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Over the last 10-15 years, the incidence of treated end-stage renal disease (ESRD) among older adults has increased and dialysis is being initiated at progressively higher levels of estimated glomerular filtration rate (eGFR). Average life expectancy after dialysis initiation among older adults is quite limited, and many experience an escalation of care and loss of independence after starting dialysis. Available data suggest that treatment decisions about dialysis initiation in older adults in the United States are guided more by system- than by patient-level factors. Stronger efforts are thus needed to ensure that treatment decisions for older adults with advanced kidney disease are optimally aligned with their goals and preferences. There is growing interest in more conservative approaches to the management of advanced kidney disease in older patients who prefer not to initiate dialysis and those for whom the harms of dialysis are expected to outweigh the benefits. A number of small single center studies, mostly from the United Kingdom report similar survival among the subset of older adults with a high burden of comorbidity treated with dialysis vs. those managed conservatively. However, the incidence of treated ESRD in older US adults is several-fold higher than in the United Kingdom, despite a similar prevalence of chronic kidney disease, suggesting large differences in the social, cultural, and economic context in which dialysis treatment decisions unfold. Thus, efforts may be needed to adapt conservative care models developed outside the United States to optimally meet the needs of US patients. More flexible approaches toward dialysis prescription and better integration of treatment decisions about conservative care with those related to modality selection will likely be helpful in meeting the needs of individual patients. Regardless of the chosen treatment strategy, time can often be a critical ally in centering care on what matters most to the patient, and a flexible and iterative approach of re-evaluation and redirection may often be needed to ensure that treatment strategies are fully aligned with patient priorities.

Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or15 ml/min per 1.73 m(2) (versus10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.

The prevalence of chronic kidney disease (CKD), defined as kidney damage present for at least three months, is highest in older ages. The elderly population is the fastest growing segment of the population developing end-stage renal disease (ESRD). In the 75 years and older age group, the adjusted incidence rate and the adjusted prevalence rate of ESRD have grown by 12.2% and 44%, respectively, from 2000 to 2012. More older patients are starting dialysis, but we also know that elderly patients with advanced CKD and ESRD are more likely to have greater disability, morbidity, and worse survival compared with older patients with less advanced kidney disease. We discuss the decision to initiate renal replacement therapy (RRT) in frail elderly patients with advanced CKD and ESRD. We also highlight the importance of discussing prognosis, dialysis modalities and their alternatives, functional status, and symptoms in the unique context of each patient’s values, goals, and care preferences. Ideally, managing advanced CKD should be viewed more as an evolving conversation than a discrete decision about dialysis initiation.

The dynamics of health and health care provision in the United States vary substantially across regions, and there is substantial regional heterogeneity in population density, age distribution, disease prevalence, race and ethnicity, poverty and the ability to access care. Geocoding and geographic information systems (GIS) are important tools to link patient or population location to information regarding these characteristics. In this review, we provide an overview of basic GIS concepts and provide examples to illustrate how GIS techniques have been applied to the study of kidney disease, and in particular to understanding the interplay between race, poverty, rural residence and the planning of renal services for this population. The interplay of socioeconomic status and renal disease outcomes remains an important area for investigation and recent publications have explored this relationship utilizing GIS techniques to incorporate measures of socioeconomic status and racial composition of neighborhoods. In addition, there are many potential challenges in providing care to rural patients with chronic kidney disease including long travel times and sparse renal services such as transplant and dialysis centers. Geospatially fluent analytic approaches can also inform system level analyses of health care systems and these approaches can be applied to identify an optimal distribution of dialysis facilities. GIS analysis could help untangle the complex interplay between geography, socioeconomic status, and racial disparities in chronic kidney disease, and could inform policy decisions and resource allocation as the population ages and the prevalence of renal disease increases.

Objectives: To evaluate the association between dynamic measures of renal function ascertained over time and onset of dementia. Design: Prospective community cohort study. Setting: Group Health, Seattle, Washington. Participants: Two thousand nine hundred sixty-eight adults aged 65 and older followed for the development of dementia over a median of 6.0 years (interquartile range 3.1�10.1 years). Measurements: Time-varying measures of renal function were constructed based on 49,340 serum creatinine measurements and included average estimated glomerular filtration rate (eGFR), eGFR trajectory, and variability in eGFR around this trajectory over 5-year exposure windows. The association between these three eGFR exposure measures and risk of dementia was estimated using a Cox regression model adjusted for other participant characteristics. Time-varying measures of urine protein by dipstick were also adjusted for in sensitivity analyses. Results: Participants with a lower eGFR had a higher incidence of dementia, but this did not reach statistical significance in adjusted analyses (omnibus P = .14). There were trends toward a higher adjusted incidence of dementia in participants with positive eGFR trajectories (omnibus P = .07) and greater variability in eGFR (omnibus P = .04) over time. The results of sensitivity analyses, including those in which time-varying measures of proteinuria were included, were consistent with those of the primary analysis. Conclusion: In a community cohort of older adults followed for a median of 6 years, strong associations were not found between measures of kidney disease severity and progression and incident dementia.

