Factors associated with mortality and high treatment expense of adult patients hospitalized with chronic kidney disease in Thailand

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Abstract

Background

Chronic kidney disease (CKD) is a global public health problem with a high risk of hospitalization and death. Few nationwide data have been reported regarding the outcomes of patients hospitalized with CKD in developing countries.

Objectives

To study the risk factors associated with mortality and high treatment costs of adult patients hospitalized with CKD in Thailand.

Methods

The medical data forms for adult inpatients with CKD collected in fiscal year 2010 were analyzed to determine the number of CKD admissions, associated comorbidities and complications, mortality rates, and hospital charges. Factors influencing mortality rates were evaluated by multiple logistic regression.

Results

The total number of CKD patients was 128,338. After adjustment, the major factors associated with high hospital charges were (a) comorbidities (e.g. pneumonia OR 3.18, 95% CI 3.03–3.34; sepsis OR 2.87, 95% CI 2.74–3.00; acute kidney injury (AKI) on preexisting CKD OR 2.83, 95% CI 2.69–2.98) and (b) dialysis treatment (i.e., hemodialysis OR 5.16, 95% CI 4.94–5.39; peritoneal dialysis OR 3.40, 95% CI 3.14–3.69). The risk factors for high mortality were: being male, elderly, having comorbidity (viz., sepsis, respiratory failure, stroke, pneumonia, ischemic heart disease, AKI in addition to CKD, heart failure, and diabetes), and CKD complications (viz., metabolic acidosis, hyperkalemia, volume overload, and anemia requiring blood transfusion).

Conclusions

Prevention and early treatment of any comorbidity and complications of CKD might reduce mortality and treatment costs of patients hospitalized with CKD.

Chronic kidney disease (CKD) is a global public health concern because of its prevalence and rising incidence, poor outcomes, and high treatment costs [1-3]. The prevalence of CKD in Thailand—both in the community and among outpatients—is high at between 4.6% and 17.5% [4-6]. Patients with CKD have an increased rate of hospitalization and a high respective risk for death [7, 8]. Cardiovascular diseases (CVD) are major comorbidities, causing high mortality and expense, as documented for western countries [7-9]. Because little information on the outcomes of patients hospitalized with CKD is available from developing countries, we analyzed the national data for Thai adult inpatients hospitalized with CKD in fiscal year 2010. We focused on identifying the epidemiological aspects of CKD and the factors affecting its mortality and treatment costs. The results of this study may provide essential information for improving care of patients with CKD.

Materials and methods

The study was approved followed an assessment by the Ethics Committee of the Faculty of Medicine, Khon Kaen University (certificate of approval No. HE541036), following the principles of the contemporary Declaration of Helsinki. The information to be analyzed was from the three main health scheme offices in Thailand: (a) the inpatient medical expense forms for fiscal year 2010 from the National Health Security Office; (b) the inpatient data from the CSMBS (Civil Servant Medical Benefit Scheme) from the Controller General’s Department; and (c) the Social Security Office. The data collected from inpatients hospitalized with CKD included: sex, age, comorbidities, complications, treatment, clinical outcomes, and hospital charge. The data were first checked for accuracy by examining for (a) overlapping information, (b) visit dates, (c) missing items, (d) incorrect coding, and (e) the correct fiscal year. We conducted a statistical analysis of age, sex, admission rates, death rates, comorbidity, complications, and the average hospital charges. Patients with CKD were identified in both primary and secondary diagnoses as code N18 of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) [10]. Hemodialysis and peritoneal dialysis were identified as codes 39.95 and 54.98 according to the ICD-9-CM 2010 classification of procedures [11].

Outcome measures

The outcome data of interest included (a) number, age, and sex of patients, (b) number of admissions, (c) length of stay, (d) hospital charges, and (e) mortality rates. The characteristics of patients with CKD and factors influencing their mortality and high treatment costs were analyzed.

Statistical analysis

The statistical analyses were conducted using SPSS Statistics for Windows, version 17 (SPSS Inc, Chicago, IL, USA). The respective continuous and categorical data were expressed as means ± SD or median (25th -75th percentiles), and percentage. Generalized estimating equation (GEE) and multiple logistic regression analysis (MLRA) were conducted to adjust the odds ratios for factors influencing a high cost accounting for multiple admissions within an individual and mortality rate, respectively.

Results

Epidemiology

In fiscal year 2010, the population over 19 years of age numbered 47,966,73474% of the total population of 64.7 million. Approximately 96% of the adult population (46,208,964 individuals) was covered by one of the three health insurance systems (viz., the Medical Welfare Scheme, the Civil Servant Medical Benefit Scheme, and the Social Security Scheme). The total number of adult inpatients was 3,876,792 (admitted 4,863,935 times), accounting for 71% of all inpatients. According to the 23 major disease groups specified in the ICD 10, diseases of the genitourinary system ranked 7th among causes of hospitalization (298,258 individuals, 7.7% of all adult inpatients, and 392,498 admissions) and 7th among causes of mortality in Thailand [12]. CKD was the most common diagnosis of genitourinary system disorders. The total number of patients with CKD was 128,338 (generating 236,439 admissions), accounting for 4.9% of all adult inpatient admissions (268 individuals or 493 visits per 100,000 adult population).

