Chronic Kidney Disease Care Research Articles

Implementation of a Co-Design Strategy to Develop a Dashboard to Support Shared Decision Making in Advanced Cancer and Chronic Kidney Disease.

Background: Shared decision making (SDM) is the process by which patients and clinicians exchange information and preferences to come to joint healthcare decisions. Clinical dashboards can support SDM by collecting, distilling, and presenting critical information, such as patient-reported outcomes (PROs), to be shared at points of care and in between appointments. We describe the implementation strategies and outcomes of a multistakeholder collaborative process known as "co-design" to develop a PRO-informed clinical dashboard to support SDM for patients with advanced cancer or chronic kidney disease (CKD). Methods: Across 14 sessions, two multidisciplinary teams comprising patients, care partners, clinicians, and other stakeholders iteratively co-designed an SDM dashboard for either advanced cancer (N = 25) or CKD (N = 24). Eligible patients, care partners, and frontline clinicians were identified by six physician champions. The co-design process included four key steps: (1) define "the problem", (2) establish context of use, (3) build a consensus on design, and (4) define and test specifications. We also evaluated our success in implementing the co-design strategy using measures of fidelity, acceptability, adoption, feasibility, and effectiveness which were collected throughout the process. Results: Mean (M) scores across implementation measures of the co-design process were high, including observer-rated fidelity and adoption of co-design practices (M = 19.1 on a 7-21 scale, N = 36 ratings across 9 sessions), as well as acceptability based on the perceived degree of SDM that occurred during the co-design process (M = 10.4 on a 0 to 12 adapted collaboRATE scale). Capturing the feasibility and adoption of convening multistakeholder co-design teams, min-max normalized scores (ranging from 0 to 1) of stakeholder representation demonstrated that, on average, 95% of stakeholder types were represented for cancer sessions (M = 0.95) and 85% for CKD sessions (M = 0.85). The co-design process was rated as either "fully" or "partially" effective by 100% of respondents, in creating a dashboard that met its intended objective. Conclusions: A co-design process was successfully implemented to develop SDM clinical dashboards for advanced cancer and CKD care. We discuss key strategies and learnings from this process that may aid others in the development and uptake of patient-centered healthcare innovations.

Community Point of Care Testing in Diagnosing and Managing Chronic Kidney Disease.

Chronic kidney disease (CKD) poses a significant global health challenge with increasing prevalence and associated morbidity. Point-of-care testing (POCT) provides an opportunity to improve CKD management and outcomes through early detection and targeted interventions, particularly in underserved communities. This review evaluates the roles of POCT in CKD, focusing on utility (through screening programs, monitoring of kidney function, and assessing participants on renally excreted medications), accuracy, and acceptability. Screening programs employing POCT have demonstrated promising outcomes, with improved rates of CKD diagnosis in groups with disparate health outcomes, offering a vital avenue for early intervention in high-risk populations. These have been conducted in rural and urban community or pharmacy settings, highlighting convenience and accessibility as important facilitators for participants. In addition, POCT holds significant promise in the monitoring of CKD, particularly in groups requiring frequent testing, such as kidney transplant recipients and patients on renin-angiotensin-aldosterone inhibitors. The consideration of the variable analytical performance of different devices remains crucial in assessing the utility of a POCT intervention for CKD. While the convenience and improved accessibility of home self-testing versus healthcare professional management is important, it must be balanced with acceptable levels of accuracy and precision to maintain patient and clinical confidence. Despite challenges including variability in accuracy and the user-friendliness of devices, patient feedback has generally remained positive, with studies reporting increased patient satisfaction and engagement. However, challenges regarding wider uptake are limited by healthcare professional confidence (in test reliability), the potential for increased workload, and early prohibitive costs. In conclusion, POCT represents a growing and valuable tool in enhancing CKD care, particularly in resource-limited settings, but careful consideration of device selection and implementation strategies is essential to achieve desired outcomes.

Prevalence, Mortality, and Access to Care for Chronic Kidney Disease in Medicaid-Enrolled Adults With Sickle Cell Disease in California: Retrospective Cohort Study.