Chronic kidney disease is common and associated with significant morbidity. Given the high risk of cardiovascular morbidity and mortality in patients with chronic kidney disease, it is important to identify and treat related risk factors. However, there is growing uncertainty about the benefits of some recommended treatment targets. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines recommend an A1C level of less than 7 percent in patients with diabetes mellitus, although there is no evidence that treatment to this goal reduces cardiovascular events or progression to end-stage renal disease. Optimal blood pressure goals are controversial, and further study is needed to determine these goals in relation to amount of proteinuria. Concurrent use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers leads to worsening kidney function and is not recommended. Lipid-lowering therapy has been shown to reduce the risk of cardiovascular events and mortality, but not progression of chronic kidney disease. The treatment of anemia in patients with chronic kidney disease, particularly the use of erythropoiesis-stimulating agents and optimal hemoglobin goals, is also controversial. Studies have shown increased morbidity and mortality with use of erythropoiesis-stimulating agents aimed at normalizing hemoglobin levels. Patients with chronic kidney disease are at high risk of morbidity and mortality from the use of intravenous contrast agents. Isotonic intravenous hydration with sodium bicarbonate or saline has been shown to prevent contrast-induced nephropathy. Gadolinium-based contrast agents should be avoided if the glomerular filtration rate is less than 30 mL per minute per 1.73 m2 because of the risk of nephrogenic systemic fibrosis.

Studies of kidney failure in older adults have focused on receipt of dialysis, which may underestimate the burden of disease if older people are less likely to receive treatment.To determine the extent to which age is associated with the likelihood of treatment of kidney failure.Community-based cohort study of 1,816,824 adults in Alberta, Canada, who had outpatient estimated glomerular filtration rate (eGFR) measured between May 1, 2002, and March 31, 2008, with a baseline eGFR of 15 mL/min/1.73 m2 or higher and who did not require renal replacement therapy at baseline. Age was categorized as 18 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 or more years and eGFR as 90 or higher, 60 to 89, 45 to 59, 30 to 44, and 15 to 29 mL/min/1.73 m2.Adjusted rates of treated kidney failure (receipt of dialysis or kidney transplantation), untreated kidney failure (progression to eGFR15 mL/min/1.73 m2 without renal replacement therapy), and death.During a median follow-up of 4.4 years, 97,451 (5.36%) died, 3295 (0.18%) developed kidney failure that was treated and 3116 (0.17%) developed kidney failure that went untreated. Within each eGFR stratum the rate of treated kidney failure was higher in younger compared with older people. For example, in the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of treated kidney failure were more than 10-fold higher among the youngest (18-44 years) compared with the oldest (≥85 years) groups (adjusted rate, 24.00 [95% CI, 14.78-38.97] vs 1.53 [95% CI, 0.59-3.99] per 1000 person-years, respectively; P.001). Rates of untreated kidney failure were consistently higher at older ages. In the eGFR stratum of 15 to 29 mL/min/1.73 m2, adjusted rates of untreated kidney failure were more than 5-fold higher among the oldest (≥85 years), compared with the youngest (18-44 years) groups (adjusted rate, 19.95 [95% CI, 15.79-25.19] vs 3.53 [95% CI, 1.56-8.01] per 1000 person-years, respectively; P.001). Rates of kidney failure overall (treated and untreated combined) demonstrated less variation across age groups; eg, the adjusted rate per 1000 person years for those with eGFR of 15-29 mL/min/1.73 m2 was 36.45 (95% CI, 24.46-54.32) among participants aged 18 to 44 years and 20.19 (95% CI, 15.27-26.69) among those aged 85 years or older (P = .01).In Alberta, Canada, rates of untreated kidney failure are significantly higher in older compared with younger individuals.

Background Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis. Study Design Retrospective cohort study. Setting & Participants 5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003. Predictor Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis. Outcomes & Measurements Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation. Results We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR 2 (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m 2 per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m 2 (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m 2 per year), 9.5% had accelerated loss of eGFR from levels >60 mL/min/1.73 m 2 (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m 2 per year), and 3.1% experienced catastrophic loss of eGFR from levels >60 mL/min/1.73 m 2 within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation. Conclusions There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.

The last decade has seen the evolution and ongoing refinement of a disease-oriented approach to chronic kidney disease (CKD). Disease-oriented models of care assume a direct causal association between observed signs and symptoms and underlying disease pathophysiologic processes. Treatment plans target underlying disease mechanisms with the goal of improving disease-related outcomes. Because average glomerular filtrate rates tend to decrease with age, CKD becomes increasingly prevalent with advancing age and those who meet criteria for CKD are disproportionately elderly. However, several features of geriatric populations may limit the utility of disease-oriented models of care. In older adults, complex comorbid conditions and geriatric syndromes are common; signs and symptoms often do not reflect a single underlying pathophysiologic process; there can be substantial heterogeneity in life expectancy, functional status, and health priorities; and information about the safety and efficacy of recommended interventions often is lacking. For all these reasons, geriatricians have tended to favor an individualized patient-centered model of care over more traditional disease-based approaches. An individualized approach prioritizes patient preferences and embraces the notion that observed signs and symptoms often do not reflect a single unifying disease process and instead reflect the complex interplay between many different factors. This approach emphasizes modifiable outcomes that matter to the patient. Prognostic information related to these and other outcomes generally is used to shape rather than dictate treatment decisions. We argue that an individualized patient-centered approach to care may have more to offer than a traditional disease-based approach to CKD in many older adults.

