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Risk prediction for hemodialysis initiation: The role of Kidney Failure Risk Equation and personalized timely
Andreia Henriques1, João Venda1, Emanuel Ferreira1,2
1Nephrology Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal.
Insights
The 2-Year Kidney Failure Risk Equation (KFRE) better predicts the need for hemodialysis (HD) initiation than estimated glomerular filtration rate (eGFR). This helps optimize arteriovenous fistula creation timing in chronic kidney disease patients.
Area of Science:
- Nephrology
- Vascular Surgery
- Predictive Analytics
Background:
- Determining the optimal timing for arteriovenous fistula (AVF) creation in patients with chronic kidney disease (CKD) is complex.
- Late referral for AVF can lead to hemodialysis (HD) initiation via central venous catheter (CVC), while early referral may result in unnecessary procedures.
- This study evaluates the predictive capabilities of estimated glomerular filtration rate (eGFR) and the 2-Year Kidney Failure Risk Equation (KFRE) for forecasting HD initiation.
Purpose of the Study:
- To compare the predictive performance of eGFR and KFRE in forecasting the need for hemodialysis initiation.
- To identify optimal thresholds for eGFR and KFRE to guide vascular access (VA) planning and referral timing in CKD patients.
- To reduce the incidence of CVC use for HD initiation and prevent unnecessary surgical interventions.
Main Methods:
- A cohort of 179 adult CKD patients referred for vascular mapping and preferring HD were included.
- Data on HD initiation timing, vascular access type, mortality, eGFR, and KFRE were collected and analyzed.
- The predictive performance of eGFR and KFRE was assessed using sensitivity, specificity, and p-values at different time points (12 and 24 months).
Main Results:
- Over 58% of patients initiated HD within 24 months, with nearly 60% starting via CVC.
- Higher KFRE, lower eGFR, male sex, and heart failure with reduced ejection fraction were associated with increased HD risk.
- KFRE demonstrated superior predictive performance compared to eGFR for both 12- and 24-month HD initiation, with specific thresholds identified for each.
Conclusions:
- The 2-Year Kidney Failure Risk Equation (KFRE) is a more effective predictor of hemodialysis initiation timing than eGFR.
- Utilizing KFRE, potentially in conjunction with eGFR and tailored thresholds, can refine risk assessment for vascular access referral.
- Improved prediction allows for better planning, reducing unnecessary procedures and minimizing reliance on central venous catheters for dialysis initiation.
Introduction:
Optimal timing for arteriovenous fistula creation in chronic kidney disease is challenging. Late referral results in hemodialysis (HD) initiation via a central venous catheter (CVC), whereas early referral may lead to unnecessary procedures. We evaluate the predictive value of estimated glomerular filtration rate (eGFR) and the 2-Year Kidney Failure Risk Equation (KFRE) in forecasting HD initiation.
Methods:
Included adults referred for vascular mapping with ⩾3 months of nephrology follow-up who selected HD as their preferred modality. The index date was the date of modality selection. We assessed HD initiation timing, vascular access (VA) type, mortality, and the predictive performance of eGFR and KFRE.
Results:
Included 179 patients, of whom 43.6% (n = 78) and 58.7% (n = 105) initiated HD within 12 and 24 months, respectively, with most (59.9%) starting via a CVC (59.9%). Within 24 months, 6.7% (n = 12) died before HD initiation. Higher urinary protein-to-creatinine ratio, higher KFRE, lower eGFR, male sex, and heart failure with reduced ejection fraction were associated with increased HD risk. Predictive thresholds for HD initiation within 12 months were eGFR <17.1 mL/min/1.73 m2 (sensitivity: 77.9%, specificity: 54.1%, p < 0.001), and KFRE >32.8% (sensitivity: 75.6%, specificity: 68.3%, p ⩽ 0.001). For 24 months, thresholds were eGFR <15.5 mL/min/1.73 m2 (sensitivity: 56.7%, specificity: 73.2%, p < 0.001), and KFRE >31.0% (sensitivity: 71.4%, specificity: 71.6%, p ⩽ 0.001). Patients exceeding the KFRE threshold had a higher risk of HD initiation than those below the eGFR threshold. A KFRE >40.0% increased specificity, while lower thresholds (>30%) improved sensitivity. Combining eGFR with KFRE enhance specificity but reduced sensitivity.
Conclusion:
KFRE demonstrates superior predictive performance compared to eGFR for VA planning. Balancing different thresholds values and integrating KFRE with eGFR, can refine HD initiation risk assessment and VA referral, preventing unnecessary surgery and minimizing HD initiation via CVC.
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