Chronic kidney disease (CKD) is a significant complication in patients with sickle cell disease (SCD), leading to increased mortality. This study aims to investigate the burden of CKD in Medicaid-enrolled adults with SCD in California, examine differences in disease burden between male and female individuals, and assess mortality rates and access to specialized care. This retrospective cohort study used the California Sickle Cell Data Collection program to identify and monitor individuals with SCD. Medicaid claims, vital records, emergency department, and hospitalization data from 2011 to 2020 were analyzed. CKD prevalence was assessed based on ICD (International Classification of Diseases) codes, and mortality rates were calculated. Access to specialized care was examined through outpatient encounter rates with hematologists and nephrologists. Among the 2345 adults with SCD, 24.4% (n=572) met the case definition for CKD. The SCD-CKD group was older at the beginning of this study (average age 44, SD 14 vs 34, SD 12.6 years) than the group without CKD. CKD prevalence increased with age, revealing significant disparities by sex. While the youngest (18-29 years) and oldest (>65 years) groups showed similar CKD prevalences between sexes (female: 12/111, 10.8% and male: 12/101, 11.9%; female: 74/147, 50.3% and male: 34/66, 51.5%, respectively), male individuals in the aged 30-59 years bracket exhibited significantly higher rates than female individuals (30-39 years: 49/294, 16.7%, P=.01; 40-49 years: 52/182, 28.6%, P=.02; and 50-59 years: 76/157,48.4%, P<.001). During this study, of the 2345 adults, 435 (18.5%) deaths occurred, predominantly within the SCD-CKD cohort (226/435, 39.5%). The median age at death was 53 (IQR 61-44) years for the SCD-CKD group compared to 43 (IQR 33-56) years for the SCD group, with male individuals in the SCD-CKD group showing significantly higher mortality rates (111/242, 45.9%; P=.009) than female individuals (115/330, 34.9%). Access to specialist care was notably limited: approximately half (281/572, 49.1%) of the SCD-CKD cohort had no hematologist visits, and 61.9% (354/572) did not see a nephrologist during this study's period. This study provides robust estimates of CKD prevalence and mortality among Medicaid-enrolled adults with SCD in California. The findings highlight the need for improved access to specialized care for this population and increased awareness of the high mortality risk and progression associated with CKD.

Nurses' knowledge, attitude, and practice toward chronic kidney disease in hemodialysis centers at Hail City, Saudi Arabia

Chronic kidney disease (CKD) is a significant global issue with clinical, social, and economic impacts. It negatively affects quality of life and is linked to higher rates of illness and death. Nurses are crucial in the early detection and management of CKD. This study aimed to evaluate the knowledge, attitudes, and practices of nurses regarding CKD, and the factors influencing these aspects in hemodialysis centers in Hail City, Saudi Arabia. A cross-sectional study was conducted from July to October 2022 using a self-administered questionnaire. This questionnaire assessed nurses’ knowledge of CKD, their attitudes toward it, and their CKD care practices. A significance level of p&lt;0.05 was used for all tests. Approximately 63.06% of the nurses provided correct answers related to CKD knowledge. Most nurses (84.52%) had positive attitudes towards caring for CKD patients, and more than half (53.06%) had positive CKD care practices. There was a significant relationship between nurses’ knowledge scores and both “years of experience” and “received information regarding CKD care” (p=0.033 and p&lt;0.001, respectively). Nurses with more experience and previous information had higher knowledge scores than those with less experience and no prior information. Additionally, nurses with more experience and previous information also had more positive attitudes toward CKD patients than those with less experience and no prior information (p=0.004 and p=0.008, respectively). Therefore, nurses with more experience and prior information about CKD care were more knowledgeable and had more positive attitudes towards CKD patients compared to those with less experience and no prior information.

Not Just Small Adults: Considerations for Pediatric Chronic Kidney Disease

Chronic kidney disease (CKD), including pediatric CKD, is a global public health concern. Pediatric CKD has lasting effects into adulthood. In this review, we focus on the etiology of pediatric CKD and unique aspects that should be considered in treating a child with CKD, such as ensuring adequate nutrition and assessing growth hormone axis dysregulation. We review risk factors for CKD progression and how clinical surveillance can be used to address modifiable factors. We address the issues of accurate glomerular filtration rate (GFR) estimation, cardiovascular disease, immunization, neurodevelopment, and planned transition to adult care. We also cover kidney failure preparation and global CKD care disparities affecting children worldwide.

Perspectives of Chronic Kidney Disease Patients on Readiness for Advance Care Planning at Komfo Anokye Teaching Hospital, Ghana.

