Transitions of Care in Advanced CKD

Transitions of Care in Advanced Chronic Kidney Disease

The transition of patients with advanced chronic kidney disease (CKD) to kidney failure and dialysis is a perilous journey associated with substantial morbidity and mortality. Mortality rates during the transition period-i.e. prior to dialysis initiation and within the first year on dialysis- exceed 40%. The precise reasons for this surge in mortality are unclear and the optimal transition pathways for patients remain undefined. Uncertainty exists on whether transition pathways should vary according to comorbidity, age, and mode of dialysis and to what extent these pathways are influenced by timing of dialysis initiation, facility-based practices, and complex organisational factors that converge to drive the decision-making process.

We hypothesize that the excess mortality that occurs during this critical transition and continue into the first year, are a consequence of measurable patient-level and facility-related factors that begin prior to dialysis, and that the characteristics of optimal transition pathway(s) associated with the lowest mortality can be clearly elucidated. The Kidney Research Consortium at the University of Limerick (UL), with national and international partnerships, propose a novel solution to map transition pathways for CKD patients using the National Kidney Disease Surveillance System.

This research programme will examine the relative contributions of patient-level factors and facility level characteristics (structure, process of care, and care pathways) on timing of initiation, modality assignment, and mortality in the first year of dialysis. Comprehensive longitudinal surveillance on sociodemographic and clinical data recorded prior to dialysis initiation will be facilitated through national information systems linked to dialysis and mortality. National surveys of adult dialysis centres and multidisciplinary teams will explore the attitudes, beliefs and complex organisational factors that operate in the transition process. This programme of research will allow us better understand transition pathways to dialysis and transplantation and help us define optimal pathways to improve patient outcomes.