Table 1 presents the characteristics of admitted CKD patients. There were 65.5% aged >60 years, 29.1% between 40-60 years, and 5.4% <40 years. Admissions of female patients were slightly greater than of males.

Table 1

Characteristics of patients hospitalized with chronic kidney disease

Characteristics of admitted CKD patients
Number of adult patients (individuals)128,338
Number of admissions (times)236,439
Age (mean ± SD) years65.5 ± 13.9
Sex (male/female)1/1.14
Common comorbidities (% of admissions)
  Hypertension53.1
  Diabetes mellitus43.0
  Hyperlipidemia13.2
  Ischemic heart disease12.4
  Heart failure10.5
  Gout8.3
  Sepsis7.8
  Pneumonia6.2
  AKI on preexisting CKD5.1
  Diarrhea5.1
  Stroke5.0
  Respiratory failure4.8
Complications (% of admissions)
  Anemia requiring blood transfusion24.4
  Hyperkalemia9.9
  Volume overload9.3
  Metabolic acidosis5.0
Dialysis treatment (% of admissions)
  Hemodialysis7.3
  Peritoneal dialysis1.9
Length of stay (days)
  Median (25th –75th percentile)3.0 (2.0-6.0)
Hospital charge (baht)
  Mean ± SD20,980 ± 126,985
  Median (25th –75th percentile)7,360 (3,866-16,599)
Mortality (%)10.7
CKD, chronic kidney disease; AKI, acute kidney injury; SD, standard deviation

Associated comorbidities

The two most frequently associated comorbidities were hypertension and diabetes mellitus (DM). In rank order, the less frequently associated comorbidities associated with CKD were: hyperlipidemia, ischemic heart disease, heart failure, gout, sepsis, pneumonia, acute kidney injury (AKI) in addition to preexisting CKD, diarrhea, stroke, and respiratory failure.

Complications

Complications for all CKD admissions included anemia (requiring blood transfusion), hyperkalemia, volume overload, and metabolic acidosis.

Dialysis treatment

CKD patients needing dialysis numbered 21,727 admissions. Mode of dialysis included: hemodialysis (n = 17,143 admissions or 78.9% admissions for CKD) and peritoneal dialysis (n = 4,584 admissions or 21.1% admissions for CKD).

Length of hospital stay

The median length of hospital stay was 3 days with minimum to maximum: 1-1,078 days. The longest median hospital stay was for patients with CKD requiring renal replacement therapy. The comorbidities associated with a longer admission duration were pneumonia, AKI in addition to preexisting CKD, sepsis, stroke and respiratory failure (Table 2).

Table 2

Length of hospital stay and hospital charges for hospitalized patients with chronic kidney disease and comorbidities, complications, and dialysis

Length of stay (days)Total hospital charge (baht)Hospital charge per day (baht)

Median (25th–75th percentile)Mean ± SDMedian (25th–75th percentile)Mean ± SDMedian (25th–75th percentile)
ComorbiditiesHypertension4(2–7)23,333 ±151,9297,759(4,028–17,866)3,564 ±11,4862,182(1,465–3,543)
Diabetes mellitus4(2–7)23,072 ±165,6347,836(4,151–17,566)3,479 ±12,2172,127(1,444–3,482)
Hyperlipidemia4 (2–7)27,754 ±79,1658,767(4,471–20,767)4,283 ±11,5702,232(1,493–3,700)
Ischemic heart disease4(2–8)37,732 ±106,75211,478(5,510–27,252)5,924 ±15,3592,729(1,782–4,597)
Heart failure4(2–8)28,369 ±107,8709,920(5,310–21,368)3,503 ±6,0352,392(1,642–3,787)
Gout4 (2–7)19,727 ±54,7887,061 (3,709–15,541)2,989 ±5,7381,930(1,323–3,095)
Sepsis6 (3–13)54,187 ±140,15119,293 (8,684–19,433)4,789 ±4,8883,412(2,054–5,756)
Pneumonia7(4–14)63,327 ±163,42019,308(8,470–55,465)4,170± 3,7473,118(1,901–5,143)
AKI on pre-existing CKD7 (4–14)57,789 ±127,68522,363(9,794–55,169)4,678 ±6,1663,182(1,995–5,286)
Diarrhea3(2–6)17,199 + 55,4615,557(3,086–11,968)2,390 ±2,7511,684(1,223–2,602)
Stroke5(3–11)44,983 ±116,44813,962(6,644–37,092)4,112 ±6,0662,860(1,826–1,686)
Respiratory failure5(2–11)55,515 ±121,60023,262(10,459–54,127)5,923 ±5,5094,691 (3,260–6,917)
ComplicationsAnemia requiring
blood transfusion4(2–8)29,857 ±97,6879,234(4,591–23,990)3,569 ±4,8302,600(1,828–3,950)
Hyperkalemia4 (2–7)25,446 ±65,6949,324(5,151–21,005)3,775 ±4,9782,696(1,850–1,246)
Volume overload4(2–7)24,277 ±315,2278,960(4,955–19,631)3,391 ±21,0332,372(1,635–3,770)
Metallic acidosis4(2–8)27,833 ±63,34911,010(5,679–25,701)4,432 ±5,5912,942(1,866–5,215)
Mode of dialysisHemodialysis8(4–15)66,302 ±245,69427,847(13,424–61,410)5,864 ±92,3033,470(2,301–5,473)
Peritoneal dialysis8(4–15)56,072 ±369,69021,850(10,218–51,175)6,711 ±177,7882,904(1,900–4,815)
CKD, chronic kidney disease; AKI, acute kidney injury