INTRODUCTION The incidence and prevalence of end-stage renal disease (ESRD) continue to increase substantially in the United States [1-2]. Prior analyses have found that veterans are at high risk for developing chronic kidney disease (CKD), the precursor to ESRD, and rates of morbidity and mortality are extremely high among veterans with kidney disease [3-5]. At onset of ESRD, the Centers for Medicare and Medicaid Services (CMS) require an ESRD Medical Evidence Report (Form 2728) be completed to certify the patient's need for renal replacement therapy and to signal eligibility for Medicare's ESRD entitlement program. Demographic, medical comorbidity, and laboratory data from Form 2728 have been used for both administrative and research purposes. The United States Renal Data System (USRDS), a comprehensive registry of all patients with ESRD in the United States, publishes annual reports describing the characteristics and clinical attributes of the population with ESRD based on information from Form 2728 [1-2]. CMS dialysis networks across the United States also use data from this source to assess quality of predialysis and dialysis care and to target quality improvement initiatives. Furthermore, researchers have used information from Form 2728 in a large number of clinical, epidemiological, and health services research studies [6-10]. However, we are aware of only one prior study that has attempted to validate any of the Form 2728 information. This study found significant underreporting of major comorbid health conditions compared with reporting of these conditions in patient medical records as a gold standard [11]. This finding raises doubts about the reporting and integrity of other data elements on Form 2728, including the use of erythropoiesis-stimulating agents (ESAs) in patients before attaining ESRD and starting renal replacement therapy (predialysis period). ESAs are recommended and used to correct severe anemia, which occurs frequently as a complication of severe CKD, and may ameliorate many of the negative sequelae of anemia, which include lower quality of life and increased hospitalization, cardiovascular complications, and mortality [12-20]. Recent USRDS reports and clinical studies have suggested that ESA underuse in patients with pre-ESRD may be contributing to the unacceptable severity of anemia in these patients at initiation of dialysis [1-2,6-10,15,19]. To better understand the quality of the data underpinning these observations, we investigated the accuracy and completeness of predialysis ESA use data on Form 2728 by comparing them with Department of Veterans Affairs (VA) pharmacy prescription records and Medicare claims records in a cohort of veterans reliant on VA and/or Medicare-covered services. We also examined whether demographic or clinical factors existed that are associated with the accuracy of the ESA use data. METHODS Study Design and Sample We conducted a retrospective analysis of receipt of ESAs among elderly veterans (aged >66 years) who initiated chronic dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. We chose this study population because we were able to confirm their receipt of predialysis ESA using prescription records and claims data, independent of information reported on Form 2728. To identify the study cohort, we used the crosswalk file made available to the VA Information Resource Center [21] from the USRDS, which identifies veterans eligible for VA-covered services who have been registered as patients with ESRD [22]. Veterans eligible for VA-covered services were defined as individuals who used VA healthcare services, were enrolled in the Veterans Health Administration, or received a pension or compensation from the VA. The initiation date of dialysis was identified with the USRDS Patients File [22]. We limited the cohort to veterans initiating chronic dialysis between January 1, 2000, and December 31, 2001, and defined the 12-month period preceding dialysis initiation as the predialysis period. …

Patients who initiate chronic dialysis with a functional arteriovenous (AV) fistula survive longer and experience fewer complications after initiation of dialysis than those who require a catheter. However, more than 80% of patients in this country begin chronic dialysis with a catheter rather than a fistula, either because they do not have a permanent access or their permanent access is not ready for use. Increasing rates of predialysis AV fistula placement is thus considered a priority area for predialysis care in this country. However, achievement of a functional AV fistula by the time of dialysis initiation is not always an easy proposition. We here outline the limitations of currently recommended approaches toward timing of AV fistula placement. We also highlight the potential complexity of patient and clinician decision making in this area. Particularly in the presence of advanced age and a high burden of comorbidity and disability, it is often uncertain whether patients will need, want, or benefit from chronic dialysis. Adding to this uncertainty, it is often not known whether, when, and after how many revisions an AV fistula will be sufficiently mature to support dialysis. We argue that it is important to acknowledge the complexity of medical decision making in this area and the limitations of currently available prognostic tools to guide such decision making. We conclude that initiation of dialysis with a catheter is appropriate for patients in whom the perceived harms of preemptive fistula placement outweigh the expected benefit.

