SAT-242 THE END OF THE CKD JOURNEY - RENAL REPLACEMENT THERAPY (RRT) OR DEATH WITHOUT RRT: THE CKD.QLD EXPERIENCE

Abstract

Patients with established chronic kidney disease (CKD) can exit the preterminal CKD state by starting RRT, or by dying without receiving RRT. The latter might die from untreated end stage kidney failure (ESKF), or from other causes. Characteristics of those starting RRT are well defined through incidence data in various registries, such as ANZDATA in Australia, but the features of those who die without RRT are less well defined. An AIHW study shows that the number of Australians who start RRT is equalled or exceeded by numbers who die with ESKF receiving RRT, but that study was not designed to define nonESKF causes of death in patients with preterminal CKD. We ascertained the outcomes of a cohort of CKD patients in public renal practices in Queensland who were enrolled in the CKD.QLD registry, and compared those who started RRT with those who died without receiving RRT. 6,371 patients in CKD.QLD (54% males, mostly CKD stages 3b, 4 and 5), were followed from consent to the CKD.QLD registry until the start of RRT, death, or a censor date of June 30, 2016. Outcomes and causes of death were further ascertained from Queensland Health records though to June 2017. Follow up ranged from 0 to 5.4 years, median (IQR) of 2.8 (3) years, or a total of 15,714 person years. By the censor date, 605 (9.5%) patients had started RRT, at a median (IQR) age of 63 (20) and 837 (13.1%) had died without RRT, at median (IQR) age 78 (14). Incidence rates were 2.79 (CI 3.4-4.0) and 5.2 (4.8-5.5) per 100 person years respectively. Rates of both were higher in males than females, with RRT incidences of 3.8 vs 2.7, p=0.001, and rates of death without 5.8 vs 4.8, p=0.001. Among 1,083 deaths without RRT through June 2017, most had multiple causes of death. ESKF was cause of death in 19%; an additional 24% had chronic renal failure documented and 25% had mention of CKD, while AKI was coexisting cause-of-death in 6.9%. Cardiovascular events were listed as causes in 69% of persons, but pulmonary deaths, malignancies, sepsis, multiorgan failure and other conditions were also frequently underlying or associated causes. Place of death was hospital for 69% of the whole nonRRT cohort, and for 80% of those who died with ESKF. Among these CKD patients from renal specialty practices, more died without RRT than started RRT. One fifth of those who died without receiving RRT died with ESKF: while chronic renal failure and CKD were associated diagnoses in an additional half. Cardiovascular events were very prominent, but other common morbidities were also well represented. Persons who died without RRT had an average survival more than 15 years longer than the dialysis–free survival of those who start RRT, and most had already exceeded the average life expectancy of people born in the same era; life expectancy was 58 for men and 62 for women people born in 1937. Most were long term survivors within their birth cohorts, a reminder that the increasing prevalence of CKD is, in part, a function of increasing longevity. Notably, ascertainment of clinically evident CKD in Queensland death certificates is now very good.