infections in the dialysis population: a major communicable disease issue! allan j. collins, md,...

Infections in the dialysis population: A major communicable disease issue!

Allan J. Collins, MD, FACPProfessor of MedicineUniversity of MinnesotaDirector, USRDS Coordinating Center

USRDS 2008 ADRUSRDS 2008 ADR

Disclosures

• Institutional research funding: NIH, CDC, National Kidney Foundation, Amgen, Baxter, Sigma Tau, NxStage, Genzyme, BMS, AMAG Pharmaceuticals

• Advisory boards in last year: WHO Advisory Panel on NCDs, Kidney Disease Improving Global Outcomes (KDIGO), International Federation of Kidney Foundations (IFKF),

• Epidemiology consulting: NxStage, Amgen, Affymax


Infectious complication in dialysis patients: an old yet new communicable disease challenge

• Trends in overall mortality show reductions in death rates in years 2-5 after onset of ESRD

• Death rates in the first year have not changed in 12 years raising concerns about the underlying morbidity contributing to the early death rates

• Cardiovascular and Infectious hospitalizations are the leading cause of morbidity yet little is known about the trends in the first months of dialysis

• Here we review the trends in hospitalization rate with particular emphasis on infections as a contributor to morbidity and mortality in the first year of treatment


Mortality rates, by modalityFigure 6.1 (Volume 2)

Incident ESRD patients; adjusted for age, gender, race, & primary diagnosis. Incident ESRD patients, 2005, used as reference cohort.


Change in all-cause & cause-specific hospitalization rates, by modalityFigure p.16 (Volume 2)

Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort. Vascular access hospitalizations are “pure” inpatient vascular access events. New vascular access codes for peritoneal dialysis patients appeared in late 1998; therefore, peritoneal dialysis vascular access values are shown as changing since 1999 rather than 1993.


Adjusted admissions for principal diagnoses, by modality Figure 6.5 (Volume 2)

Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort.


Trends in hospitalization surveillance data in the dialysis population• Overall, hospitalization rates have changed little over the

last 10-12 years• However, there have been significant changes in the types

of hospitalizations with vascular access events transitioning to the outpatient setting with increases in cardiovascular disease and infectious hospitalizations

• Hospitalization secondary to pneumonia have increased but have begun to plateau since 2003

• Vascular access infectious event have more than doubled in the last 10 years an area of major concern! By most standards this would be considered a major

communicable disease problem yet the CDC stopped its survey in 2004!!!!

Who and what is responsible for this trend?


Infectious complications in dialysis patients

• Infectious hospitalizations have increased in part related to the increases in pneumonia but this trend appears to be reversing with increased evidence of pneumococcal pneumonia vaccinations

• Preventive care in the form of influenza vaccinations needs attention and is clearly within the domain of the providers!

• Yet other sources of infectious events likely contribute to the increased hospitalization rates


Vascular access use at initiation, 1st outpatient access, 2006 (From Medical Evidence

Form 2728) Figure 3.1 (Volume 2)

incident hemodialysis patients, 2006.

82% Catheters


First access at initiation, by nephrologist care, 2006Figure 3.4 (Volume 2)

incident hemodialysis patients, 2006, with new (revised edition) Medical Evidence forms.


Pre-ESRD nephrologist care, 2006Table 3.a (Volume 2)

incident ESRD patients, 2006, with new (revised edition) Medical Evidence forms.

None 0-12 >12

All 41.6 35.0 23.4Mean age 62.3 63.0 63.3Female 41.5 35.4 23.2Race

White 39.8 35.4 24.9African American 46.0 33.8 20.2Native American 39.0 35.8 25.2Asian 41.9 37.5 20.6

Hispanic 48.9 33.3 17.8Access at initiation

Catheter 50.3 32.4 17.3Fistula 10.0 44.2 45.8Graft 21.6 43.3 35.1

Maturing Fistula 31.1 42.5 26.4ESA use 5.7 52.1 42.2Dietary care 1.1 56.0 42.9eGFR

<5 56.4 26.6 17.15-<10 40.4 35.1 24.510-<15 37.0 37.5 25.5>=15 44.4 34.8 20.8

Primary diagnosisDiabetes 36.9 38.2 24.8*Diabetes as a comorbidity 38.7 37.0 24.3Hypertension 44.7 34.0 21.3Glomerulonephritis 32.5 35.0 32.5Cystic kidney 18.4 36.7 44.9

