Impact of predialysis therapeutic practices on patient outcomes during the first year of dialysis: the Pharmacoepidemiologic AVENIR study.

ABSTRACT

BACKGROUND: Studies evaluating patient outcomes in dialysis as a function of quality of predialysis therapeutic care are lacking. OBJECTIVE: To evaluate the association of quality of predialysis therapeutic practices with survival and hospitalization during the first year of dialysis. RESEARCH DESIGN: The AVantagE de la Néphroprotection dans l'Insuffisance Rénale study was an observational cohort study. Cox models explored the association between quality of therapeutic practices and survival over the first year whereas logistic regression measured the association with total duration of hospitalization (0 to 6 d, ≥7 d) among surviving patients at 1 year. SUBJECTS: All adult patients with chronic kidney disease starting dialysis in Lorraine (France) between 2005 and 2006. MEASURES: The appropriateness of therapeutic practices was evaluated with reference to current guidelines covering 5 aspects of chronic kidney disease hypertension/proteinuria, anemia, bone disease, metabolic acidosis, and dyslipidemia. Each patient was then assigned a quality of therapeutic practices rating (high, moderate, or poor) depending on the number of aspects appropriately managed. RESULTS: Quality of predialysis therapeutic practices was high in 18.2% of the 566 included patients, moderate in 62.5%, and poor in 19.3%. In multivariate analysis, the higher the quality of practices, the better the survival rate during the first year of dialysis [High hazard ratio (HR) 1; moderate HR 1.56, P=0.09; poor HR 1.95, P=0.02]. Conversely, quality of therapeutic practices was not associated with duration of hospitalization among the 390 surviving patients at 1 year. CONCLUSION: This study suggests that quality of predialysis therapeutic practices is positively associated with survival during the first year of dialysis.