Background Factors driving the trend of earlier dialysis initiation for persons with end-stage renal disease are unknown. We wanted to determine the association of the number and type of signs and symptoms with timing of initiation of dialysis in US nursing home residents. Study Design Observational study. Setting & Participants We used data from the US Renal Data System linked with the Minimum Data Set, a national registry of nursing home residents. The cohort consisted of 2,402 nursing home residents who initiated dialysis between 1998 and 2000 and had at least 2 recorded clinical assessments in the year before dialysis initiation. Predictors We evaluated 7 clinical signs and symptoms: dependence in activities of daily living, cognitive function, edema, dyspnea, nutritional problems, vomiting, and body size. Outcomes Earlier dialysis initiation was defined as estimated glomerular filtration rate ≥15 mL/min/1.73 m 2 at the start of dialysis. Results Median estimated glomerular filtration rate at the start of dialysis was 9.8 (25th-75th percentile, 7.4-13.4) mL/min/1.73 m 2 . After adjustment for age, sex, race, and comorbid conditions, each additional sign or symptom was associated with a higher odds for earlier dialysis initiation (OR, 1.16 per symptom; 95% CI, 1.06-1.28), as was each adversely changing sign or symptom (OR, 1.26 per symptom; 95% CI, 1.16-1.38). The population-attributable risk for earlier dialysis initiation associated with having one or more signs and symptoms of volume overload, cognitive decline, increasing activities of daily living dependence, and weight loss was 31%; volume overload had the largest aggregate population-attributable risk. Limitations We lacked information about metabolic indications for dialysis initiation. Conclusions Volume overload, cognitive decline, increasing activities of daily living dependence, and weight loss were associated with earlier dialysis initiation; however, these factors explained less than one-third of cases of earlier dialysis initiation in nursing home residents.

To examine the effect of exclusive and dual use of Department of Veterans Affairs (VA) and Medicare healthcare systems on outpatient predialysis nephrology care.Retrospective cohort study.Receipt, timeliness, and intensity of predialysis nephrology care were evaluated among 8033 veterans who initiated dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. Propensity scores were incorporated into analyses to minimize potential selection bias from nonrandom veteran allocation to healthcare systems.Among the cohort, 17.4% were users of VA services only (VA-only users), 38.5% were users of Medicare-covered services only (Medicare-only users), and 44.1% were users of both VA and Medicare-covered services (dual users). Sixty-six percent of VA-only and dual users and 58.1% of Medicare-only users received predialysis nephrology care. Compared with Medicare-only users, dual users were more likely (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.07-1.17) and VA-only users were as likely (RR, 0.98; 95% CI, 0.88-1.08) to have received predialysis nephrology care. Compared with Medicare-only use, VA-only use (RR, 0.63; 95% CI, 0.50-0.81) and dual use (RR, 0.78; 95% CI, 0.70-0.88) were associated with a lower likelihood of late nephrology care (3 months before dialysis initiation).More than one-third of older veterans initiating dialysis do not receive nephrology care beforehand. Dual use of VA and Medicare-covered services was associated with greater receipt and favorable timeliness of predialysis nephrology care, while use of only Medicare-covered services was associated with late predialysis nephrology care. Further studies to identify reasons for system-level variations in access to predialysis nephrology care may assist in identifying opportunities for improvement.

As the population of the United States ages, the prevalence of age-related chronic conditions such as hypertension and chronic kidney disease (CKD) will also increase. Available studies in nationally representative samples and select outpatient populations indicate that hypertension is very common in older adults with CKD, and despite the use of medication it is often poorly controlled. Generally, less than one-third of the elderly patients with CKD achieve a level of blood pressure control consistent with that of the current guideline recommendations. However, limited evidence is available from observational studies and clinical trials to inform management of hypertension in the elderly population with CKD. The available published data suggest that the relationship between clinical outcomes and the treatment of hypertension among older adults with CKD is complex and distinct from that of their younger counterparts. Larger and more robust analyses are needed for a better understanding of the association between hypertension, its treatment, and clinical events in elderly patients with CKD.

Our goals in this review are to describe what is known about the prevalence and clinical implications of non-dialysis-dependent chronic kidney disease in the elderly and to discuss some of the most common challenges to managing older patients with chronic kidney disease.

Background and objectives: Clinical outcomes after kidney transplant have improved considerably in the United States over the past several decades. However, the degree to which this has occurred uniformly across the country is unknown. Design, setting, participants, & measurements: Regional variations in graft failure after kidney transplant during three different time periods were examined. These time periods were chosen to coincide with major shifts in immunosuppressant usage: Era 1, cyclosporine usage, 1988 through 1989; Era 2, introduction of tacrolimus and mycophenolate mofetil, 1994 through 1995; and Era 3, widespread use of tacrolimus and mycophenolate mofetil, 1998 through 1999. Patient data were obtained from the United States Renal Data System database. For each period, regional differences in time from transplant to graft failure (organ removal, death, or return to dialysis) were examined. For each region, differences in graft failure over time were examined. Results: One-year graft survival rates ranged from 76% to 83% between regions in Era 1 (n = 13,669), from 84% to 89% in Era 2 (n = 17,456), and from 87.5% to 92% in Era 3 (n = 20,375). Three-year graft survival ranged from 65% to 75% between regions in Era 1, from 84% to 89% in Era 2, and from 77% to 86% in Era 3. Adjusted models for donor and recipient characteristics showed improvements in graft survival over time in all United Network for Organ Sharing regions with minimal variation across regions. Conclusions: Regional differences in graft survival after kidney transplant are minimal, particularly when compared with the dramatic improvements in graft survival that have occurred over time.

