Kidney Week

Abstract: FR-PO1116

Comparing eGFR-Based vs. Kidney Failure Risk Equation-Based Strategies to Identify Veterans with Advanced CKD for Kidney Transplant Referral: A National VA Cohort Study

Session Information

• Transplantation: Clinical - Transplant Access, Recipient Evaluation, Living Donors, Pregnancy, and More
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2002 Transplantation: Clinical

Authors

• Paulus, Amber B., Virginia Commonwealth University, Richmond, Virginia, United States

Amber B. Paulus, PhD

• Gupta, Gaurav, Virginia Commonwealth University, Richmond, Virginia, United States

Gaurav Gupta, MD

• Shukla, Ashutosh M., University of Florida Health, Gainesville, Florida, United States

Ashutosh M. Shukla, MD, MBBS, FASN

• Silvey, Scott, Richmond VA Medical Center, Richmond, Virginia, United States

Scott Silvey, PhD

• Patel, Nilang G., Richmond VA Medical Center, Richmond, Virginia, United States

Nilang G. Patel, MD, MS, FASN

Background

Transplant evaluation is typically recommended once eGFR falls below 20 mL/min/1.73m² and US OPTN policy allows pre–emptive listing only below this threshold. 2–year Kidney Failure Risk Equation(KFRE) may offer an alternative strategy to identify high risk patients earlier & more accurately. We evaluated (1) characteristics of veterans meeting traditional eGFR ≤20 vs. KFRE ≥40% criteria, and (2) how these strategies differ in capturing patients who ultimately receive pre–emptive transplant referral, listing, or transplantation.

Methods

We created a national cohort of US veterans with advanced CKD using VA-CDW, VA Community Care Network,CMS & USRDS/UNOS data (2009–2023). Race–free CKD–EPI eGFR and 2–yr KFRE were calculated at all outpatient timepoints. Two non-mutually exclusive index cohorts were created: (1) first eGFR ≤20 and (2) first KFRE ≥40%. Exclusions approximated a transplant–eligible population as follows: prior ESRD/transplant, nursing home or frail status, home oxygen use, BMI >40, and non–skin cancer. Pre–emptive events were defined as those occurring before dialysis or death.

Results

22,309 of eGFR ≤20, and 12,823 of KFRE ≥40% were included in the final analysis. 43.2% of the eGFR ≤20 cohort also had KFRE ≥40%, Of those in KFRE ≥40% cohort, 71.0% had eGFR <20; while additional 29% with eGFR >20 were eligible for referral by KFRE criteria.

Compared with eGFR<20, veterans identified by KFRE≥40% were younger, had more albuminuria, higher comorbidity, and were more Hispanic/non-White. Nephrology engagement within 1 year was higher in the KFRE cohort than the eGFR cohort (64.8% vs. 57.2%; p<0.001) and was associated with higher referral.

Pre–emptive referral and waitlisting remained low but were higher in KFRE>40% than eGFR<20: referral 16.2% vs 12.8%, waitlisting 3.8% vs 2.7%, and transplant 0.7% vs 0.6%.

Earlier referral was associated with younger age, lower comorbidity burden, urban residence, higher income and higher education.

Conclusion

Among veterans with advanced CKD, eGFR ≤20 identified a larger, more heterogeneous population, whereas KFRE ≥40% identified a smaller group with higher predicted short-term kidney failure risk, including more minorities. Low referral, waitlisting, and transplantation rates highlight the need to explore a standardized VA workflow that converts high-risk status into timely referral.