Hospital charges

The median hospital charge was 7,360 (3,866– 16,599) baht. Hospital charge was correlated with length of stay (r = 0.39, P < 0.001). The most frequent comorbidities associated with high daily hospital expense were ischemic heart disease, respiratory failure, sepsis, and AKI in addition to preexisting CKD (Table 2).

Crude and adjusted odds ratios of factors related with high expense are presented in Table 3. After adjustment, the factors affecting high hospital charges (>50,000 baht or >US$1,500 per admission) were: (a) male sex, (b) comorbidities (e.g., pneumonia, sepsis, AKI in addition to preexisting CKD, (c) complications (i.e., anemia requiring blood transfusion, hyperkalemia), and (e) dialysis treatment (i.e., hemodialysis or peritoneal dialysis).

Table 3

Factors influencing high hospital charges (>50,000 baht) among Thai adult patients hospitalized with CKD

VariablesNo. of admissions (times)No. of high cost admission (%)Crude odds ratio (95% CI)PAdjusted odds ratio (95% CI)P
Sex
  Female126,0278,490(6.7)1<0.001
  Male110,4129,662(8.8)1.31(1.27–1.36)1.29(1.25–1.34)
Age (years)
  19–304,376405(9.3)11
  31–408,392715(8.5)0.92(0.80–1.06)0.241.03(0.88–1.20)0.72
  41–5022,1721,682(7.6)0.81 (0.72–0.92)<0.0010.90(0.78–1.03)0.13
  51–6046,5713,408(7.3)0.77(0.68–0.86)<0.0010.81(0.71–0.92)0.002
  61–7062,6724,324(6.9)0.72(0.64–0.81)<0.0010.75 (0.66–0.85)<0.001
  71–8064,2885,065 (7.9)0.82(0.72–0.92)<0.0010.84(0.74–0.96)0.01
  >8027,9682,553(9.1)0.95 (0.84–1.07)0.400.95(0.83–1.09)0.48
Comorbidities
  Hypertension (yes/no)125,565/110,87411,037(8.8)/7,115(6.4)1.38(1.34–1.42)<0.0011.21(1.17–1.26)<0.001
  Diabetes mellitus (yes/no)101,664/134,7758,775 (8.6)/9,377 (7.0)1.27(1.23–1.31)<0.0011.20(1.16–1.25)<0.001
  Hyperlipidemia (yes/no)31,229/205,2103,449(11.0)/14,703(7.2)1.51(1.45–1.57)<0.0011.38(1.32–1.45)<0.001
  Ischemic heart disease (yes/no)29,272/207,1674,406(15.1)/13,746(6.6)2.42(2.33–2.51)<0.0012.35 (2.24–2.45)<0.001
  Heart failure (yes/no)24,915/211,5242,679(10.8)/15,473(7.3)1.53(1.46–1.60)<0.0011.13(1.07–1.19)<0.001
  Sepsis (yes/no)18,528/217,9114,586(24.8)/13,566(6.2)4.62(4.44–4.79)<0.0012.87(2.74–3.00)<0.001
  Pneumonia (yes/no)14,732/221,7074,004(27.2)/14,148(6.4)5.18(4.98–5.40)<0.0013.18(3.03–3.34)<0.001
  AKI plus preexisting CKD (yes/no)12,133/224,3063,351(27.6)/14,801(6.6)5.09(4.88–5.31)<0.0012.83 (2.69–2.98)<0.001
  Stroke (yes/no)11,886/224,5532,313(19.5)/15,839(7.1)2.97(2.83–3.12)<0.0012.41 (2.27–2.55)<0.001
  Respiratory failure (yes/no)11,347/225,0923,080(27.1)/15,072(6.7)5.02(4.80–5.25)<0.0012.10(1.99–2.22)<0.001
Complications
  Anemia requiring blood Transfusion (yes/no)57,727/178,7127,442(12.9)/10,710(6.0)2.38(2.31–2.46)<0.0012.13(2.06–2.21)<0.001
  Hyperkalemia (yes/no)23,505/212,9342,532(10.8)/15,620(7.3)1.57(1.51–1.64)<0.0011.09(1.03–1.14)0.002
  Metabolic acidosis (yes/no)11,897/224,5421,549(13.0)/16,603(7.4)1.90(1.80–2.00)<0.0011.03(0.96–1.10)0.42
Mode of dialysis
  Hemodialysis17,143/219,2965,239(30.6)/12,913(5.9)6.45 (6.22–6.70)<0.0015.16(4.94–5.39)<0.001
  Peritoneal dialysis4,584/231,8551,170(25.5)/16,982(7.3)4.16(3.89–4.46)<0.0013.40(3.14–3.69)<0.001
AKI; acute kidney injury

Predictors of mortality

The mortality rate for inpatients with CKD was 10.7%. Multiple logistic regression analysis revealed the factors influencing the mortality rate were: male sex, age >80 years, comorbidity (sepsis, respiratory failure, stroke, pneumonia, ischemic heart disease, AKI on preexisting CKD, heart failure, and DM) and complications (metabolic acidosis, hyperkalemia, volume overload, and anemia requiring blood transfusion) (Table 4).