End-stage renal disease disproportionately affects black persons, but it is unknown when in the course of chronic kidney disease racial differences arise. Understanding the natural history of racial differences in kidney disease may help guide efforts to reduce disparities.We compared white/black differences in the risk of end-stage renal disease and death by level of estimated glomerular filtration rate (eGFR) at baseline in a national sample of 2,015,891 veterans between 2001 and 2005.Rates of end-stage renal disease among black patients exceeded those among white patients at all levels of baseline eGFR. The adjusted hazard ratios for end-stage renal disease associated with black versus white race for patients with an eGFRor = 90, 60-89, 45-59, 30-44, 15-29, and15 mL/min/1.73 m2, respectively, were 2.14 (95% confidence interval [CI], 1.72-2.65), 2.30 (95% CI, 2.02-2.61), 3.08 (95% CI, 2.74-3.46), 2.47 (95% CI, 2.26-2.70), 1.86 (95% CI, 1.75-1.98), and 1.23 (95% CI, 1.12-1.34). We observed a similar pattern for mortality, with equal or higher rates of death among black persons at all levels of eGFR. The highest risk of mortality associated with black race also was observed among those with an eGFR 45-59 mL/min/1.73 m2 (hazard ratio 1.32, 95% CI, 1.27-1.36).Racial differences in the risk of end-stage renal disease appear early in the course of kidney disease and are not explained by a survival advantage among blacks. Efforts to identify and slow progression of chronic kidney disease at earlier stages may be needed to reduce racial disparities.

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995-2003 within 1800 ZIP codes in California, Hawaii and the US-Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas withor =20% vs.5% residents living in poverty, 0.41 [0.32-0.53], p0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians-Pacific Islanders vs. whites, 0.64 [0.51-0.80], p0.001 for areas with5% and 0.30 [0.21-0.44], p0.001 for areas withor =20% residents living in poverty; race-poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource-poor neighborhoods.

Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the group's decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement.

Whether renal dysfunction is an important factor in postoperative risk assessment has been difficult to prove. In an attempt to provide more compelling evidence, we conducted a systematic review comparing the risk of death and cardiac events in patients with and without chronic kidney disease who underwent elective noncardiac surgery. From electronic databases, web search engines, and bibliographies, 31 cohort studies were selected, evaluating postoperative outcomes in patients with chronic kidney disease. These patients had higher risks of postoperative death and cardiovascular events compared to those with preserved renal function. The pooled incidence of postoperative death was significantly less in those with preserved renal function than in those patients with chronic kidney disease. Meta-regression showed a graded relationship between disease severity and postoperative death. In adjusted analysis, chronic kidney disease had a similar strength of association with postoperative death as diabetes, stroke, and coronary disease. Our review identifies chronic kidney disease as an independent risk factor for postoperative death and cardiovascular events after elective, noncardiac surgery.

Background. It is unknown whether chronic kidney disease (CKD) influences receipt of highly active antiretroviral therapy (HAART) among patients with the human immunodeficiency virus (HIV) and whether prescription practices contribute to excess mortality. Methods. We conducted a retrospective observational study involving HIV-infected patients with established indications for HAART and an outpatient serum creatinine level measured in the Veterans Affairs health care system. Patients were followed up for the outcomes of HAART exposure (percentage of follow-up time treated with HAART), inadequate dose adjustment of renally eliminated antiretroviral medications, and time to death. Results. A total of 1041 patients (8.5%) had CKD, defined as an estimated glomerular filtration rate (eGFR)

Importance There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision. Objective To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice. Design, Setting, and Participants A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014. Main Outcomes and Measures Central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records. Results Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0-6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73 m 2 . The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities. Conclusions and Relevance The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences.

Few studies have compared the incidence of end-stage renal disease (ESRD) among individuals with the human immunodeficiency virus (HIV) and diabetes. We followed a national sample of 2,015,891 US veterans over a median peroid of 3.7 years for progression to ESRD. The age- and sex-adjusted incidence of ESRD (per 1000 person-years) among HIV-infected black patients was nearly an order of magnitude higher than among HIV-positive white patients, almost twice that of diabetic whites, and similar to that among diabetic blacks. In multivariate Cox proportional hazards analysis, diabetes was associated with an increased risk of ESRD among white patients, but HIV was not. Among black individuals, however, both HIV and diabetes conferred a similar increase in the risk of ESRD (4- to 5-fold increase compared to white individuals without HIV or diabetes). HIV and diabetes carry a similar risk of ESRD among black patients, highlighting the importance of developing strategies to prevent and treat renal disease among HIV-infected black individuals.

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m(2) for 18 to 44 year old patients to 15 ml/min per 1.73 m(2) for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels45 ml/min per 1.73 m(2) at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of3 ml/min per 1.73 m(2). In conclusion, age is a major effect modifier among patients with an eGFR of60 ml/min per 1.73 m(2), challenging us to move beyond a uniform stage-based approach to managing CKD.

End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated.To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities.Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities.U.S. metropolitan ZIP codes with differing percentages of black residents.Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244).Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates).Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes withor =75% black residents vs.10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes withor =75% black residents vs.10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets.Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code.The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.

