Original Investigation
Pathogenesis and Treatment of Kidney Disease
Potentially Preventable Hospitalization as a Complication of CKD: A Cohort Study

https://doi.org/10.1053/j.ajkd.2014.03.012Get rights and content

Background

Ambulatory care–sensitive conditions have been described as those that (if appropriately managed in an outpatient setting) generally do not require subsequent hospitalization. Our goal was to identify clinical populations of people who are at the highest risk of ambulatory care−sensitive conditions related to chronic kidney disease (CKD).

Setting & Participants

2,003,054 adults (including 238,747 adults with CKD) residing in Alberta, Canada, with at least one serum creatinine measurement between 2002 and 2009.

Predictors

Estimated glomerular filtration rate and albuminuria categories, CKD status, demographics, and clinical characteristics.

Outcomes

Hospitalization with heart failure, hyperkalemia, volume overload, or malignant hypertension.

Measurements

We used the Alberta Kidney Disease Network database, which incorporates data from Alberta Health, the Northern and Southern Alberta Renal Programs, and clinical laboratories in Alberta.

Results

During a median follow-up of 4.1 years, 43,863 participants were hospitalized for heart failure; 6,274 participants, for hyperkalemia; 2,035 participants, for volume overload; and 481 participants, for malignant hypertension. All 4 conditions were more common at lower estimated glomerular filtration rates and in the presence of albuminuria. In the subset of participants with CKD, heart failure, hyperkalemia, and volume overload were associated most strongly with older age, diabetes, chronic liver disease, and prior heart failure. Malignant hypertension was associated with prior hypertension, aboriginal status, and peripheral vascular disease. Remote-dwelling participants were more likely to experience heart failure and malignant hypertension than those living closer to providers.

Limitations

No data for medication use or potentially important process-based outcomes for study participants.

Conclusions

Our findings suggest that future studies seeking to determine how to prevent ambulatory care–sensitive conditions in people with CKD should target remote dwellers and those with comorbid conditions such as concomitant heart failure and liver disease.

Section snippets

Methods

This study has been reported according to published guidelines.8

Study Cohort

Of 3,897,684 potentially eligible patients, 2,007,653 adult patients had an outpatient serum creatinine measurement between May 1, 2002, and March 31, 2009, and at least 3 years of prebaseline data (for assessment of comorbid conditions at baseline). Of these, 2,862 had prior end-stage renal disease (long-term renal replacement therapy or had received a kidney transplant) and 1,737 had baseline eGFRs < 15 mL/min/1.73 m2. Therefore, 2,003,054 participants were included in the study cohort (Fig 1).

Discussion

Avoiding the need for hospitalization is a clinically relevant outcome for patients, and the higher than average rate of hospitalization for people with CKD is an important driver of the high health care costs attributable to this population.15 For these reasons, there is substantial interest in using high-quality ambulatory care to prevent hospitalization in people with CKD.16 Efforts to achieve this objective have been hampered by an inability to distinguish potentially preventable from

Acknowledgements

We thank Sophanny Tiv for graphics support and Ghenette Houston for administrative support.

Support: This work was supported by a team grant to the Interdisciplinary Chronic Disease Collaboration from the Alberta Heritage Foundation for Medical Research (AHFMR). This work was supported in part by the Canadian Institutes for Health Research (200709MOP-178552-PUB-CBAA-62156) and a Leaders Opportunity Fund grant from the Canada Foundation for Innovation. Dr Tonelli is supported by an AHFMR

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    A list of the members of the Alberta Kidney Disease Network is available at www.akdn.info.

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