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What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

ABSTRACT: The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.

SUBMITTER: Moranne O

PROVIDER: S-EPMC10479600 | biostudies-literature | 2022

REPOSITORIES: biostudies-literature

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What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

Moranne Olivier O Hamroun Aghilès A Couchoud Cécile C

Frontiers in nephrology 20230117

The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialys ...[more]

PMID: 37675001

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Project description:Rationale & objectiveBlood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP.Study designProspective observational cohort study.Setting & populationIn total, 2,755 hypertensive patients with CKD stages 3-4, receiving care from a nephrologist, from the French CKD-Renal Epidemiology and Information Network (CKD-REIN cohort study).ExposurePatient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary care physician and specialist encounters.OutcomesChanges in antihypertensive drug-class prescription during follow-up: add-on or withdrawal.Analytical approachHierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level and linear mixed models to describe systolic BP trajectory.ResultsAt baseline, median age was 69 years, and mean estimated glomerular filtration rate was 33 mL/min/1.73 m². In total, 66% of patients were men, 81% had BP ≥ 130/80 mm Hg, and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons, and 25 per 100 for withdrawals. After adjusting for risk factors, systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on (1.35, 95% confidence interval [CI], 1.01-1.80), whereas a lower education level was associated with increased HR for withdrawal (1.23, 95% CI, 1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 vs none) were associated with higher HRs of add-on and withdrawal (1.52, 95% CI, 1.06-2.18; 1.57, 95% CI, 1.12-2.19, respectively), whereas associations with visit frequency to other physicians varied with their specialty. Mean systolic BP decreased by 4 mm Hg following drug add-on but tended to increase thereafter.LimitationsLack of information on prescriber and drug dosing.ConclusionsIn patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients' tolerability. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved.

Project description:Rationale & objectiveOlder patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non-dialysis-dependent population.Study designIn-person interviewer-administered surveys of patients 70 years and older with non-dialysis-dependent CKD stage 4 or 5 and their self-identified care partners.Setting & participants42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston.OutcomesCompletion of advance directives and self-reported perceptions, preferences, and experiences of ACP.Analytical approachDescriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses.ResultsMost patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians' judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team.LimitationsSingle metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size.ConclusionsPatients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.

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What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

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What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

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