This study examined the impact of advance care planning (ACP) on the quality of life for patients with chronic kidney disease (CKD) at Komfo Anokye Teaching Hospital in Ghana. It specifically investigated patients' perspectives on their readiness for ACP. Utilizing a qualitative descriptive design, one-on-one interviews were conducted with CKD patients at the renal clinic, employing a semi-structured interview guide for thematic analysis of audio data. The findings revealed a gap in understanding among CKD patients, with participants acknowledging their vulnerability to renal failure, often linked to a medical history of diabetes and hypertension. Despite recognizing potential outcomes such as dialysis dependency or death, some patients retained hope for a cure, relying on faith. The initial kidney failure diagnosis induced shock and distress, leading many patients to prefer the comfort and familiarity of home-based care, including dialysis. Meanwhile, a minority favored hospital care to protect their children from psychological trauma. Most patients deemed legal preparations unnecessary, citing limited assets or a lack of concern for posthumous estate execution. These insights emphasize the necessity for targeted education and support in ACP to enhance patient outcomes in chronic kidney disease care and end-of-life planning.

Concordance With Screening and Treatment Guidelines for Chronic Kidney Disease in Type 2 Diabetes

Chronic kidney disease (CKD) is an often-asymptomatic complication of type 2 diabetes (T2D) that requires annual screening to diagnose. Patient-level factors linked to inadequate screening and treatment can inform implementation strategies to facilitate guideline-recommended CKD care. To identify risk factors for nonconcordance with guideline-recommended CKD screening and treatment in patients with T2D. This retrospective cohort study was performed at 20 health care systems contributing data to the US National Patient-Centered Clinical Research Network. To evaluate concordance with CKD screening guidelines, adults with an outpatient clinician visit linked to T2D diagnosis between January 1, 2015, and December 31, 2020, and without known CKD were included. A separate analysis reviewed prescription of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and sodium-glucose cotransporter 2 (SGLT2) inhibitors in adults with CKD (estimated glomerular filtration rate [eGFR] of 30-90 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio [UACR] of 200-5000 mg/g) and an outpatient clinician visit for T2D between October 1, 2019, and December 31, 2020. Data were analyzed from July 8, 2022, through June 22, 2023. Demographics, lifestyle factors, comorbidities, medications, and laboratory results. Screening required measurement of creatinine levels and UACR within 15 months of the index visit. Treatment reflected prescription of ACEIs or ARBs and SGLT2 inhibitors within 12 months before or 6 months following the index visit. Concordance with CKD screening guidelines was assessed in 316 234 adults (median age, 59 [IQR, 50-67] years), of whom 51.5% were women; 21.7%, Black; 10.3%, Hispanic; and 67.6%, White. Only 24.9% received creatinine and UACR screening, 56.5% received 1 screening measurement, and 18.6% received neither. Hispanic ethnicity was associated with lack of screening (relative risk [RR], 1.16 [95% CI, 1.14-1.18]). In contrast, heart failure, peripheral arterial disease, and hypertension were associated with a lower risk of nonconcordance. In 4215 patients with CKD and albuminuria, 3288 (78.0%) received an ACEI or ARB; 194 (4.6%), an SGLT2 inhibitor; and 885 (21.0%), neither therapy. Peripheral arterial disease and lower eGFR were associated with lack of CKD treatment, while diuretic or statin prescription and hypertension were associated with treatment. In this cohort study of patients with T2D, fewer than one-quarter received recommended CKD screening. In patients with CKD and albuminuria, 21.0% did not receive an SGLT2 inhibitor or an ACEI or an ARB, despite compelling indications. Patient-level factors may inform implementation strategies to improve CKD screening and treatment in people with T2D.

Yoga for Promoting Physical and Mental Health in Patients with Chronic Kidney Disease: A Systematic Review

Chronic kidney disease (CKD) is a growing global public health burden with significant physical and mental health challenges. This study aimed to systematically review the available evidence on the effects of yoga interventions on improving the physical and mental health of patients with CKD. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. The systematic search was conducted in January 2023 using Scopus and PubMed, resulting in 99 documents, of which 9 met the selection criteria. The studies explored the effects of different types of yoga interventions on various health aspects in hemodialysis and CKD patients. The durations ranged from 15 days to 6 months. The types of yoga used varied, including Hatha Yoga, Pranayama, and yoga therapy. Outcome measures included dialysis adequacy, fatigue, insomnia, lipid profile, oxidative stress, renal function, blood pressure, and quality of life. The findings demonstrate the feasibility of the yoga intervention and the positive effects of the intervention on health outcomes, such as improved dialysis adequacy, reduced fatigue and insomnia, better lipid profiles, decreased oxidative stress, enhanced renal function, lowered blood pressure, and improved quality of life. Yoga interventions show promise as a complementary approach for managing CKD. The positive effects observed on multiple health outcomes suggest the potential benefits of incorporating yoga into CKD care. However, further well-designed trials are needed to strengthen the evidence base. Healthcare providers should consider including yoga as part of a comprehensive approach to improve the well-being of CKD patients.

