An independent validation of the kidney failure risk equation in an Asian population

Predictive Value of Kidney Failure Risk Equation and Neutrophil Gelatinase-Associated Lipocalin for Chronic Kidney Disease Progression in Chinese Population - A Retrospective Study

Objective

To analyze the independent associations of the Kidney Failure Risk Equation (KFRE) and neutrophil gelatinase-associated lipocalin (NGAL) with end-stage renal disease (ESRD) among patients with chronic kidney disease (CKD) stages 3-5 in China and evaluate their predictive values for ESRD.

Patients and Methods

A total of 716 patients with CKD stages 3-5 at the time of the initial renal medicine referral were retrospectively enrolled, and the study outcome was the observed incidence of ESRD at 2 years after the initial referral. Baseline characteristics were collected, and relevant laboratory indexes, including neutrophil gelatinase-associated lipocalin (NGAL), were detected. The binary logistic regression model was used to analyze the independent associations, and the receiver operating characteristic (ROC) curve was used to assess the predictive values.

Results

The 2-year incidence of ESRD was 20.5% (147/716). The 4-variable KFRE, 8-variable KFRE and NGAL were independently associated with ESRD after adjusting for potential confounding factors. The AUCs of the 4-variable KFRE, 8-variable KFRE and NGAL for predicting ESRD among patients with CKD stages 3-5 were 0.711 [standard error (SE): 0.026, 95% confidence interval (CI): 0.662-0.761], 0.725 (SE: 0.025, 95% CI: 0.677-0.774) and 0.736 (SE: 0.024, 95% CI: 0.686-0.785), respectively. The AUC of the 4-variable KFRE plus NGAL was significantly higher than those of the 4-variable KFRE and NGAL alone (0.900 vs 0.711, Z = 6.297, P < 0.001; 0.900 vs 0.736, Z = 5.795, P < 0.001), and the AUC of the 8-variable KFRE plus NGAL was also significantly higher than those of the 8-variable KFRE and NGAL alone (0.911 vs 0.725, Z = 6.491, P < 0.001; 0.911 vs 0.736, Z = 6.298, P < 0.001).

Conclusion

The KFRE was able to independently predict progression of CKD stage 3-5 to ESRD in Chinese population. The addition of NGAL to the KFRE was able to elevate the predictive value when applied in predicting 2-year ESRD.

Representation of multimorbidity and frailty in the development and validation of kidney failure prognostic prediction models: a systematic review

BACKGROUND

Prognostic models that identify individuals with chronic kidney disease (CKD) at greatest risk of developing kidney failure help clinicians to make decisions and deliver precision medicine. It is recognised that people with CKD usually have multiple long-term health conditions (multimorbidity) and often experience frailty. We undertook a systematic review to evaluate the representation and consideration of multimorbidity and frailty within CKD cohorts used to develop and/or validate prognostic models assessing the risk of kidney failure.

METHODS

We identified studies that described derivation, validation or update of kidney failure prognostic models in MEDLINE, CINAHL Plus and the Cochrane Library-CENTRAL. The primary outcome was representation of multimorbidity or frailty. The secondary outcome was predictive accuracy of identified models in relation to presence of multimorbidity or frailty.

RESULTS

Ninety-seven studies reporting 121 different kidney failure prognostic models were identified. Two studies reported prevalence of multimorbidity and a single study reported prevalence of frailty. The rates of specific comorbidities were reported in a greater proportion of studies: 67.0% reported baseline data on diabetes, 54.6% reported hypertension and 39.2% reported cardiovascular disease. No studies included frailty in model development, and only one study considered multimorbidity as a predictor variable. No studies assessed model performance in populations in relation to multimorbidity. A single study assessed associations between frailty and the risks of kidney failure and death.

CONCLUSIONS

There is a paucity of kidney failure risk prediction models that consider the impact of multimorbidity and/or frailty, resulting in a lack of clear evidence-based practice for multimorbid or frail individuals. These knowledge gaps should be explored to help clinicians know whether these models can be used for CKD patients who experience multimorbidity and/or frailty.

SYSTEMATIC REVIEW REGISTRATION

This review has been registered on PROSPERO (CRD42022347295).

Deep learning algorithms for predicting renal replacement therapy initiation in CKD patients: a retrospective cohort study

BACKGROUND

Chronic kidney disease (CKD) requires accurate prediction of renal replacement therapy (RRT) initiation risk. This study developed deep learning algorithms (DLAs) to predict RRT risk in CKD patients by incorporating medical history and prescriptions in addition to biochemical investigations.