Table 4

Prognostic factors influencing mortality rates of adult Thai patients hospitalized with chronic kidney disease

VariablesNo. of patients (individuals)Dead individuals and mortality rate (%)Crude odds ratio (95% CI)PAdjusted odds ratio* (95% CI)P
Sex
  Female66,1346,814(10.3)11
  Male62,2046,941(11.2)1.10(1.05-1.14)<0.0011.07(1.03-1.11)0.001
Age (years)
  19-301,869189(10.1)11
  31-404,135400(9.7)0.95(0.79-1.14)0.601.13(0.92-1.39)0.23
  41-5010,5561,127(10.7)1.06(0.90-1.25)0.471.20(1.00-1.45)0.049
  51-6023,0732,318(10.0)0.99(0.85-1.16)0.931.09(0.91-1.30)0.36
  61-7032,8373,277(10.0)0.98(0.84-1.15)0.851.08(0.91-1.29)0.38
  71-8037,7274,039(10.7)1.07(0.91-1.24)0.421.19(0.99-1.41)0.06
  >8018,1412,405(13.3)1.36(1.16-1.59)<0.0011.52(1.27-1.81)<0.001
Comorbidities
  Diabetes mellitus (yes/no)58,427/69,9116,795(11.6)/6,960(10.01.19(1.15-1.23)<0.0011.13(1.08-1.19)<0.001
  Ischemic heart disease (yes/no)19,264/109,0743,178(16.5)/10,577(9.7)1.84(1.76-1.92)<0.0011.64(1.55-1.73)<0.001
  Heart failure (yes/no)18,174/110,1643,277(18.0)/10,478(9.5)2.09(2.01-2.18)<0.0011.42(1.35-1.50)<0.001
  Sepsis (yes/no)16,792/111,5466,146(36.6)/7,609(6.8)7.89(7.58-8.20)<0.0014.96(4.75-5.19)<0.001
  Pneumonia (yes/no)13,247/115,0913,860(29.1)/9,895(8.6)4.37(4.19-4.56)<0.0011.81(1.72-1.91)<0.001
  AKI plus preexisting CKD (yes/no)11,367/116,9712,972(26.1)/10,783(9.2)3.49(3.33-3.65)<0.0011.63(1.54-1.72)<0.001
  Stroke (yes/no)9,527/118,8112,071(21.7)/11,684(9.8)2.55(2.42-2.68)<0.0012.16(2.03-2.30)<0.001
  Respiratory failure (yes/no)10,596/117,7424,707(44.4)/9,048(7.7)9.60(9.19-10.03)<0.0014.14(3.94-4.36)<0.001
Complications
Anemia requiring blood Transfusion (yes/no) 38,730/89,6085,916(15.3)/7,839(8.7)1.88(1.81-1.95)<0.0011.21(1.16-1.27)<0.001
  Hyperkalemia (yes/no)19,165/109,1733,728(19.5)/10,027(9.2)2.39(2.29-2.49)<0.0011.51(1.44-1.59)<0.001
  Volume overload (yes/no)15,213/113,1252,831(18.6)/10,924(9.7)2.14(2.04-2.24)<0.0011.25(1.18-1.32)<0.001
  Metabolic acidosis (yes/no)10,561/117,7772,799(26.5)/10,956(9.3)3.52(3.35-3.69)<0.0011.74(1.64-1.84)<0.001
Chronic kidney disease, CKD; AKI, acute kidney injury

Discussion

CKD is defined as abnormalities in the kidney structure or function or a decreased glomerular filtration rate (GFR <60 mL/min/1.73 m2) for more than three months, or both [13]. Code N18 in the ICD-10 represents an older nomenclature for chronic renal failure—a decreased GFR comparable to patients with stage 3a–5 CKD (GFR <60 mL/min/1.73 m2). Our study found the major diseases associated with CKD were hypertension and DM. The less prevalent comorbidities, albeit causing long duration of admission, high treatment cost, and mortality were pneumonia, sepsis, respiratory failure, AKI in addition to CKD, stroke and ischemic heart disease. CKD with complications are also associated with higher mortality. The degree of CKD severity increased in-hospital mortality of patients with acute coronary syndrome [14-17], heart failure [18-20], cardiac surgery [21], and stroke [22-24]. The reasons for the poor outcome specifically among these patients are: (a) CKD is itself an independent factor, (b) CKD is usually associated with multiple comorbidities, (c) the associated diseases precipitate serious complications, and (d) standard care for comorbidities are underutilized [15, 17, 19, 20]. Moreover, in-hospital costs and length of hospitalization of CKD patients represent a substantial economic burden, which is associated with comorbidity— especially of cardiovascular diseases, DM, and infections [14, 19, 20, 25]. Optimum therapeutic interventions made early, and appropriate medication, might improve clinical outcomes and reduce the cost of hospitalization.

