Original Investigation Frequency of Early Predialysis Nephrology Care and Postdialysis Cardiovascular Events Ju-Yeh Yang, MD, MS, 1,2 Jenq-Wen Huang, PhD, 3 Likwang Chen, PhD, 4 Yun-Yi Chen, MS, 5 Mei-Fen Pai, MD, 1 Kuei-Ting Tung, MD, 1 Yu-Sen Peng, PhD, 1 and Kuan-Yu Hung, PhD 3 Background: Patients with kidney failure are at a high risk for cardiovascular events. Predialysis nephrology care has been reported to improve postdialysis survival, but its effects on postdialysis major adverse cardiovascular events (MACEs) have not been comprehensively studied. Study Design: Observational cohort study. Setting & Participants: We used data from the National Health Insurance Research Database in Taiwan. Adult patients who initiated maintenance dialysis therapy in 1999 to 2010 were enrolled. Predictor: We created 3 subtypes of predialysis nephrology care based on the time between the first nephrology visit and the initiation of dialysis therapy: early frequent (duration $ 6 months; at least 1 nephrology visit every 3 months), early infrequent (duration $ 6 months, ,1 nephrology visit every 3 months), and late (duration , 6 months). Outcomes: MACE was defined using the primary diagnosis in hospitalization records of acute myocardial infarction, acute heart failure, acute stroke, or sudden death. Measurements: We investigated the associations of different subtypes of nephrology care with postdialysis 1-year MACEs. Results: Among the 60,329 eligible patients, 24,477 (40.6%) had early frequent, 12,763 (21.2%) had early infrequent, and 23,089 (38.3%) had late nephrology care. Compared to the late-nephrology-care group, the early-frequent group was associated with an w10% lower risk for 1-year MACEs (HR of 0.89 [95% CI, 0.82-0.96] for first MACE and relative risk of 0.91 [95% CI, 0.84-0.98] for recurrent MACEs). However, the early-infrequent-care group had similar risks for MACEs as the late group (HR of 0.95 [95% CI, 0.86-1.05] for first MACE and relative risk of 0.94 [95% CI, 0.86-1.02] for recurrent MACEs). Limitations: Lack of physical and biochemical information because of inherent limitations from adminis- trative claims data. Conclusions: Early frequent nephrology care for 6 or more months before the initiation of long-term dialysis therapy may improve 1-year postdialysis major cardiovascular outcomes. Am J Kidney Dis. -(-):---. ª 2017 by the National Kidney Foundation, Inc. INDEX WORDS: Predialysis nephrology care; cardiovascular events; major adverse cardiac event (MACE); transition of care; end-stage renal disease (ESRD); dialysis; dialysis initiation; dialysis access; quality of care; survival; chronic kidney disease (CKD). P atients with chronic kidney disease (CKD) have a 5- to 10-fold higher risk for cardiovascular (CV) diseases, such as coronary artery disease, stroke, and heart failure, than age-matched controls. 1 Moreover, CV events are the leading cause of death in patients with CKD. 2 However, clinical trials focusing on controlling traditional CV risk factors failed to detect an improvement in CV outcomes in patients with CKD. In addition to traditional CV risk factors (hy- pertension, diabetes, and dyslipidemia), patients with CKD are known to have several uremia-related nontraditional CV risk factors, such as anemia, pro- teinuria, mineral and bone disorder, malnutrition, metabolic acidosis, uremic toxins, oxidative stress, and inflammation. 1-4 Studies have shown that predialysis nephrology care can effectively control CKD-related complications and can reduce mortality in and hospitalization of patients with end-stage renal disease on maintenance dialysis therapy. 5-10 Improved control of uremia-related nontraditional factors might theoretically reduce the risk for CV complications in patients with end-stage renal disease. However, clinical data are limited and do not clearly delineate the association between pre- dialysis nephrology care and CV outcomes in patients From the 1 Division of Nephrology and 2 Department of Quality Management Center, Far Eastern Memorial Hospital, New Taipei City; 3 Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei; 4 Institute of Popu- lation Health Sciences, National Health Research Institutes, Zhunan; and 5 Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan. Received August 24, 2016. Accepted in revised form December 19, 2016. Address correspondence to Yu-Sen Peng, PhD, Division of Nephrology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, No. 21, Sec. 2, Nanya S. Rd, Banciao Dist, New Taipei City 220, Taiwan, R.O.C. E-mail: taan70@yahoo.com.tw Ó 2017 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2016.12.018 Am J Kidney Dis. 2017;-(-):--- 1