METHODS

A multi-centre retrospective cohort study was conducted in three major hospitals in Hong Kong. CKD patients with an eGFR < 30ml/min/1.73m2 were included. DLAs of various structures were created and trained using patient data. Using a test set, the DLAs' predictive performance was compared to Kidney Failure Risk Equation (KFRE).

RESULTS

DLAs outperformed KFRE in predicting RRT initiation risk (CNN + LSTM + ANN layers ROC-AUC = 0.90; CNN ROC-AUC = 0.91; 4-variable KFRE: ROC-AUC = 0.84; 8-variable KFRE: ROC-AUC = 0.84). DLAs accurately predicted uncoded renal transplants and patients requiring dialysis after 5 years, demonstrating their ability to capture non-linear relationships.

CONCLUSIONS

DLAs provide accurate predictions of RRT risk in CKD patients, surpassing traditional methods like KFRE. Incorporating medical history and prescriptions improves prediction performance. While our findings suggest that DLAs hold promise for improving patient care and resource allocation in CKD management, further prospective observational studies and randomized controlled trials are necessary to fully understand their impact, particularly regarding DLA interpretability, bias minimization, and overfitting reduction. Overall, our research underscores the emerging role of DLAs as potentially valuable tools in advancing the management of CKD and predicting RRT initiation risk.

Risk Prediction and Management of Chronic Kidney Disease in People Living with Type 2 Diabetes Mellitus

People with type 2 diabetes mellitus have increased risk of chronic kidney disease and atherosclerotic cardiovascular disease. Improved care delivery and implementation of guideline-directed medical therapy have contributed to the declining incidence of atherosclerotic cardiovascular disease in high-income countries. By contrast, the global incidence of chronic kidney disease and associated mortality is either plateaued or increased, leading to escalating direct and indirect medical costs. Given limited resources, better risk stratification approaches to identify people at risk of rapid progression to end-stage kidney disease can reduce therapeutic inertia, facilitate timely interventions and identify the need for early nephrologist referral. Among people with chronic kidney disease G3a and beyond, the kidney failure risk equations (KFRE) have been externally validated and outperformed other risk prediction models. The KFRE can also guide the timing of preparation for kidney replacement therapy with improved healthcare resources planning and may prevent multiple complications and premature mortality among people with chronic kidney disease with and without type 2 diabetes mellitus. The present review summarizes the evidence of KFRE to date and call for future research to validate and evaluate its impact on cardiovascular and mortality outcomes, as well as healthcare resource utilization in multiethnic populations and different healthcare settings.

Clinical Decision Support Tools in the Electronic Medical Record

The integration of clinical decision support (CDS) tools into electronic medical record (EMR) systems has become common. Although there are many benefits for both patients and providers from successful integration, barriers exist that prevent consistent and effective use of these tools. Such barriers include tool alert fatigue, lack of interoperability between tools and medical record systems, and poor acceptance of tools by care providers. However, successful integration of CDS tools into EMR systems have been reported; examples of these include the Statin Choice Decision Aid, and the Kidney Failure Risk Equation (KFRE). This article reviews the history of EMR systems and its integration with CDS tools, the barriers preventing successful integration, and the benefits reported from successful integration. This article also provides suggestions and strategies for improving successful integration, making these tools easier to use and more effective for care providers.

The kidney failure risk equation predicts kidney failure: Validation in an Australian cohort

AIMS

Predicting progression to kidney failure for patients with chronic kidney disease is essential for patient and clinicians' management decisions, patient prognosis, and service planning. The Tangri et al Kidney Failure Risk Equation (KFRE) was developed to predict the outcome of kidney failure. The KFRE has not been independently validated in an Australian Cohort.

METHODS

Using data linkage of the Tasmanian Chronic Kidney Disease study (CKD.TASlink) and the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), we externally validated the KFRE. We validated the 4, 6, and 8-variable KFRE at both 2 and 5 years. We assessed model fit (goodness of fit), discrimination (Harell's C statistic), and calibration (observed vs predicted survival).

RESULTS

There were 18 170 in the cohort with 12 861 participants with 2 years and 8182 with 5 years outcomes. Of these 2607 people died and 285 progressed to kidney replacement therapy. The KFRE has excellent discrimination with C statistics of 0.96-0.98 at 2 years and 0.95-0.96 at 5 years. The calibration was adequate with well-performing Brier scores (0.004-0.01 at 2 years, 0.01-0.03 at 5 years) however the calibration curves, whilst adequate, indicate that predicted outcomes are systematically worse than observed.

CONCLUSION

This external validation study demonstrates the KFRE performs well in an Australian population and can be used by clinicians and service planners for individualised risk prediction.

