Dialysis Transition Patterns of Chronic Kidney Disease Patients With and Without Heart Failure

To compare dialysis transition patterns of chronic kidney disease (CKD) patients with heart failure (HF) and without HF, including inpatient "crash start" initiation of long-term ("maintenance") dialysis, early dialysis initiation as evaluated by estimated glomerular filtration rate (eGFR), and rate of central venous catheter (CVC) use for hemodialysis.

A cross-sectional study was performed within Kaiser Permanente Southern California of patients (age ≥18 years) with observed incidence of CKD who initiated maintenance dialysis between January 1, 2007, and December 31, 2018. Heart failure was further categorized into HF with preserved ejection fraction (>40%) or HF with reduced ejection fraction (≤40%). Associations between HF and risk of inpatient initiation of maintenance dialysis or hemodialysis vascular access were assessed by rate ratio (RR) using Poisson regression with robust variance error.

Of 6812 patients with CKD initiating dialysis, 2498 (37%) had HF. Inpatient dialysis initiation occurred in 463 (18.5%) patients with HF vs 416 (9.6%) without HF. Mean (SD) eGFR at dialysis was 11.3 (6.2) mL/min per 1.73 m² with HF vs 9.4 (5.2) mL/min per 1.73 m² without HF (P<.001). Of 5499 patients who initiated hemodialysis, CVC use occurred in 1302 (58.5%) HF patients vs 1698 (51.9%) non-HF patients. Compared with non-HF patients, patients with HF had multivariate RRs (95% CI) of 1.46 (1.26 to 1.69) and 1.04 (0.99 to 1.10) for inpatient dialysis initiation and CVC use, respectively. Patients with HF with reduced ejection fraction had CVC placement RR of 1.23 (1.14 to 1.33).

Patients with CKD and HF had higher rates of suboptimal dialysis initiation: more frequent inpatient dialysis starts, more frequent CVC placement for hemodialysis access, and higher eGFR at dialysis initiation. Our findings suggest that CKD patients with HF may warrant different management strategies as they progress to dialysis.