None 0-12 >12

All 41.6 35.0 23.4Mean age 62.3 63.0 63.3Female 41.5 35.4 23.2Race

White 39.8 35.4 24.9African American 46.0 33.8 20.2Native American 39.0 35.8 25.2Asian 41.9 37.5 20.6

Hispanic 48.9 33.3 17.8Access at initiation

Catheter 50.3 32.4 17.3Fistula 10.0 44.2 45.8Graft 21.6 43.3 35.1

Maturing Fistula 31.1 42.5 26.4ESA use 5.7 52.1 42.2Dietary care 1.1 56.0 42.9eGFR

<5 56.4 26.6 17.1

10-<15 37.0 37.5 25.5>=15 44.4 34.8 20.8

Primary diagnosisDiabetes 36.9 38.2 24.8

38.7 37.0 24.3Hypertension 44.7 34.0 21.3

Cystic kidney 18.4 36.7 44.9


Cumulative probability of catheter placementFigure 1.8 (Volume 2)

Medicare: hemodialysis patients who initiate dialysis at age 67 or older during the year specified. Includes those with Medicare as primary payor during the two years prior to initiation & through the first six months of ESRD; pre-ESRD claims used for months prior to initiation date. Medstat (EGHP): patients with first date of regular & continuous dialysis in 2000 or 2005, regardless of age. Only one year of claims prior to the start of dialysis was available for the 2000 cohort.


Cumulative probability of multiple catheter placements determined from service claimsFigure 1.9 (Volume 2)

Medicare: hemodialysis patients who initiate dialysis at age 67 or older during the year specified. Includes those with Medicare as primary payor during the two years prior to initiation & through the first six months of ESRD; pre-ESRD claims used for months prior to initiation date. Medstat (EGHP): patients with first date of regular & continuous dialysis in 2000 or 2005, regardless of age. Only one year of claims prior to the start of dialysis was available for the 2000 cohort.


Per person per year vascular access costs, by physician specialty Figure 11.24 (Volume 2)

period prevalent hemodialysis patients. Costs determined as the payment amount for each line-level access procedure billed through physician/ supplier claims.


Catheter events & complicationsFigure 5.27 (Volume 2)

Prevalent hemodialysis patients age 20 & older, ESRD CPM data; only includes patients who are also in the USRDS database. Year represents the prevalent year & the year the CPM data were collected. Access is that listed as “current” on the CPM data collection form.


Arteriovenous fistula events & complications Figure 5.28 (Volume 2)



Arteriovenous graft events & complications Figure 5.29 (Volume 2)



Period prevalent hemodialysis patients with or without simple fistulas. Data from physician/supplier claims. Some patients may have more than one access at a given point in time.

Access procedures in prevalent hemodialysis patients, by diabetic status Figure hp.13 (Volume 2)

Change to cuffed catheters


Vascular access utilization and infectious complications

• Arteriovenous fistula utilization rates have increased during the same time as the Fistula First initiative has been stressed

• The Fistula First effort is also associated with reductions in the use of grafts and changes in catheter utilization rates

• Infectious complication are highest with catheters and lowest with fistulas but there are similar rates with grafts.

• What are the trends in infectious hospitalizations that may relate to vascular access complications


Change in all-cause & cause-specific hospitalization rates, by modality: prevalentFigure p.22

Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort. Vascular access hospitalizations are “pure” inpatient vascular access events, as described in Appendix A. New vascular access codes for peritoneal dialysis patients appeared in late 1998; therefore, peritoneal dialysis vascular access values are shown as changing since 1999 rather than 1993.


500

520

540

560

580

600

620

640

660

680

700

All 0<

1

All 1<

2

All 2<

3

All 3<

6

All 6<

9

All 9<

12

1993

1997

2001

2005

Trends in cardiovascular Hospitalizations in the First Year by months

Adjusted for age, gender, race and cause of ESRD R

ate

per

1,0

00 P

t Y

rs

Incident Cohort Year

Increased cardiovascular hospitalizations


Trends in Infectious Hospitalization rates in the 1st year by monthAdjusted for age, gender, race and cause of ESRD

300350400

450500550600

650700

All 0<

1

All 1<

2

All 2<

3

All 3<

6

All 6<

9

All 9<

12

1993

1997

2001

2005

Rat

e p

er 1

,000

Pt

Yrs


Increased infectious hospitalizations


300

350

400

450

500

550

600

650

700

750

800

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

All 0<1

All 1<2

All 2<3

All 3<6

All 6<9

All 9<12

Trends in cardiovascular Hospitalizations in the First Year by months

Adjusted for age, gender, race and cause of ESRD

Rat

e p

er 1

,000

Pt

Yrs


Cardiovascular Infections


Trends in CVD and Infectious Hospitalization rates in the first monthAdjusted for age, gender, race and cause of ESRD

Rat

e p

er 1

,000

Pt

Yrs


Infectious hospitalizations now approach CVD for the 1st time!