ESKD Risk Prediction Model in a Multicenter Chronic Kidney Disease Cohort in China: A Derivation, Validation, and Comparison Study

BACKGROUND AND OBJECTIVES

In light of the growing burden of chronic kidney disease (CKD), it is of particular importance to create disease prediction models that can assist healthcare providers in identifying cases of CKD individual risk and integrate risk-based care for disease progress management. The objective of this study was to develop and validate a new pragmatic end-stage kidney disease (ESKD) risk prediction utilizing the Cox proportional hazards model (Cox) and machine learning (ML).

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

The Chinese Cohort Study of Chronic Kidney Disease (C-STRIDE), a multicenter CKD cohort in China, was employed as the model's training and testing datasets, with a split ratio of 7:3. A cohort from Peking University First Hospital (PKUFH cohort) served as the external validation dataset. The participants' laboratory tests in those cohorts were conducted at PKUFH. We included individuals with CKD stages 1~4 at baseline. The incidence of kidney replacement therapy (KRT) was defined as the outcome. We constructed the Peking University-CKD (PKU-CKD) risk prediction model employing the Cox and ML methods, which include extreme gradient boosting (XGBoost) and survival support vector machine (SSVM). These models discriminate metrics by applying Harrell's concordance index (Harrell's C-index) and Uno's concordance (Uno's C). The calibration performance was measured by the Brier score and plots.

RESULTS

Of the 3216 C-STRIDE and 342 PKUFH participants, 411 (12.8%) and 25 (7.3%) experienced KRT with mean follow-up periods of 4.45 and 3.37 years, respectively. The features included in the PKU-CKD model were age, gender, estimated glomerular filtration rate (eGFR), urinary albumin-creatinine ratio (UACR), albumin, hemoglobin, medical history of type 2 diabetes mellitus (T2DM), and hypertension. In the test dataset, the values of the Cox model for Harrell's C-index, Uno's C-index, and Brier score were 0.834, 0.833, and 0.065, respectively. The XGBoost algorithm values for these metrics were 0.826, 0.825, and 0.066, respectively. The SSVM model yielded values of 0.748, 0.747, and 0.070, respectively, for the above parameters. The comparative analysis revealed no significant difference between XGBoost and Cox, in terms of Harrell's C, Uno's C, and the Brier score (p = 0.186, 0.213, and 0.41, respectively) in the test dataset. The SSVM model was significantly inferior to the previous two models (p < 0.001), in terms of discrimination and calibration. The validation dataset showed that XGBoost was superior to Cox, regarding Harrell's C, Uno's C, and the Brier score (p = 0.003, 0.027, and 0.032, respectively), while Cox and SSVM were almost identical concerning these three parameters (p = 0.102, 0.092, and 0.048, respectively).

CONCLUSIONS

We developed and validated a new ESKD risk prediction model for patients with CKD, employing commonly measured indicators in clinical practice, and its overall performance was satisfactory. The conventional Cox regression and certain ML models exhibited equal accuracy in predicting the course of CKD.

Asia-Inclusive Clinical Research and Development Enabled by Translational Science and Quantitative Clinical Pharmacology: Toward a Culture That Challenges the Status Quo

Access lag to innovative therapies in Asian populations continues to present a challenge to global health. Recent progressive changes in the global regulatory landscape, including newer guidelines, are enabling simultaneous global drug development and near-simultaneous global drug registration. The International Conference on Harmonization (ICH) E17 guideline outlines general principles for the design and analysis of multiregional clinical trials (MRCTs). We posit that translational research and quantitative clinical pharmacology tools are core enablers for Asia-inclusive global drug development aligned with ICH E17 principles. Assessment of ethnic sensitivity should be initiated early in the development lifecycle to inform the need for, and extent of, Asian phase I ethno-bridging data. Relevant ethno-bridging data may be generated as standalone Asian phase I trials, as part of Western First-In-Human trials, or under accelerated development settings as a lead-in phase in an MRCT. Quantitative understanding of human clearance mechanisms and pharmacogenetic factors is vital to forecasting ethnic sensitivity in drug exposure using physiologically-based pharmacokinetic models. Stratification factors to control heterogeneity in MRCTs can be identified by reverse translational research incorporating pharmacometric disease models and model-based meta-analyses. Because epidemiological variations can extend to the molecular level, quantitative systems pharmacology models may be useful in forecasting how molecular variation in therapeutic targets or pathway proteins across populations might impact treatment outcomes. Through prospective evaluation of conservation in drug- and disease-related intrinsic and extrinsic factors, a pooled East Asian region can be implemented in Asia-inclusive MRCTs to maximize efficiency in substantiating evidence of benefit-risk for the region at-large with a Totality of Evidence approach.