The present study revealed that patients with CKD aged between 70 and 80 years, and older had significantly increased mortality compared with younger patients. Prognosis of elderly CKD patients depended on several factors including functional, psychosocial, and cognitive status, occurrence of malnutrition, associated comorbidities and treatments. These patients should receive comprehensive geriatric assessment and multidimensional management for improving of prognosis [26].

An important finding was that severe infection, especially pneumonia, was a leading cause of associated disease resulting in the highest hospital charges and mortality. This supports a previous finding that pneumonia is a serious complication in older patients with CKD, who are more likely to have comorbidities—especially CVD, higher pneumonia severity index, and greater mortality than patients with pneumonia, but without CKD [27]. In addition, patients with CKD are susceptible to infection because of an impaired innate immune system including impaired neutrophil and macrophage function [28]. Further study is needed to identify risk factors and organism causing pneumonia in Thai patients with CKD to determine a strategy for preventing pneumonia and reducing mortality.

The prevalence of CVD—including coronary heart disease, congestive heart failure, left ventricular hypertrophy, and stroke—are increased in patients with CKD, and progress with the severity of CKD, leading to morbidity and mortality [14, 19, 22, 24, 29]. Occurrence of CKD in patients with CVD increased related hospital cost and mortality [15, 16, 18]. The interaction of cardiac and renal functions has been established and designated as cardio–renal syndrome [30]. The relationship between the heart and kidneys is bidirectional and mediated by several mechanisms: namely, hemodynamic change, hormonal effects, activation of the sympathetic nervous system and renin–angiotensin–aldosterone system, metabolic derangement, malnutrition, and inflammation [31, 32]. Moreover, common risk factors and complications of CKD (i.e., hypertension, diabetes mellitus, dyslipidemia, albuminuria, anemia, hyperkalemia, and volume overload) aggravate CVD. Therefore, treatment of these factors will improve CVD outcomes.

Data presented in the Tables presents the characteristics of patients with CKD with and without AKI, demonstrating that patients with CKD patients with AKI had significantly more comorbidity, CKD complications, dialysis treatment, length of hospital stay, hospital charges, and mortality. These findings confirm those found in other studies [33-35]. AKI and CKD have a bidirectional relationship; such that AKI is associated with progression to CKD and preexisting CKD increases the risk of AKI [36-38]. Therefore, more effort should be made to prevent AKI in patients with CKD.

Early and appropriate treatment of complications of CKD among outpatients may reduce the chance of admission. For example, receiving an adequate dose of erythropoiesis-stimulating agent and iron supplement decreases the need for blood transfusion and hospitalization [39, 40]. Patient education regarding limiting high potassium and salt intake and proper adherence to medication might reduce the occurrence of hyperkalemia and volume overload requiring hospital admission.

A strength of this study is that almost all Thai adult patients hospitalized with CKD were included. Therefore, the results should provide an overview of the situation. Notwithstanding, the lack of a registered nationwide laboratory system means that there is no defined staging of CKD in patients in the present study. However, because of the retrospective nature of the study design, some data might not be complete. The record of hospital charges for each group represents an average, which might not wholly characterize the severity of individual patients, nor include details of the procedures and medical instruments needed for each patient.

Conclusions

Pneumonia, sepsis, respiratory failure, AKI in addition to preexisting CKD, stroke, and ischemic heart disease were the major diseases associated with high hospital charges and mortality of CKD patients. Prevention and early treatment of these comorbidities and CKD complications should reduce the poor outcome of, and treatment costs for, patients hospitalized with CKD.

Acknowledgment

Funding from the Faculty of Medicine, Khon Kaen University, supported the study. The Thailand Research Fund is acknowledged for assistance in this project (No. IRG 5780016). We thank Mr. Bryan Roderick Hamman for assistance with the English language presentation of the manuscript.

Conflict of interest statement: The authors have no conflicts of interest to declare.

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  • 15

    Szummer K Lundman P Jacobson SH Sch n S Lindb ck J Stenestrand U et al. Relation between renal function presentation use of therapies and inhospital complications in acute coronary syndrome: data from the SWEDEHEART register. J Intern Med. 2010; 268:40-9.

  • 16

    Volkmann MA Behr PE Burmeister JE Consoni PR Kalil RA Prates PR et al. Hidden renal dysfunction causes increased in-hospital mortality risk after coronary artery bypass graft surgery. Rev Bras Cir Cardiovasc. 2011; 26:319-25.

  • 17

    Tessone A Gottlieb S Barbash IM Garty M Porath A Tenenbaum A et al. Underuse of standard care and outcome of patients with acute myocardial infarction and chronic renal insufficiency. Cardiology. 2007; 108: 193-9.

    • Crossref
    • Export Citation
  • 18

    Heywood JT Fonarow GC Costanzo MR Mathur VS Wigneswaran JR Wynne J. High prevalence of renal dysfunction and its impact on outcome in 118465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Card Fail. 2007; 13:422-30.

    • Crossref
    • Export Citation
  • 19

    Yang YH Wang L An F Huang JH Ma JP Li GP et al. Renal dysfunction and survival in hospitalized patients with chronic heart failure: a retrospective analysis. Zhonghua Xin Xue Guan Bing Za Zhi. 2009; 37:729-33.