Percent change in hospital admissions from Day 90: 1993 to 2005Incident dialysis patients age 20 and older

-10

0

10

20

30

40

50

60

70

80

90

100

110

0-<1 1-<2 2-<3 3-<6 6-<9 9-<12

months after day 90 of dialysis

pe

rce

nt

ch

an

ge

in a

dm

iss

ion

ra

tes

fro

m

19

93

to

20

05

all-cause

cardiovascular

infection

*Model based adjustment for age, sex, race, cause of ESRD: Interval Poisson regression (ASN 2008 poster)


Percent change in hospital admissions from day 1: 1993 to 2005Incident hemodialysis patients age 65 and older

-10

10

30

50

70

90

110

130

150

170

190

210

230

0-<1 1-<2 2-<3 3-<6 6-<9 9-<12

months after dialysis initiation

pe

rce

nt

ch

an

ge

in a

dm

iss

ion

ra

tes

fro

m

19

93

to

20

05

all-cause

cardiovascular

infection

vascular access infection

*Model based adjustment for age, sex, race, cause of ESRD: Interval Poisson regression (ASN 2008 poster)


Adjusted admissions for principal diagnoses, by modality Figure 6.5 (Volume 2)

Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort.

*early data noted declinebut must be confirmed

2004 ADR

Incident dialysis patients with 90-day rule, Medicare as primary payor, & Part A & B claims, 1992–2000 combined; adjusted for age, gender, race, & primary diagnosis. Reference cohort: patients without corresponding diseases in the first year after ESRD initiation + 90 days.

Adjusted relative risk of mortality after pneumonia: dialysisFigure 6.29

Foley RN, Guo H, Snyder JJ, Gilbertson DT, Collins AJ: Septicemia in the United States Dialysis Population, 1991 to 1999. Journal of the American Society of Nephrology 15 (4): 1038-1045, 2004

2004 ADR

Incident dialysis patients with 90-day rule, Medicare as primary payor, & Part A & B claims, 1992–2000 combined; adjusted for age, gender, race, & primary diagnosis. Reference cohort: patients without corresponding diseases in the first year after ESRD initiation + 90 days.

Adjusted relative risk of mortality after VA event: dialysis Figure 6.30

Foley RN, Guo H, Snyder JJ, Gilbertson DT, Collins AJ: Septicemia in the United States Dialysis Population, 1991 to 1999. Journal of the American Society of Nephrology 15 (4): 1038-1045, 2004


Trends in Infectious hospitalizations

• Infectious hospitalizations have substantially increased over the last 10-13 years

• The increase in infectious hospitalizations is more than 4 times greater compared to cardiovascular events in the first months

• The increase in infectious hospitalization rates is approaching that of cardiovascular events which is a new finding and they appear to be interrelated

• The risk of death after an infectious hospitalization event is significant and is associated with CVD events (The infection/inflammation multiplier hypothesis)!


Conclusions• Death rates in the first months of dialysis are high and need to be

addressed• Infectious hospitalizations in the 1st months of dialysis have

increased nearly 2 fold • Vascular access infectious hospitalizations are up nearly 3 fold • The consequences of late referral and delayed vascular access

planning result in the use of catheters with the accompanying complications and risk of infection and premature death!

• The high rates of catheter utilization and associated infectious complications suggest a major effort is needed to reduce catheter utilization (Catheter Last!).

• CMS under the QIO scope of work should act to increase early referral and a “Planned Transition” to dialysis consistent with the MIPPA CKD Stage 4 education benefit!

• CMS should implement a similar effort for planned transition as was done for Fistula First by engaging health plans, physicians, hospitals and public health infection control officials to reduce the use of catheters!


Acknowledgements• The USRDS Coordinating Center produced the material in

this talk based on contributions from the entire staff of SAS programmers Biostatistians Epidemiologist Physcians Pharm Ds Co-investigators Graphics designers and editors

• We would like to thank CMS and the NIH project officers for their support and oversight of the USRDS and the entire kidney disease community for the hard work they do and providing the data!

infections in the dialysis population: a major communicable disease issue! allan j. collins, md,...

Documents

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incident esrd patients

adr trends

adr mortality rates

period prevalent esrd

adr infectious complications

dialysis population

affymax slide