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Atiquzzaman M, Er L, Djurdjev O, Bevilacqua M, Elliott M, Birks PC, Wong MM, Yi TW, Singh A, Tangri N, Levin A. Implications of Implementing the 2021 CKD-EPI Equation Without Race on Managing Patients With Kidney Disease in British Columbia, Canada. Kidney Int Rep 2024; 9:830-842. [PMID: 38765563 PMCID: PMC11101769 DOI: 10.1016/j.ekir.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction We investigated the implications of implementing race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation among real-world patients with chronic kidney disease (CKD) from British Columbia (BC), Canada. Methods This study included nondialysis-dependent patients with CKD aged ≥19 years who were registered in the Patient Records and Outcome Management Information System (PROMIS) as of March 31, 2016 (index date) with ≥1 serum creatinine measurement within 1 year before the index date. Patients with a history of kidney transplantation before the index date were excluded. CKD-EPI 2021 versus 2009 equation was the exposure variable. Difference in mean estimated glomerular filtration rate (eGFR) and number (%) of patients reclassified to a different eGFR category were estimated. We used Fine and Gray subdistribution hazard model to investigate the association between change in eGFR category and progression to kidney failure (incident maintenance dialysis or kidney transplantation) within 2 years. Results A total of 11,604 patients (median age 73 years, 52% male) were included. Compared to the 2009 equation, eGFR from 2021 equation was on average 2.7 ml/min per 1.73 m2 higher. Variation was higher among males. Overall, ∼17% of the study sample were reclassified to a category with higher eGFR by 2021 equation (switchers). The highest proportion (28%) of patients were reclassified from G5 to G4. The risk of progressing to kidney failure was 22% less among switchers compared to nonswitchers; adjusted subdistribution hazard ratio (HR) (95% confidence interval [CI]) is 0.78 (0.65, 0.94). Conclusion CKD-EPI 2021 equation appeared to provide higher eGFR compared to 2009 equation. This higher eGFR values appeared to be concordant with subsequent real-world CKD progression outcomes. Higher eGFR from the 2021 equation may have substantial clinical implications in both diagnosis as well as long-term care of patients with CKD.
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Affiliation(s)
- Mohammad Atiquzzaman
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lee Er
- BC Renal, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- BC Renal, Vancouver, British Columbia, Canada
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Micheli Bevilacqua
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark Elliott
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter C. Birks
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle M.Y. Wong
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tae Won Yi
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anurag Singh
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Navdeep Tangri
- Section of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adeera Levin
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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Levin A. Predicting Outcomes in Nephrology: Lots of Tools, Limited Uptake: How Do We Move Forward? J Am Soc Nephrol 2024; 35:361-363. [PMID: 38087445 PMCID: PMC10914199 DOI: 10.1681/asn.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Affiliation(s)
- Adeera Levin
- Medicine, Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
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Atiquzzaman M, Zhu B, Romann A, Er L, Djurdjev O, Bevilacqua M, Wong MMY, Birks P, Yi TW, Singh A, Tangri N, Levin A. Kidney Failure Risk Equation in vascular access planning: a population-based study supporting value in decision making. Clin Kidney J 2024; 17:sfae008. [PMID: 38327282 PMCID: PMC10847629 DOI: 10.1093/ckj/sfae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Indexed: 02/09/2024] Open
Abstract
Background The Kidney Failure Risk Equation (KFRE) can play a better role in vascular access (VA) planning in patients with chronic kidney disease (CKD) requiring hemodialysis (HD). We described the VA creation and utilization pattern under existing estimated glomerular filtration rate (eGFR)-based referral, and investigated the utility of KFRE score as an adjunct variable in VA planning. Methods Patients with CKD aged ≥18 years with eGFR <20 mL/min/1.73 m2 who chose HD as dialysis modality from January 2010 to August 2020 were included from a population-based database in British Columbia, Canada. Modality selection date was the index date. Exposures were categorized as (i) current eGFR-based referral, (ii) eGFR-based referral plus KRFE 2-year risk score on index date (KFRE-2) >40% and (iii) eGFR-based referral plus KFRE-2 ≤40%. We estimated the proportion of patients who started HD on arteriovenous fistula/graft (AVF/G) within 2 years, indicating timely pre-emptive creation, and the proportion of patients in whom AVF/G was created but did not start HD within 2 years, indicating too-early creation. Results Study included 2581 patients, median age 71 years, 60% male. Overall, 1562(61%) started HD and 276 (11%) experienced death before HD initiation within 2 years. Compared with current referral, the proportion of patients who started HD on AVF/G was significantly higher when KFRE-2 was considered in addition to current referral (49% vs 58%, P-value <.001). Adjunct KFRE-2 significantly reduced too-early creation (31% vs 18%, P-value <.001). Conclusions KFRE in addition to existing eGFR-based referral for VA creation has the potential to improve VA resource utilization by ensuring more patients start HD on AVF/G and may minimize too-early/unnecessary creation. Prospective research is necessary to validate these findings.
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Affiliation(s)
- Mohammad Atiquzzaman
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | | | | | - Lee Er
- BC Renal, Vancouver, Canada
| | - Ognjenka Djurdjev
- BC Renal, Vancouver, Canada
- Provincial Clinical Policy Analytics and Registry Initiatives, Data Analytics, Reporting and Evaluation, Provincial Health Services Authority, Vancouver, Canada
| | - Micheli Bevilacqua
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Michelle M Y Wong
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Peter Birks
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Tae Won Yi
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Anurag Singh
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Adeera Levin
- BC Renal, Vancouver, Canada
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
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Patel DM, Churilla BM, Thiessen-Philbrook H, Sang Y, Grams ME, Parikh CR, Crews DC. Implementation of the Kidney Failure Risk Equation in a United States Nephrology Clinic. Kidney Int Rep 2023; 8:2665-2676. [PMID: 38106577 PMCID: PMC10719573 DOI: 10.1016/j.ekir.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The kidney failure risk equation (KFRE) estimates a person's risk of kidney failure and has great potential utility in clinical care. Methods We used mixed methods to explore implementation of the KFRE in nephrology clinics. Results KFRE scores were integrated into the electronic health record at Johns Hopkins Medicine and were displayed to nephrology providers. Documentation of KFRE scores increased over time, reaching 25% of eligible outpatient nephrology clinic notes at month 11. Three providers documented KFRE scores in >75% of notes, whereas 25 documented scores in <10% of notes. Surveys and focus groups of nephrology providers were conducted to probe provider views on the KFRE. Survey respondents (n = 25) reported variability in use of KFRE for decisions such as maintaining nephrology care, referring for transplant evaluation, or providing dialysis modality education. Provider perspectives on the use of KFRE, assessed in 2 focus groups of 4 providers each, included 3 common themes as follows: (i) KFRE scores may be most impactful in the care of specific subsets of people with chronic kidney disease (CKD); (ii) there is uncertainty about KFRE risk-based thresholds to guide clinical care; and (iii) education of patients, nephrology providers, and non-nephrology providers on appropriate interpretations of KFRE scores may help maximize their utility. Conclusion Implementation of the KFRE was limited by non-uniform provider adoption of its use, and limited knowledge about utilization of the KFRE in clinical decisions.
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Affiliation(s)
- Dipal M. Patel
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bryce M. Churilla
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather Thiessen-Philbrook
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Morgan E. Grams
- Division of Precision Medicine, Department of Medicine, New York University, New York, New York, USA
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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