A prediction model with lifestyle factors improves the predictive ability for renal replacement therapy: a cohort of 442 714 Asian adults

Background

There are limited renal replacement therapy (RRT) prediction models with good performance in the general population. We developed a model that includes lifestyle factors to improve predictive ability for RRT in the population at large.

Methods

We used data collected between 1996 and 2017 from a medical screening in a cohort comprising 442 714 participants aged 20 years or over. After a median follow-up of 13 years, we identified 2212 individuals with end-stage renal disease (RRT, n: 2091; kidney transplantation, n: 121). We built three models for comparison: model 1: basic model, Kidney Failure Risk Equation with four variables (age, sex, estimated glomerular filtration rate and proteinuria); model 2: basic model + medical history + lifestyle risk factors; and model 3: model 2 + all significant clinical variables. We used the Cox proportional hazards model to construct a points-based model and applied the C statistic.

Results

Adding lifestyle factors to the basic model, the C statistic improved in model 2 from 0.91 to 0.94 (95% confidence interval: 0.94, 0.95). Model 3 showed even better C statistic value i.e., 0.95 (0.95, 0.96). With a cut-off score of 33, model 3 identified 3% of individuals with RRT risk in 10 years. This model detected over half of individuals progressing to RRT, which was higher than the sensitivity of cohort participants with stage 3 or higher chronic kidney disease (0.53 versus 0.48).

Conclusions

Our prediction model including medical history and lifestyle factors improved the predictive ability for end-stage renal disease in the general population in addition to chronic kidney disease population.

Development of New Equations Predicting the Mortality Risk of Patients on Continuous RRT

Background

Predicting the risk of death in patients admitted to the critical care unit facilitates appropriate management. In particular, among patients who are critically ill, patients with continuous RRT (CRRT) have high mortality, and predicting the mortality risk of these patients is difficult. The purpose of this study was to develop models for predicting the mortality risk of patients on CRRT and to validate the models externally.

Methods

A total of 699 adult patients with CRRT who participated in the VolumE maNagement Under body composition monitoring in critically ill patientS on CRRT (VENUS) trial and 1515 adult patients with CRRT in Seoul National University Hospital were selected as the development and validation cohorts, respectively. Using 11 predictor variables selected by the Cox proportional hazards model and clinical importance, equations predicting mortality within 7, 14, and 28 days were developed with development cohort data.

Results

The equation using 11 variables had area under the time-dependent receiver operating characteristic curve (AUROC) values of 0.75, 0.74, and 0.73 for predicting 7-, 14-, and 28-day mortality, respectively. All equations had significantly higher AUROCs than the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. The 11-variable equation was superior to the SOFA and APACHE II scores in the integrated discrimination index and net reclassification improvement analyses.

Conclusions

The newly developed equations for predicting CRRT patient mortality showed superior performance to the previous scoring systems, and they can help physicians manage patients.

Prediction models used in the progression of chronic kidney disease: A scoping review

OBJECTIVE

To provide a review of prediction models that have been used to measure clinical or pathological progression of chronic kidney disease (CKD).

DESIGN

Scoping review.

DATA SOURCES

Medline, EMBASE, CINAHL and Scopus from the year 2011 to 17th February 2022.

STUDY SELECTION

All English written studies that are published in peer-reviewed journals in any country, that developed at least a statistical or computational model that predicted the risk of CKD progression.

DATA EXTRACTION

Eligible studies for full text review were assessed on the methods that were used to predict the progression of CKD. The type of information extracted included: the author(s), title of article, year of publication, study dates, study location, number of participants, study design, predicted outcomes, type of prediction model, prediction variables used, validation assessment, limitations and implications.

RESULTS

From 516 studies, 33 were included for full-text review. A qualitative analysis of the articles was compared following the extracted information. The study populations across the studies were heterogenous and data acquired by the studies were sourced from different levels and locations of healthcare systems. 31 studies implemented supervised models, and 2 studies included unsupervised models. Regardless of the model used, the predicted outcome included measurement of risk of progression towards end-stage kidney disease (ESKD) of related definitions, over given time intervals. However, there is a lack of reporting consistency on details of the development of their prediction models.

CONCLUSIONS

Researchers are working towards producing an effective model to provide key insights into the progression of CKD. This review found that cox regression modelling was predominantly used among the small number of studies in the review. This made it difficult to perform a comparison between ML algorithms, more so when different validation methods were used in different cohort types. There needs to be increased investment in a more consistent and reproducible approach for future studies looking to develop risk prediction models for CKD progression.

