Early Predialysis Nephrology Care May Prevent CV Events

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Patients with early and frequent nephrology visits before dialysis initiation had about a 10% lower risk for major adverse cardiovascular events.
Patients with early and frequent nephrology visits before dialysis initiation had about a 10% lower risk for major adverse cardiovascular events.

Seeing a nephrologist early and often before starting dialysis may help kidney failure patients prevent a major cardiovascular (CV) event, according to a new study from Taiwan.

Ju-Yeh Yang, MD, MS, of Far Eastern Memorial Hospital in New Taipei City, Taiwan, and colleagues analyzed data from more than 60,000 dialysis patients from Taiwan's National Health Insurance Research database 1999-2010. All patients received pre-dialysis nephrology care, including 40.6% with early, frequent visits, 21.2% with early, infrequent visits, and 38.3% with late visits. In Taiwan, referrals are not required to see nephrologists.

Patients with early, frequent visits had an 11% lower risk for major CV events and a 9% lower risk for a first CV event in the year after dialysis initiation compared with those who received late care, according to results published online ahead of print in the American Journal of Kidney Diseases. Early, frequent care meant a patient visited a nephrologist every 3 months for 6 or more months before initiating hemodialysis or peritoneal dialysis. Care was considered late when the first nephrology visit, whether inpatient or outpatient, occurred within 6 months of starting dialysis therapy.

Patients in the early, infrequent care group saw a nephrologist more than 6 months before dialysis initiation, but the visits occurred less than every 3 months. This group fared no better than the late group for a first or recurrent CV event. 

Results proved similar by type of CV event -- heart failure, ischemic stroke, hemorrhagic stroke, and sudden cardiac death -- except for acute myocardial infarction (AMI). The investigators adjusted for visits to a cardiologist and other relevant factors. Patients with a low comorbidity burden appeared to benefit the most from nephrology care.

“These observations again indicate the beneficial role of nephrology care in managing nontraditional risk factors,” Dr Yang and colleagues wrote. Nephrology care may improve anemia and uremia. In a previous study published in JAMA Internal Medicine (2002;162:2002-2006) that examined predialysis nephrology care and mortality, Jerry Avorn, MD, and colleagues suggested nephrology care benefits such as erythropoietin treatment, preparation of the dialysis access, and prevention of emergent dialysis, they noted. 

“Improved control of anemia, fluid overload, and potassium homeostasis could decrease the risk for acute heart failure, stroke, and sudden death in a short time frame,” Dr Yang and the team stated. “However, the effect of nephrology care on AMI might take several years to become apparent.”

Although the investigators accounted for hypertension and diabetes, they were unable to fully adjust for lipid levels and other traditional cardiovascular risk factors, which is a limitation.

Reference

1. Yang JY, Huang JW, Chen L, et al. Frequency of Early Predialysis Nephrology Care and Postdialysis Cardiovascular Events. Am J Kidney Dis. 2017. doi: 10.1053/j.ajkd.2016.12.018 [Epub before print]

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