To determine whether age should inform our approach toward permanent vascular access placement in patients with chronic kidney disease, we conducted a retrospective cohort study among 11 290 non-dialysis patients with an estimated glomerular filtration rate (eGFR)

Previous research supports an association between hepatitis C virus (HCV) infection and glomerulonephritis. However, little is known about the association between HCV and chronic kidney disease. The cross-sectional association between prevalent hepatitis C seropositivity and albuminuria and estimated GFR (eGFR), respectively, was examined among 15,029 participants in the Third National Health and Nutrition Examination Survey (NHANES III). In the multivariate analysis, we noted an age-dependent association between HCV seropositivity and albuminuria (adjusted odds ratios and 95% confidence intervals 0.83, 0.39 to 1.75 for ages 20 to 39; 1.84, 1.00 to 3.37 for ages 40 to 59; 2.47, 1.27 to 4.80 for > or =60 yr of age). There was no significant association observed for hepatitis C seropositivity and low eGFR (

Current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria for chronic kidney disease (CKD) are intended to apply to all age groups. However, it is unclear whether different levels of estimated GFR (eGFR) have the same prognostic significance in older and younger patients. The study cohort was composed of Department of Veterans Affairs (VA) patients who were aged 18 to 100 yr and had at least one outpatient serum creatinine measurement between October 1, 2001, and September 30, 2002 (n=2583,911). Patients with ESRD were excluded. GFR was estimated using the Modification of Diet in Renal Disease equation using each patient's first outpatient creatinine measurement during the study period. The association of eGFR with survival was measured by age group. Twenty percent of cohort patients had an eGFR

PAD has been overlooked in many epidemiologic studies evaluating cardiovascular risk associated with renal disease. Conversely, CKD has not been evaluated as a potential risk factor in epidemiologic studies of PAD. PAD, however,seems to be more prevalent among patients with even moderate CKD than in the general population and is most common among chronic dialysis patients, one third or more of whom have a low ABI. Patients with CKD also seem to be at increased risk for developing claudication and for requiring surgical intervention for lower extremity PAD. Furthermore, even moderate CKD seems to be a risk factor for postoperative death and complications after both lower extremity amputation and revascularization procedures. Conversely, even asymptomatic PAD seems to be a risk factor for death among dialysis patients. In the general population, statins, antiplatelet agents (particularly clopidogrel), antihypertensive agents, and ACE inhibitors all have a proven benefit in reducing cardiovascular events in patients with PAD and in some instances may also reduce PAD events. Available evidence suggests that patients with CKD also experience cardio-vascular risk reduction with statin and ACE-inhibitor therapy, but these therapies have not been shown to reduce PAD events specifically in patients with CKD. Further studies are needed to identify interventions that can specifically reduce the incidence of PAD complications in patientswith CKD. Although it is clear that mortality and complication rates after both lower extremity amputation and revascularization are increased in patients with even moderate CKD, currently available observational studies do not provide clear guidance for surgical decision making in CKD patients with limb-threatening ischemia. Further studies are needed to evaluate the risksand benefits of amputation over revascularizationamong patients with CKD and to investigatereasons for the high mortality associated with these procedures in this patient group. Further studies are also needed to measure the impact of CKD on care processes for PAD with the goal of identifying target areas for improvement.

Background— Although renal insufficiency is a recognized risk factor for coronary artery disease, little is known about the epidemiology of lower-extremity peripheral arterial disease (PAD) in persons with renal insufficiency. Methods and Results— We examined the cross-sectional association of PAD, defined as an ankle-brachial index (ABI) −1 · 1.73 m −2 , among 2229 eligible participants in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000. An estimated 1.2±0.3 million persons ≥40 years old with CRCL −1 · 1.73 m −2 (24%) have PAD defined as an ABI −1 · 1.73 m −2 ). The association of ABI P =0.011, referent category ABI 1.0 to 1.3). Conclusions— Clinicians should be aware of the remarkably high prevalence of PAD among patients with renal insufficiency. In the clinical setting, accurate identification of patients with renal insufficiency combined with routine ABI measurement in this group would greatly enhance efforts to detect subclinical PAD.

Few data are available on the impact of renal insuf- ficiency on short-term operative outcomes after lower extrem- ity surgical revascularization. We used prospectively collected data from the Department of Veterans Affairs' National Sur- gical Quality Improvement Program (NSQIP) to explore the association with renal dysfunction of adverse outcomes occur- ring within 30 d of lower extremity surgical revascularization in a cohort of all patients undergoing at least one lower extremity surgical revascularization from 1/1/94 to 9/30/01 ( n 18,217). Even moderate renal insufficiency (estimated GFR 30-59cc/min/1.73m 2 ) was associated with an increased inci- dence of postoperative death (adjusted odds ratio (OR) 1.44, 95% confidence interval (CI), 1.17 to 1.77, P 0.001), cardiac arrest (OR 1.43, CI 1.09 to 1.88, P 0.011), myocardial infarction (OR 1.68, 1.39 to 2.16, P 0.001), unplanned intubation (OR 1.69, CI 1.39 to 2.07, P 0.001) and pro- longed intubation (OR 1.57, CI 1.28 to 1.94, P 0.001) within 30 d of lower extremity revascularization. However, the incidence of wound infection and graft failure requiring return to the oper- ating room did not appear to be substantially higher in this group. Our data also show that patients with renal insufficiency under- going revascularization were more likely to require distal proce- dures and to present with limb-threatening infection compared to those with normal renal function. Efforts to improve pre-and post-operative care in patients with renal insufficiency undergoing lower extremity revascularization should take into account the increased incidence of postoperative death and cardiopulmonary complications in this group in addition to more traditional con- cerns about operative site complications. Further studies are needed to explore reasons for the higher rate of limb-threatening infection in patients with renal insufficiency undergoing revascularization.

