1. Characteristics of patients Without renal recovery
Cessation of Renal Replacement Therapies with Improved Kidney Function in the ESRD Medicare Program The Fistula First Breakthrough Initiative Data Committee
Background
Results
ESRD has meant “Loss of kidney function, with need for kidney replacement treatments”, however, as evidence will show, some patients may not actually be afflicted with ESRD in the first place, and may instead be individuals suffering from types of acute kidney injury.
Characteristics of patients
Without Renal Recovery
With Renal Recovery
p value
No restart
Restart N
181,037 (94.25%)
11,054 (5.75%)
0.010
11,053 (99.03%)
1916 (0.97%)
Age (years)
63.9 ± 15.6
62.3 ± 15.6
<0.001
Male (%)
56.5
58.3
58.6
57.7
0.425
Access (%)
AV Fistula (%)
14.79
1.86
7.41
AV graft (%)
3.39
0.89
1.25
Catheter (%)
80.92
96.41
90.08
Other (%)
0.90
0.84
Insurance coverage
Employer (%)
93.2
6.8
Medicare Adv. (%)
94.5
5.5
0.168
Medicare (%)
94.6
5.4
48.11
55.17
Medicaid (%)
95.2
4.8
21.49
25.21
None (%)
93.9
6.1
0.087
8.21
5.17
Prior Nephrology care
56.91
24.19%
24.19
46.09
< 6months (%)
21.11
26.69
29.69
22.42
6 – 12 months (%)
36.37
40.65
38.05
> 12 months (%)
42.52
29.66
39.52
Primary diagnosis
Diabetes (%)
42.94
21.38
41.54
Hypertension (%)
27.80
19.07
21.092
0.004
AIN (%)
0.17
2.02
0.26
ATN (%)
2.29
22.05
6.84
Other toxic agents (%)
0.39
1.51
0.63
0.002
Cholesterol emboli (%)
0.33
1.01
0.42
0.012
Multiple myeloma (%)
0.93
2.48
1.36
0.003
Unknown Etiology (%)
3.87
7.34
3.6
Comorbids
33.57
23.43
41.39
76.34
65.26
76.93
CHF (%)
29.78
22.08
36.95
CVA (%)
8.5
6.59
9.19
No Comorbids (%)
0.02
0.1
0.167
Multivariate model for persistent recovery of renal function
Recovery
Odds Ratio
Std Error z
P value
95% CI
Age < 65
Reference
Age > 65
0.870
0.023
-5.160
0.000
0.825
0.917
Male
Female
0.977
0.021
-1.090
0.275
0.937
1.019
Access
AV Fistula
AV graft
1.847
0.232
4.890
1.444
2.361
Catheter
4.545
0.329
20.940
3.944
5.237
Other
3.535
0.473
9.430
2.719
4.596
Race
White
Black
0.530
0.015
0.501
0.560
0.562
0.034
-9.520
0.499
0.633
ESRD Network
ESRD Network 1
1.252
0.112
2.510
0.012
1.051
1.491
ESRD Network 2
1.151
0.091
1.770
0.076
0.985
1.345
ESRD Network 3
ESRD Network 4
1.653
0.130
6.400
1.417
1.929
ESRD Network 5
2.237
0.167
10.760
1.932
2.590
ESRD Network 6
2.298
11.460
1.993
2.649
ESRD Network 7
2.525
0.180
12.970
2.195
2.904
ESRD Network 8
0.190
12.310
2.179
2.926
ESRD Network 9
2.015
0.143
9.850
1.753
2.317
ESRD Network 10
1.673
0.138
6.250
1.424
1.965
ESRD Network 11
1.664
0.122
6.920
1.440
1.922
ESRD Network 12
2.211
0.173
10.150
1.897
2.578
ESRD Network 13
2.595
0.200
12.400
2.232
3.017
ESRD Network 14
1.502
0.111
5.510
1.300
1.737
ESRD Network 15
1.981
0.152
8.880
1.704
2.304
ESRD Network 16
1.610
5.350
1.353
1.917
ESRD Network 17
1.539
0.127
5.220
1.309
1.809
ESRD Network 18
2.037
0.146
9.940
2.344
Comorbid
Hypertension
0.849
0.020
-6.890
0.811
0.890
Diabetes
0.927
0.025
-2.780
0.005
0.879
0.978
Cardiac Disease
0.812
0.019
-8.730
0.775
0.851
Insurance
Medicare
0.916
0.024
-3.310
0.001
0.965
Medicaid
0.813
0.022
-7.780
0.772
0.856
No Medical coverage
0.705
0.029
-8.520
0.651
0.764
Diagnosis
Unknown Etiology
1.462
0.064
8.610
1.341
1.594
Hypertensive Nephropathy
0.687
0.645
0.732
Diabetic glomerulosclerosis
0.551
0.018
0.517
0.586
Acute Injury
5.136
0.168
50.090
4.818
5.476
Other nephrotoxic agents
3.339
0.311
12.930
2.781
4.009
Multiple Myeloma
1.683
0.119
7.370
1.465
1.933
Methods
A total of 205,399 incident ESRD hemodialysis patients from 2008 & 2009 were tracked over two years in the CMS SIMS registry. Start dates were initialized with incident dialysis. Recovery, if reported, was marked from dialysis facility updates transmitted through ESRD Networks and entered into the SIMs central repository on a daily basis. Patients who were restarted on dialysis during the period were excluded from our primary analysis.
Diagnoses with highest rates of recovery of renal function
With renal recovery
Without renal recovery
Acute interstitial nephritis
42.7% (223)
57.8% (299)
Tubular necrosis
37% (2,437)
63% (4,144)
Nephropathy caused by other agents
19.1% (167)
80.9% (709)
Cholesterol emboli, renal emboli
15.9% (112)
84.1% (594)
Other renal disorders
15.5% (409)
84.5% (594)
Multiple Myeloma
14% (274)
86% (1,688)
Hepatorenal syndrome
12.8% (127)
87.2% (865)
Etiology uncertain
10.4% (811)
89.6% (7,001)
Overall
5.8% (11,032)
94.2% (180,887)
Geographical Variation in rates of Renal Recovery
Discussion
Conclusions
In the US ESRD program 6.6% of patients experienced renal recovery with a median time to recovery of 74 days. Approx 14.5% of patients subsequently were restarted on dialysis. Patients with persistent recovery of renal function, tended to be white, below 65 years of age, with temporary accesses (catheters or other) and the etiology of their kidney disease was acute injury (AIN, ATN, cholesterol emboli or hepatorenal syndrome) or exposure to a nephrotoxic agent.