  • 20

    Chew DP Astley C Molloy D Vaile J De Pasquale CG Aylward P. Morbidity mortality and economic burden of renal impairment in cardiac intensive care. Intern Med J. 2006; 36:185-92.

    • Crossref
    • Export Citation
  • 21

    Howell NJ Keogh BE Bonser RS Graham TR Mascaro J Rooney SJ et al. Mild renal dysfunction predicts in-hospital mortality and postdischarge survival following cardiac surgery. Eur J Cardiothorac Surg. 2008; 34:390-5.

    • Crossref
    • Export Citation
  • 22

    Ovbiagele B. Chronic kidney disease and risk of death during hospitalization for stroke. J Neurol Sci. 2011; 301:46-50.

    • Crossref
    • Export Citation
  • 23

    Agrawal V Rai B Fellows J McCullough PA. Inhospital outcomes with thrombolytic therapy in patients with renal dysfunction presenting with acute ischaemic stroke. Nephrol Dial Transplant. 2010; 25: 1150-7.

    • Crossref
    • Export Citation
  • 24

    Brzosko S Szkolka T Mysliwiec M. Kidney disease is a negative predictor of 30-day survival after acute ischaemic stroke. Nephron Clin Pract. 2009; 112: c79-85.

    • Crossref
    • Export Citation
  • 25

    Morduchowicz G Boner G. Hospitalizations in dialysis end-stage renal failure patients. Nephron. 1996; 73: 413-6.

    • Crossref
    • Export Citation
  • 26

    Pilotto A Panza F Sancarlo D Paroni G Maggi S Ferrucci L. Usefulness of the multidimensional prognostic index (MPI) in the management of older patients with chronic kidney disease. J Nephrol. 2012; 25 (Suppl 19):S79-S84.

  • 27

    Viasus D Garcia-Vidal C Cruzado JM Adamuz J Verdaguer R Manresa F et al. Epidemiology clinical features and outcomes of pneumonia in patients with chronic kidney disease. Nephrol Dial Transplant. 2011; 26:2899-906.

    • Crossref
    • Export Citation
  • 28

    Heinzelmann M Mercer-Jones MA Passmore JC. Neutrophils and renal failure. Am J Kidney Dis. 1999; 34:384-99.

    • Crossref
    • Export Citation
  • 29

    Chen XN Pan XX Yu HJ Shen PY Zhang QY Zhang W et al. Analysis of cardiovascular disease in Chinese inpatients with chronic kidney disease. Intern Med. 2011; 50:1797-801.

    • Crossref
    • Export Citation
  • 30

    McCullough PA Verrill TA. Cardiorenal interaction: appropriate treatment of cardiovascular risk factors to improve outcomes in chronic kidney disease. Postgrad Med. 2010; 122:25-34.

    • Crossref
    • Export Citation
  • 31

    Ronco C Di Lullo L. Cardiorenal syndrome. Heart Fail Clin. 2014; 10:251-80.

    • Crossref
    • Export Citation
  • 32

    Di Lullo L House A Gorini A Santoboni A Russo D Ronco C. Chronic kidney disease and cardiovascular complications. Heart Fail Rev. 2015; 20:259-72.

    • Crossref
    • Export Citation
  • 33

    Malleshappa P Shah BV. Prevalence of chronic kidney disease and the incidence of acute kidney injury in patients with coronary artery disease in Mumbai India. Heart Views. 2015; 16:47-52.

    • Crossref
    • Export Citation
  • 34

    Mahmoud LB Pariente A Kammoun K Hakim A Ghozzi H Sahnoun Z Risk factors for acute decompensation of chronic kidney disease in hospitalized patients in the nephrology department: a case-control study. Clin Nephrol. 2014; 81:86-92.

    • Crossref
    • Export Citation
  • 35

    Zhou Q Zhao C Xie D Xu D Bin J Chen P et al. Acute and acute-on-chronic kidney injury of patients with decompensated heart failure: impact on outcomes. BMC Nephrol. 2012; 13:51.

    • Crossref
    • Export Citation
  • 36

    Pannu N. Bidirectional relationships between acute kidney injury and chronic kidney disease. Curr Opin Nephrol Hypertens. 2013; 22:351-6.

    • Crossref
    • Export Citation
  • 37

    Belayev LY Palevsky PM. The link between acute kidney injury and chronic kidney disease. Curr Opin Nephrol Hypertens. 2014; 23:149-54.

    • Crossref
    • Export Citation
  • 38

    Chawla LS Kimmel PL. Acute kidney injury and chronic kidney disease: an integrated clinical syndrome. Kidney Int. 2012; 82:516-24.

    • Crossref
    • Export Citation
  • 39

    Knight TG Ryan K Schaefer CP D’Sylva L Durden ED. Clinical and economic outcomes in Medicare beneficiaries with stage 3 or stage 4 chronic kidney disease and anemia: the role of intravenous iron therapy. J Manag Care Pharm. 2010; 16:605-15.