Nephrology nurse practitioner model of care for chronic kidney disease: Lessons learned and informing future healthcare delivery

Background: Chronic kidney disease (CKD) affects more than 10% of the Australian adult population. It is a progressive disease that involves multiple physiological systems and is associated with several comorbid conditions, making it particularly burdensome on patients and the healthcare system. Alternative models of healthcare delivery are required to slow the progression to kidney failure. Aim: To describe the characteristics, patient profiles, and health outcomes of patients with CKD attending a nephrology nurse practitioner-led clinic. Design: Longitudinal health-service exploratory design. Methods: Following ethics approval, data were extracted from a chronic kidney disease registry for all consenting patients who attended a nephrology nurse practitioner-led clinic. Data were analysed descriptively. Results: Over the study period, 253 patients (122 male and 131 female) attended the clinic. The mean age was 70.27 ± 10.48 years, and at baseline most had either chronic kidney disease grade 3A (32.8%) or 3B (41.5%). For the majority of those who remained in the clinic, kidney function remained stable or slightly improved. A large proportion were within recommended target ranges for systolic (85.6%) and diastolic (98%) blood pressure although many had high BMI (mean 31.99 ± 6.47) and HbA1c (57.1%). Conclusion: The nephrology nurse practitioner-led clinic demonstrated effectiveness in addressing CKD targets for patients and provides an opportunity to transform traditional primary and specialist healthcare delivery. What is already known about the topic? Early intervention in chronic kidney disease (CKD) can slow or halt the progression of the disease, reducing long-term burden and healthcare costs. An integrated model of care including primary and specialist providers is considered optimal for the early detection and treatment of CKD. An integrated nephrology nurse practitioner model is an emerging model of care for CKD patients. However, studies investigating the cost-effectiveness, efficacy, and characteristics of this model compared to specialist or primary care in Australia are lacking. What this paper adds: This paper describes the characteristics and outcomes of a nephrology nurse practitioner-led outpatient clinic embedded within a multidisciplinary model of care. The majority of patients who remained in nephrology nurse practitioner care maintained recommended CKD targets. The findings provide evidence that nephrology nurse practitioners are able to manage patients with less advanced CKD grades who have comorbid conditions and other health risk-factors.

Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health.

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care.

#1637 Diverging trends in kidney replacement therapy (KRT) incidence in Madrid and Catalonia in the past decade

