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Kidney Week

Abstract: PO0450

Comparison of Predicted Risk of Renal Replacement Therapy vs. eGFR for Arteriovenous Fistula Placement in CKD: A Retrospective Analysis

Session Information

Category: CKD (Non-Dialysis)

  • 2101 CKD (Non-Dialysis): Epidemiology, Risk Factors, and Prevention

Authors

  • Park, Ken J., Kaiser Permanente Northwest, Portland, Oregon, United States
  • Thorp, Micah L., Kaiser Permanente Northwest, Portland, Oregon, United States
  • Keast, Erin, Kaiser Permanente Center for Health Research Northwest Region, Portland, Oregon, United States
  • Benuzillo, Jose G., Edwards Lifesciences Corp, Irvine, California, United States
  • Mosen, David, Kaiser Permanente Center for Health Research Northwest Region, Portland, Oregon, United States
  • Johnson, Eric S., Kaiser Permanente Northwest, Portland, Oregon, United States
Background

The complexity in predicting which and when patients with chronic kidney disease (CKD) will progress to renal replacement therapy (RRT) contributes to 80% of patients starting hemodialysis without a functioning permanent access. Studies suggest AVF referral at eGFR of 15-20 ml/min increases the likelihood of starting dialysis with an AVF. We were interested in whether a prediction model developed at Kaiser Permanente Northwest better predicted progression to RRT at 1 year compared to eGFR.

Methods

We retrospectively followed 613 patients with stage 4 CKD between ages of 18 to 89 from May 2013 to May 2018 followed by nephrology who had a nephrology visit with an eGFR and a calculatable 2-yr risk for RRT around 12 months before end of follow up (defined as death, initiation of RRT, or 2 years from initial enrollment date). We calculated sensitivity, specificity, and area under the curve (AUC) based on a range of 2-yr risk for RRT (20%, 40%, 60%, and 80%) and compared them to eGFR threshold of 15 ml/min and 20 ml/min at the 12 month visit prior to end of follow up. We compared 2-yr risk for RRT vs. eGFR using a decision curve analysis.

Results

At end of follow up, 12% had died and 14% had progressed to RRT (69% hemodialysis, 22% peritoneal dialysis, 9% transplant). Compared to eGFR threshold of 20 ml/min, specificity and specificity was greater at 2-yr RRT risk of 40% (73% and 49% for eGFR threshold of 20 ml/min respectively compared to 85% and 54% respectively for 2-yr RRT risk threshold of 40%). Compared to eGFR threshold of 15 ml/min, specificity and specificity was greater at 2-yr RRT risk of 80% (97% and 11% for eGFR threshold of 15 ml/min respectively compared to 98% and 18% respectively for 2-yr RRT risk threshold of 80%). The AUC was greater between 2-yr RRT of 20% to 40% (0.73 to 0.70) compared to eGFR between 15 ml/min to 20 ml/min (0.54-0.61). Decision curve analysis showed better net benefit using 2-yr risk >40% compared to eGFR of 20 ml/min above a 1 year threshold of 25%.

Conclusion

In patients with CKD stage 4, 2-yr risk for RRT better predicted progression to RRT at 1 year compared to eGFR alone. Our study suggests that use of prediction model for RRT may be an important tool for determining optimal timing for AVF referral.