Validation of a Novel Predictive Algorithm for Kidney Failure in Patients Suffering from Chronic Kidney Disease: The Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD)

Current equation-based risk stratification algorithms for kidney failure (KF) may have limited applicability in real world settings, where missing information may impede their computation for a large share of patients, hampering one from taking full advantage of the wealth of information collected in electronic health records. To overcome such limitations, we trained and validated the Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD), a novel algorithm predicting end-stage kidney disease (ESKD). PROGRES-CKD is a naïve Bayes classifier predicting ESKD onset within 6 and 24 months in adult, stage 3-to-5 CKD patients. PROGRES-CKD trained on 17,775 CKD patients treated in the Fresenius Medical Care (FMC) NephroCare network. The algorithm was validated in a second independent FMC cohort (n = 6760) and in the German Chronic Kidney Disease (GCKD) study cohort (n = 4058). We contrasted PROGRES-CKD accuracy against the performance of the Kidney Failure Risk Equation (KFRE). Discrimination accuracy in the validation cohorts was excellent for both short-term (stage 4-5 CKD, FMC: AUC = 0.90, 95%CI 0.88-0.91; GCKD: AUC = 0.91, 95% CI 0.86-0.97) and long-term (stage 3-5 CKD, FMC: AUC = 0.85, 95%CI 0.83-0.88; GCKD: AUC = 0.85, 95%CI 0.83-0.88) forecasting horizons. The performance of PROGRES-CKD was non-inferior to KFRE for the 24-month horizon and proved more accurate for the 6-month horizon forecast in both validation cohorts. In the real world setting captured in the FMC validation cohort, PROGRES-CKD was computable for all patients, whereas KFRE could be computed for complete cases only (i.e., 30% and 16% of the cohort in 6- and 24-month horizons). PROGRES-CKD accurately predicts KF onset among CKD patients. Contrary to equation-based scores, PROGRES-CKD extends to patients with incomplete data and allows explicit assessment of prediction robustness in case of missing values. PROGRES-CKD may efficiently assist physicians' prognostic reasoning in real-life applications.

Albuminuria, proteinuria, and dipsticks: novel relationships and utility in risk prediction

PURPOSE OF REVIEW

Albuminuria is associated with progression of kidney disease and is the accepted gold standard for screening, staging, and prognostication of chronic kidney disease. This review focuses on current literature that has explored applications of albuminuria as a surrogate outcome, variable used in kidney failure risk prediction for novel populations, and variable that may be predicted by other proteinuria measures.

RECENT FINDINGS

Change in albuminuria shows promise as a surrogate outcome for kidney failure, which may have major implications for trial design and conduct. The kidney failure risk equation (KFRE) has been validated extensively to date and has now been applied to pediatric patients with kidney disease, advanced age, different causes of kidney disease, various countries, and those with prior kidney transplants. As albumin-to-creatinine ratios (ACRs) are not always available to clinicians and researchers, two recent studies have independently developed equations to estimate ACR from other proteinuria measures.

SUMMARY

The utility of albuminuria and the KFRE continues to grow in novel populations. With the ability to convert more widely available (and inexpensive) proteinuria measures to ACR estimates, the prospect of incorporating kidney failure risk prediction into routine care within economically challenged healthcare jurisdictions may finally be realized.

Low serum total CO2 and its association with mortality in patients being followed up in the nephrology outpatients clinic

Large-scale studies have not been conducted to assess whether serum hypobicarbonatemia increases the risk for kidney function deterioration and mortality among East-Asians. We aimed to determine the association between serum total CO₂ (TCO₂) concentrations measured at the first outpatient visit and clinical outcomes. In this multicenter cohort study, a total of 42,231 adult nephrology outpatients from 2001 to 2016 were included. End-stage renal disease (ESRD) patients on dialysis within 3 months of the first visit were excluded. Instrumental variable (IV) was used to define regions based on the proportion of patients with serum TCO₂ < 22 mEq/L. The crude mortality rate was 12.2% during a median 77.0-month follow-up period. The Cox-proportional hazard regression model adjusted for initial kidney function, alkali supplementation, and the use of diuretics demonstrated that low TCO₂ concentration was not associated with progression to ESRD, but significantly increased the risk of death. The IV analysis also confirmed a significant association between initial TCO₂ concentration and mortality (HR 0.56; 95% CI 0.49–0.64). This result was consistently significant regardless of the underlying renal function. In conclusion, low TCO₂ levels are significantly associated with mortality but not with progression to ESRD in patients with ambulatory care.