintiles 3-5 (versus 1) were at increased parathyroidectomy risk (RR ranged from 2.05, 95 % CI 1.10-3.82, for quintile 3 to 2.73, 95 % CI 1.50-4.98, for quintile 5).



Facility level analysis of a large prevalent sample of US patients on hemodialysis demonstrates that patients in facilities with the least control of PTH, Ca, and P had the greatest risk of parathyroidectomy or the combination of cardiovascular hospitalization or death.
Denver Nephrology, Denver, CO, USA.
Geoffrey A
GA
Block
Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South Eighth St, Suite S4.210, Minneapolis, MN, 55404, USA.
Akeem A
AA
Yusuf
Outcomes Insights, Westlake Village, CA, USA.
Mark D
MD
Danese
Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA.
Heidi S
HS
Wirtz
Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South Eighth St, Suite S4.210, Minneapolis, MN, 55404, USA.
Yan
Y
Hu
Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA.
Thy P
TP
Do
Global Medical Organization, Amgen, Inc., Thousand Oaks, CA, USA.
Kerry
K
Cooper
Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South Eighth St, Suite S4.210, Minneapolis, MN, 55404, USA. dgilbertson@cdrg.org.
David T
DT
Gilbertson
Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA.
Brian D
BD
Bradbury
Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South Eighth St, Suite S4.210, Minneapolis, MN, 55404, USA.|Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
Allan J
AJ
Collins
D000293:Adolescent; D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D002118:Calcium / Q000097:blood; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000401:mortality*; D012080:Chronic Kidney Disease-Mineral and Bone Disorder / Q000097:blood* / Q000401:mortality* / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy / Q000706:statistics & numerical data; D010710:Phosphates / Q000097:blood; D006435:Renal Dialysis; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult
D010281:Parathyroid Hormone; D010710:Phosphates; D002118:Calcium
Chronic kidney disease-mineral bone disorder; End-stage renal disease; Hemodialysis