Abstract
BackgroundPatients with chronic kidney disease (CKD) are at high risk of end-stage kidney disease (ESKD). The Kidney Failure Risk Equation (KFRE), which predicts ESKD risk among patients with CKD, has not been validated in primary care clinics in Southeast Asia (SEA). Therefore, we aimed to (1) evaluate the performance of existing KFRE equations, (2) recalibrate KFRE for better predictive precision, and (3) identify optimally feasible KFRE thresholds for nephrologist referral and dialysis planning in SEA.MethodsAll patients with CKD visiting nine primary care clinics from 2010 to 2013 in Singapore were included and applied 4-variable KFRE equations incorporating age, sex, estimated glomerular filtration rate (eGFR), and albumin-to-creatinine ratio (ACR). ESKD onset within two and five years were acquired via linkage to the Singapore Renal Registry. A weighted Brier score (the squared difference between observed vs predicted ESKD risks), bias (the median difference between observed vs predicted ESKD risks) and precision (the interquartile range of the bias) were used to select the best-calibrated KFRE equation.ResultsThe recalibrated KFRE (named Recalibrated Pooled KFRE SEA) performed better than existing and other recalibrated KFRE equations in terms of having a smaller Brier score (square root: 2.8% vs. 4.0–9.3% at 5 years; 2.0% vs. 6.1–9.1% at 2 years), less bias (2.5% vs. 3.3–5.2% at 5 years; 1.8% vs. 3.2–3.6% at 2 years), and improved precision (0.5% vs. 1.7–5.2% at 5 years; 0.5% vs. 3.8–4.2% at 2 years). Area under ROC curve for the Recalibrated Pooled KFRE SEA equations were 0.94 (95% confidence interval [CI]: 0.93 to 0.95) at 5 years and 0.96 (95% CI: 0.95 to 0.97) at 2 years. The optimally feasible KFRE thresholds were > 10–16% for 5-year nephrologist referral and > 45% for 2-year dialysis planning. Using the Recalibrated Pooled KFRE SEA, an estimated 82 and 89% ESKD events were included among 10% of subjects at highest estimated risk of ESKD at 5-year and 2-year, respectively.ConclusionsThe Recalibrated Pooled KFRE SEA performs better than existing KFREs and warrants implementation in primary care settings in SEA.
Highlights
Patients with chronic kidney disease (CKD) are at high risk of end-stage kidney disease (ESKD)
For the 5-year cohort, compared to patients excluded for lack of established care or missing a second measurement of serum creatinine (n = 102,258), those included in the analysis (n = 131,718) were more likely to have hypertension (87.5% vs 32.5%, P < 0.001) or type 2 diabetes mellitus (44.6% vs 14.2%, P < 0.001)
Statement of principal findings Using electronic health records linked with national renal registry, we found that the recalibrated Kidney Failure Risk Equation (KFRE) (Recalibrated Pooled KFRE Southeast Asia (SEA) equation) had better performance than existing KFRE equations in terms of having a lower Brier score, less bias and improved precision for predicting ESKD in multi-ethnic patients visiting the primary care clinics
Summary
Patients with chronic kidney disease (CKD) are at high risk of end-stage kidney disease (ESKD). The Kidney Failure Risk Equation (KFRE), which predicts ESKD risk among patients with CKD, has not been validated in primary care clinics in Southeast Asia (SEA). We aimed to (1) evaluate the performance of existing KFRE equations, (2) recalibrate KFRE for better predictive precision, and (3) identify optimally feasible KFRE thresholds for nephrologist referral and dialysis planning in SEA. The Original KFRE equation has been validated in more than 30 countries [17,18,19,20,21,22], recalibrated for non-North Americans using primarily European populations, and a Pooled KFRE equation has been developed [17] These KFRE equations were developed and evaluated primarily in patients visiting the nephrology clinics [16,17,18]. The existing KFRE equations have not been evaluated in the SEA population
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