Background: Amputation is more common in hemodialysis patients than in the general population, but risk factors for amputation in this population have not been studied extensively. Methods: We used the US Renal Data System Dialysis Morbidity and Mortality Study Waves 3 and 4 in combination with Medicare discharge data to identify factors associated with lower-extremity amputation (excluding toe amputations) in hemodialysis patients. We used stepwise multivariable logistic regression analysis to identify variables most strongly associated with amputation within 2 years of the study start date. Results: Male sex, diabetes, previous diagnosis of peripheral vascular disease (PVD), mean systolic blood pressure, and elevated serum phosphorus level were associated with the outcome of amputation within 2 years of the study start date. Among patients without diabetes, a previous diagnosis of cardiac disease, longer time from initiation of dialysis therapy (vintage), and previous hospitalization for limb ischemia were associated with increased risk for future amputation. Conclusion: The importance of preventing amputation in this population cannot be overemphasized. The strength of the association of amputation with PVD makes a strong case for screening all dialysis patients for this disease. The association of amputation with serum phosphorus level reported here should be explored further because this may offer an avenue for future intervention to reduce amputation rates. Am J Kidney Dis 41:162-170. © 2003 by the National Kidney Foundation, Inc.

Peripheral vascular disease (PVD) is common among patients undergoing hemodialysis, but little is known regarding the risk factors for PVD in this population. Data from waves 1, 3, and 4 of the United States Renal Data System Dialysis Morbidity and Mortality Study were used to examine cross-sectional associations of a range of conventional cardiovascular risk factors and uremia- or dialysis-related variables with PVD. Univariate and multivariate logistic regression models were developed using wave 3 and 4 data. Odds ratios for the multivariate model derived using wave 3 and 4 data were then compared with those obtained with the wave 1 data set. For both data sets, PVD was positively associated with the duration of dialysis (vintage) and malnourished status and was negatively associated with serum albumin and parathyroid hormone levels and predialysis diastolic BP. Kt/V was negatively associated with PVD in waves 3 and 4 but not in wave 1. PVD was associated with increasing age, white (versus non-white) race, male gender, diabetes mellitus, coronary artery disease, cerebrovascular disease, smoking, and left ventricular hypertrophy, as for the general population, but not with hypertension or hyperlipidemia. In conclusion, PVD among hemodialysis patients is associated with both dialysis-specific variables and most conventional cardiovascular risk factors other than hypertension and hyperlipidemia. Future studies should prospectively examine the association of these variables identified in cross-sectional analyses with the de novo development of PVD in this population.

Importance Older adults are often excluded from clinical trials. The benefit of preventive interventions tested in younger trial populations may be reduced when applied to older adults in the clinical setting if they are less likely to survive long enough to experience those outcomes targeted by the intervention. Objective To extrapolate a treatment effect similar to those reported in major randomized clinical trials of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for prevention of end-stage renal disease (ESRD) to a real-world population of older patients with chronic kidney disease. Design, Setting, and Participants Simulation study in a retrospective cohort conducted in Department of Veterans Affairs medical centers. We included 371 470 patients 70 years or older with chronic kidney disease. Exposure Level of estimated glomerular filtration rate (eGFR) and proteinuria. Main Outcomes and Measures Among members of this cohort, we evaluated the expected effect of a 30% reduction in relative risk on the number needed to treat (NNT) to prevent 1 case of ESRD over a 3-year period. These limits were selected to mimic the treatment effect achieved in major trials of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for prevention of ESRD. These trials have reported relative risk reductions of 23% to 56% during observation periods of 2.6 to 3.4 years, yielding NNTs to prevent 1 case of ESRD of 9 to 25. Results The NNT to prevent 1 case of ESRD among members of this cohort ranged from 16 in patients with the highest baseline risk (eGFR of 15-29 mL/min/1.73 m2with a dipstick proteinuria measurement of ≥2+) to 2500 for those with the lowest baseline risk (eGFR of 45-59 mL/min/1.73 m2with negative or trace proteinuria and eGFR of ≥60 mL/min/1.73 m2with dipstick proteinuria measurement of 1+). Most patients belonged to groups with an NNT of more than 100, even when the exposure time was extended over 10 years and in all sensitivity analyses. Conclusions and Relevance Differences in baseline risk and life expectancy between trial subjects and real-world populations of older adults with CKD may reduce the marginal benefit to individual patients of interventions to prevent ESRD.

