Enhancing vascular access planning in CKD: validating the 40% KFRE threshold for predicting ESKD in a French...

Establishing the optimal timing for creating vascular access in patients with chronic kidney disease (CKD) is a critical and challenging aspect of patient management. The Kidney Disease: Improving Global Outcomes guidelines propose using a 40% 2-year threshold based on the Kidney Failure Risk Equation (KFRE) for this purpose. However, the effectiveness of this threshold compared with traditional methods, such as estimated glomerular filtration rate (eGFR), is not well-established.

In this monocentric retrospective cohort study, we analyzed data from patients referred for vascular mapping before arteriovenous fistula (AVF) creation between April 2013 and June 2023. The study aimed to compare the ≥40% 2-year KFRE threshold with a <15 mL/min/1.73 m² eGFR threshold for predicting end-stage kidney disease (ESKD). We assessed the probability of ESKD, considering death before AVF creation as a competing risk. Discrimination between KFRE and eGFR was evaluated using C-statistics.

The study included 238 patients with a mean age of 65.2 years and a mean eGFR of 13.3 mL/min/1.73 m². Over a median follow-up of 10.7 months, 178 patients developed ESKD, and 21 died before ESKD. Probability of ESKD at 1 year was 77.6% (95% CI 69.9%-85.3%) using a ≥40% 4-variable KFRE threshold versus 65.8% (95% CI 58.3%-73.3%) using a <15 mL/min/1.73 m² eGFR threshold. The C-statistics indicated better predictive ability for the 8-variable KFRE at 6 months [0.82 (95% CI 0.76-0.88)], while both 4- and 8-variable KFRE models were effective for 1-year predictions [0.835 (95% CI 0.78-0.89) and 0.82 (95% CI 0.76-0.875), respectively]. Sensitivity and specificity analyses favored the ≥40% KFRE threshold over the eGFR threshold.

This study suggests that using a ≥40% 2-year KFRE threshold for planning vascular access in CKD patients is promising and potentially superior to the traditional <15 mL/min/1.73 m² eGFR threshold. This approach may offer a balance between minimizing premature AVF creation and the risk of starting dialysis via a central venous catheter.