  • 40

    Maddux FW Shetty S del Aguila MA Nelson MA Murray BM. Effect of erythropoiesis-stimulating agents on healthcare utilization costs and outcomes in chronic kidney disease. Ann Pharmacother. 2007; 41:1761-9.

    • Crossref
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1

    Levey AS Atkins R Coresh J Cohen EP Collins AJ Eckardt KU et al. Chronic kidney disease as a global public health problem: approaches and initiatives—a position statement from Kidney Disease Improving Global Outcomes. Kidney Int. 2007; 72:247-9.

    • Crossref
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  • 2

    Collins AJ Gilbertson DT Snyder JJ Chen SC Foley RN. Chronic kidney disease awareness screening and prevention: rationale for the design of a public education program. Nephrology (Carlton). 2010; 15(Suppl 2):37-42.

  • 3

    Kronenberg F. Emerging risk factors and markers of chronic kidney disease progression. Nat Rev Nephrol. 2009; 5:677-89.

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  • 4

    Ingsathit A Thakkinstian A Chaiprasert A Sangthawan P Gojaseni P Kiattisunthorn K et al. Prevalence and risk factors of chronic kidney disease in the Thai adult population: Thai SEEK study. Nephrol Dial Transplant. 2010; 25:1567-75.

    • Crossref
    • Export Citation
  • 5

    Perkovic V Cass A Patel AA Suriyawongpaisal P Barzi F Chadban S et al. High prevalence of chronic kidney disease in Thailand. Kidney Int. 2008; 73: 473-9.

    • Crossref
    • Export Citation
  • 6

    Domrongkitchaiporn S Sritara P Kitiyakara C Stitchantrakul W Krittaphol V Lolekha P et al. Risk factors for development of decreased kidney function in a southeast Asian population: a 12-year cohort study. J Am Soc Nephrol. 2005; 16:791-9.

    • Crossref
    • Export Citation
  • 7

    Daratha KB Short RA Corbett CF Ring ME Alicic R Choka R et al. Risks of subsequent hospitalization and death in patients with kidney disease. Clin J Am Soc Nephrol. 2012; 7:409-16.

    • Crossref
    • Export Citation
  • 8

    Go AS Chertow GM Fan D McCulloch CE Hsu CY. Chronic kidney disease and the risks of death cardiovascular events and hospitalization. N Engl J Med. 2004; 351:1296-305.

    • Crossref
    • Export Citation
  • 9

    Wiebe N Klarenbach SW Allan GM Manns BJ Pelletier R James MT et al. Potentially preventable hospitalization as a complication of CKD: a cohort study. Am J Kidney Dis. 2014; 64:230-8.

    • Crossref
    • Export Citation
  • 10

    World Health Organization (WHO). International classification of diseases version 10 (ICD-10). [online] 2013. [cited 2013 Oct 22]. Available from: http://www.who.int/classifications/icd10

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    World Health Organization (WHO). ICD-9-CM 2010 classification of procedures. International classification of diseases 9th revision clinical modification. [online] 2013. [cited 2013 Oct 22]. Available from: http://medinfo.psu.ac.th/pr/pr2012/ICD/ICD9CM.pdf. Accessed Oct 22 2013.

  • 12

    Anunnatsiri S Reungjui S Thavornpitak Y Pukdeesamai P Mairiang P. Disease patterns among Thai adult population: an analysis of data from the hospitalization National Health Insurance System 2010. J Med Assoc Thai. 2012; 95(Suppl 7):S74-S80.

  • 13

    Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013; 3: 1-150.

  • 14

    Meyer A Bunzemeier H Hausberg M Walter M Roeder N Breithardt G et al. Impact of different stages of chronic kidney disease on in-hospital costs in patients with coronary heart disease. Nephrol Dial Transplant. 2008; 23:1955-60.

    • Crossref
    • Export Citation
  • 15

    Szummer K Lundman P Jacobson SH Sch n S Lindb ck J Stenestrand U et al. Relation between renal function presentation use of therapies and inhospital complications in acute coronary syndrome: data from the SWEDEHEART register. J Intern Med. 2010; 268:40-9.

  • 16

    Volkmann MA Behr PE Burmeister JE Consoni PR Kalil RA Prates PR et al. Hidden renal dysfunction causes increased in-hospital mortality risk after coronary artery bypass graft surgery. Rev Bras Cir Cardiovasc. 2011; 26:319-25.

  • 17

    Tessone A Gottlieb S Barbash IM Garty M Porath A Tenenbaum A et al. Underuse of standard care and outcome of patients with acute myocardial infarction and chronic renal insufficiency. Cardiology. 2007; 108: 193-9.

    • Crossref
    • Export Citation
  • 18

    Heywood JT Fonarow GC Costanzo MR Mathur VS Wigneswaran JR Wynne J. High prevalence of renal dysfunction and its impact on outcome in 118465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Card Fail. 2007; 13:422-30.

    • Crossref
    • Export Citation
  • 19

    Yang YH Wang L An F Huang JH Ma JP Li GP et al. Renal dysfunction and survival in hospitalized patients with chronic heart failure: a retrospective analysis. Zhonghua Xin Xue Guan Bing Za Zhi. 2009; 37:729-33.