Belluno district (Veneto region, northeast Italy): age distribution and morbidity. Am J Med Genet 1990;suppl 7: 84-6. 5. Hanifin JM, Rajka G. Diagnostic features of atopic dermatiffs. Acta Derm Venereol Suppl (Stockh) 1980;92: 44-7. 6. Schmied C, Saurat J-H. Epidfmiologie de la dermatite atopique. Ann Dermatol Venereol 1989;116:729-34. 7. Schachner L. A statistical analysis of a pediatric dermatology clinic. Pediatr Dermatol 1983;1:157-64. 8. Palazzo R, Schepis C, Dispinzeri A, et al. Study of cutaneous hydration in subjects with Down's syndrome. In: Cerimele D, Fabrizi G, Serri F, editors. Atti del 3 ° Simposio Intemazionale di Dermatologia Pediatrica 14-17 Settembre, 1988 Mazara del Vallo (TP). Napoli: L'Antologia, 1988:23944.

Based on the finding that estimated glomerular filtration rate (eGFR) and albuminuria were associated with mortality and treated end-stage renal disease in younger and older adults, Dr Hallan and colleagues1 concluded that there should be �a common definition and staging of CKD [chronic kidney disease] based on eGFR and albuminuria for all age groups.�

Identification of specific genetic loci that contribute to susceptibility to rheumatoid arthritis (RA) in humans has been hampered by several factors, including: i) multiple interacting genetic loci contributing to susceptibility; ii) complex interactions of environmental and genetic factors; iii) genetic heterogeneity; and iv) low penetrance. We have, therefore, mapped quantitative trait loci (QTLs) that control inflammatory arthritis susceptibility and/or severity in progeny of two inbred rat strains with significantly different susceptibilities to collagen-induced arthritis (CIA), an animal model for RA. Not surprisingly, we identified a major susceptibility factor, Cia1, on chromosome 20 in the vicinity of the rat major histocompatibility complex (MHC). However, by limiting the analysis to animals with arthritis-susceptible MHC genotypes and using genome-wide QTL analytic techniques, we also found four non-MHC QTLs-Cia2, 3, 4 and 5-on chromosomes 1, 4, 7 and 10, that contributed to disease severity. In addition, a QTL on chromosome 8 was suggestive for linkage. Characterization of the genes underlying these QTLs will facilitate the identification of key biochemical pathways regulating experimental autoimmune arthritis in rats and may provide insights into RA and other human autoimmune diseases. These genes may also represent novel targets for therapy.

Background During the past decade, a trend has been observed in the United States toward initiation of chronic dialysis at higher levels of estimated glomerular filtration rate. This likely reflects secular trends in the composition of the dialysis population and a tendency toward initiation of dialysis earlier in the course of kidney disease. Methods The goal of this study was to generate model-based estimates of the magnitude of changes in the timing of dialysis initiation between 1997 and 2007. We used information from a national registry for end-stage renal disease on estimated glomerular filtration rate at initiation among patients who received their first chronic dialysis treatment in 1997 or 2007. We used information regarding predialysis estimated glomerular filtration rate slope from an integrated health care system. Results After accounting for changes in the characteristics of new US dialysis patients from 1997 to 2007, we estimate that chronic dialysis was initiated a mean of 147 days earlier (95% confidence interval, 134-160) in the later compared with the earlier year. Differences in timing were consistent across a range of patient subgroups but were most pronounced for those aged 75 years or older; the mean difference in timing in that subgroup was 233 days (95% confidence interval, 206-267). Conclusions Chronic dialysis appears to have been initiated substantially earlier in the course of kidney disease in 2007 compared with 1997. In the absence of strong evidence to suggest that earlier initiation of chronic dialysis is beneficial, these findings call for careful evaluation of contemporary dialysis initiation practices in the United States.

Context An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis. Objectives To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care. Design, Setting, and Participants Retrospective observational study using a national ESRD registry to identify a cohort of 41 420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare. Main Outcome Measures Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices. Results Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged ≥80 years and women aged ≥85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21 190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses. Conclusion There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.

Albuminuria is associated with an increased risk of death independent of level of renal function. Whether this association is similar for adults of all ages is not known.We examined the association between the albumin to creatinine ratio (ACR) and all-cause mortality after stratification by estimated glomerular filtration rate (eGFR) and age group in 94 934 veterans with diabetes mellitus. Cohort members had at least 1 ACR recorded in the Veterans Affairs Health Care System between October 1, 2002, and September 30, 2003, and were followed up for death through October 15, 2009.From the youngest to the oldest age group, the prevalence of an eGFR less than 60 mL/min/1.73 m(2) ranged from 11% to 41%; microalbuminuria (ACR 30-299 mg/g) ranged from 19% to 28%; and macroalbuminuria (ACRor =300 mg/g) ranged from 3.2% to 3.7%. Of patients with an eGFR less than 60 mL/min/1.73 m(2), 72% of those younger than 65 years, 74% of those 65 to 74 years old, and 59% of those 75 years and older had an eGFR of 45 to 59 mL/min/1.73 m(2). In all age groups, less than 35% of these patients had albuminuria (ie, ACRor =30 mg/g). In patients 75 years and older, the ACR was independently associated with an increased risk of death at all levels of eGFR after adjusting for potential confounders. In younger age groups, this association was present at higher levels of eGFR but seemed to be attenuated at lower levels [corrected].The ACR is independently associated with mortality at all levels of eGFR in older adults with diabetes and may be particularly helpful for risk stratification in the large group with moderate reductions in eGFR.