Kidney Failure Risk Equation in vascular access planning: a population-based study supporting value in decision...

Area of Science:

• Nephrology
• Vascular Surgery
• Health Services Research

Background:

• Vascular access (VA) planning is crucial for patients with chronic kidney disease (CKD) undergoing hemodialysis (HD).
• Current referral practices rely on estimated glomerular filtration rate (eGFR), but its utility in optimizing VA creation timing is debated.
• The Kidney Failure Risk Equation (KFRE) may offer a more precise tool for predicting future dialysis needs and guiding VA planning.

Purpose of the Study:

• To evaluate the effectiveness of the KFRE score as an adjunct to eGFR-based referral for vascular access planning in CKD patients.
• To compare VA creation and utilization patterns under eGFR-based referral versus KFRE-informed referral.
• To assess the impact of KFRE on timely pre-emptive VA creation and the incidence of too-early VA creation.

Main Methods:

• A population-based cohort study included 2581 CKD patients (eGFR <20 mL/min/1.73 m²) in British Columbia, Canada (2010-2020).
• Patients were categorized based on referral strategy: eGFR-based, eGFR + KFRE-2 risk score >40%, or eGFR + KFRE-2 risk score ≤40%.
• Outcomes measured included the proportion of patients starting HD with an arteriovenous fistula/graft (AVF/G) within 2 years and the proportion of AVF/G created but not utilized within 2 years.

Main Results:

• Adjunct KFRE-2 significantly increased the proportion of patients starting HD on AVF/G compared to eGFR-based referral alone (58% vs. 49%, P < .001).
• Incorporating KFRE-2 substantially reduced the rate of too-early AVF/G creation (18% vs. 31%, P < .001).
• Despite 61% initiating HD, 11% died before dialysis initiation within the 2-year study period.

Conclusions:

• Integrating the KFRE score into existing eGFR-based referral protocols can optimize vascular access planning for hemodialysis patients.
• This approach enhances VA resource utilization by increasing timely AVF/G creation and minimizing unnecessary early procedures.
• Further prospective studies are warranted to validate these findings and refine KFRE's role in clinical practice.