  • 20

    Chew DP Astley C Molloy D Vaile J De Pasquale CG Aylward P. Morbidity mortality and economic burden of renal impairment in cardiac intensive care. Intern Med J. 2006; 36:185-92.

    • Crossref
    • Export Citation
  • 21

    Howell NJ Keogh BE Bonser RS Graham TR Mascaro J Rooney SJ et al. Mild renal dysfunction predicts in-hospital mortality and postdischarge survival following cardiac surgery. Eur J Cardiothorac Surg. 2008; 34:390-5.

    • Crossref
    • Export Citation
  • 22

    Ovbiagele B. Chronic kidney disease and risk of death during hospitalization for stroke. J Neurol Sci. 2011; 301:46-50.

    • Crossref
    • Export Citation
  • 23

    Agrawal V Rai B Fellows J McCullough PA. Inhospital outcomes with thrombolytic therapy in patients with renal dysfunction presenting with acute ischaemic stroke. Nephrol Dial Transplant. 2010; 25: 1150-7.

    • Crossref
    • Export Citation
  • 24

    Brzosko S Szkolka T Mysliwiec M. Kidney disease is a negative predictor of 30-day survival after acute ischaemic stroke. Nephron Clin Pract. 2009; 112: c79-85.

    • Crossref
    • Export Citation
  • 25

    Morduchowicz G Boner G. Hospitalizations in dialysis end-stage renal failure patients. Nephron. 1996; 73: 413-6.

    • Crossref
    • Export Citation
  • 26

    Pilotto A Panza F Sancarlo D Paroni G Maggi S Ferrucci L. Usefulness of the multidimensional prognostic index (MPI) in the management of older patients with chronic kidney disease. J Nephrol. 2012; 25 (Suppl 19):S79-S84.

  • 27

    Viasus D Garcia-Vidal C Cruzado JM Adamuz J Verdaguer R Manresa F et al. Epidemiology clinical features and outcomes of pneumonia in patients with chronic kidney disease. Nephrol Dial Transplant. 2011; 26:2899-906.

    • Crossref
    • Export Citation
  • 28

    Heinzelmann M Mercer-Jones MA Passmore JC. Neutrophils and renal failure. Am J Kidney Dis. 1999; 34:384-99.

    • Crossref
    • Export Citation
  • 29

    Chen XN Pan XX Yu HJ Shen PY Zhang QY Zhang W et al. Analysis of cardiovascular disease in Chinese inpatients with chronic kidney disease. Intern Med. 2011; 50:1797-801.

    • Crossref
    • Export Citation
  • 30

    McCullough PA Verrill TA. Cardiorenal interaction: appropriate treatment of cardiovascular risk factors to improve outcomes in chronic kidney disease. Postgrad Med. 2010; 122:25-34.

    • Crossref
    • Export Citation
  • 31

    Ronco C Di Lullo L. Cardiorenal syndrome. Heart Fail Clin. 2014; 10:251-80.

    • Crossref
    • Export Citation
  • 32

    Di Lullo L House A Gorini A Santoboni A Russo D Ronco C. Chronic kidney disease and cardiovascular complications. Heart Fail Rev. 2015; 20:259-72.

    • Crossref
    • Export Citation
  • 33

    Malleshappa P Shah BV. Prevalence of chronic kidney disease and the incidence of acute kidney injury in patients with coronary artery disease in Mumbai India. Heart Views. 2015; 16:47-52.

    • Crossref
    • Export Citation
  • 34

    Mahmoud LB Pariente A Kammoun K Hakim A Ghozzi H Sahnoun Z Risk factors for acute decompensation of chronic kidney disease in hospitalized patients in the nephrology department: a case-control study. Clin Nephrol. 2014; 81:86-92.

    • Crossref
    • Export Citation
  • 35

    Zhou Q Zhao C Xie D Xu D Bin J Chen P et al. Acute and acute-on-chronic kidney injury of patients with decompensated heart failure: impact on outcomes. BMC Nephrol. 2012; 13:51.

    • Crossref
    • Export Citation
  • 36

    Pannu N. Bidirectional relationships between acute kidney injury and chronic kidney disease. Curr Opin Nephrol Hypertens. 2013; 22:351-6.

    • Crossref
    • Export Citation
  • 37

    Belayev LY Palevsky PM. The link between acute kidney injury and chronic kidney disease. Curr Opin Nephrol Hypertens. 2014; 23:149-54.

    • Crossref
    • Export Citation
  • 38

    Chawla LS Kimmel PL. Acute kidney injury and chronic kidney disease: an integrated clinical syndrome. Kidney Int. 2012; 82:516-24.

    • Crossref
    • Export Citation
  • 39

    Knight TG Ryan K Schaefer CP D’Sylva L Durden ED. Clinical and economic outcomes in Medicare beneficiaries with stage 3 or stage 4 chronic kidney disease and anemia: the role of intravenous iron therapy. J Manag Care Pharm. 2010; 16:605-15.

  • 40

    Maddux FW Shetty S del Aguila MA Nelson MA Murray BM. Effect of erythropoiesis-stimulating agents on healthcare utilization costs and outcomes in chronic kidney disease. Ann Pharmacother. 2007; 41:1761-9.

    • Crossref
    • Export Citation
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