Abstract Background and Aims Chronic kidney disease (CKD) is one of the fastest growing global causes of death and the number of persons on KRT is increasing. A critical assessment of current clinical practice across regions may identify best clinical practice, providing a benchmark to improve outcomes. Given the long life expectancy in Spain and its high proportion of the population over 65 y/o, analysis of Spanish data may provide insight for the future for other European countries. Catalonia (Cat) and Madrid (Mad) are two of the most populated Spanish Autonomous Communities, have similar life expectancy (above 83 years) and GDP per capita, and together account for 30% of Spanish population and 38% of GDP. The aim was to set the basis for benchmarking in CKD care and KRT initiation by comparing the evolving KRT incidence of two representative Spanish Autonomous Communities. Method We compared the KRT incidence in Cat and Mad from 2012 to 2021, using data from European Renal Association (ERA) Registry annual reports and the Spanish Instituto Nacional de Estadistica's (INE) census. Results From 2012 to 2021, the incidence of KRT (day 1) adjusted for age and sex increased by 69.7 pmp (59% increase) in Cat (from 118.7 to 188.4 pmp) and by 14.2 pmp (12% increase) in Mad (from 115.5 to 129.7 pmp). The differential incidence of KRT between Cat and Mad increased from 3.2 to 58.7 pmp, i.e., 1734% increase (Fig. 1A). As a result, the incidence of KRT was 45% higher in Cat than in Mad in 2021 (up from 3% higher in 2012). During the same period, the median age to start KRT increased from 67.0 to 69.6 years (2.6 years, 3.9%) in Cat and from 66.1 to 66.9 years (0.8 years, 1.2%) in Mad. Median age at KRT initiation in 2021 was 3 years older in Cat in both men (Cat 70.0 (58.4-77.8), Mad 67.3 (56.9-76.2)) and women (Cat 69.0 (58.4-77.2), Mad 66.1 (51.7-75.8)). In subgroup analysis by age and sex, the largest difference in KRT incidence in 2021 was observed for women and for those aged 75+ years: Cat/Mad KRT incidence (pmarp) ratio was 1.79 in women 75+, 1.62 in men 75+, 1.49 in women &amp;lt;75 y/o, 1.34 in men &amp;lt;75 y/o (Fig. 1B). The gap between Cat and Mad increased progressively with age in both men and women and the slope was steeper for women. The contribution of diabetes to the overall incidence of KRT ranged from 16.8% to 23.2% in Cat and from 24.3% to 29.0% in Mad between 2012 and 2021, remaining grossly stable or decreasing slightly over time. For most causes, the incidence adjusted for age and sex in Cat and Mad was similar, with largest differences observed for unknown cause (the most common cause in Cat: Cat 45.9 pmp, Mad 7.9 pmp) and missing (the 3rd most common cause in Cat after unknown and diabetes: Cat 25.4 pmp, Mad 0) (Fig. 1C). Together, unknown and missing causes of CKD accounted for 38.1% of incident KRT cases in Cat in 2021. Pre-emptive transplantation was 3-fold more common in Cat in 2021 (7.6% vs 2.7%), while incidence of haemodialysis and peritoneal dialysis were similar (Fig. 1D). Conclusion In conclusion, trends for KRT incidence differed for two Autonomous Communities from the same country, broadly comparable in terms of population, life expectancy and GDP. The incidence of KRT was higher in Catalonia, and the gap increasing over time, especially among the elderly and older women, with unknown cause of CKD being the leading cause of incident KRT. An in-depth analysis of the drivers of these differences may bring interesting insight into best practice for CKD prevention, treatment to slow CKD progression and prescription and initiation of KRT.

#1611 Diverging epidemiology of kidney replacement therapy (KRT) prevalence in Madrid and Catalonia between 2012 and 2021

Abstract Background and Aims Chronic kidney disease (CKD) is one of the fastest growing global causes of death and the number of persons on kidney replacement therapy (KRT) is increasing. A critical assessment of current clinical practice in different regions may identify best clinical practice and provide a benchmark to improve outcomes. Given the current long-life expectancy in Spain and its high proportion of elderly population, analysis of Spanish data may provide insight of interest for the future for other European countries. Catalonia (Cat) and Madrid (Mad) are among the three most populated Spanish Autonomous Communities and have similar life expectancy, gross domestic product (GDP) and GDP per capita, accounting for 30% of Spain's population and 38% of GDP. The aim was to set the basis for benchmarking in CKD care and KRT initiation and care by comparing the evolving prevalence of KRT in Cat and Mad. Method We compared KRT prevalence in Cat and Mad over the past years using data from European Renal Association (ERA) Registry annual reports and Spanish Instituto Nacional de Estadística's (INE) census. Results From 2012 to 2021, the adjusted prevalence of KRT per million population (pmp) increased by 275.8 (1221 to 1479, 22.6% increase) in Cat and by 134.8 (1046 to 1118, 12.9% increase) in Mad. The difference between Cat and Mad increased from 175 to 316 pmp (60% increase), resulting in a 26.8% higher KRT prevalence in Cat than in Mad in 2021 (up from 16.7% higher in 2012) (Fig. 1A). During the same period, the median age of prevalent KRT patients increased from 63.2 to 65.4 years (yrs) (2.2 yrs, 3.5%) in Cat and from 62.2 to 63.8 years (1.6 yrs, 2.6%) in Mad. In 2021, median age for prevalent patients on KRT was 1.6 yrs older in Cat (65.4 (53.9, 75.3)) than in Mad (63.8 (52.6, 74.1)), this difference being of 2.5 yrs in women (Cat 65.5 (53.6, 75.7), Mad (63 (51, 73.8), difference) and 1.1 yrs in men (Cat 65.3 (53.9, 75); Mad 64.2 (53.4, 74.3)). In subgroup analysis by age and sex, prevalence of KRT per million age-related population (pmarp) in 2021 was always higher in Cat than in Mad, except for women aged 20-44 yrs (363.7 in Cat, 370.5 in Mad, Cat/Mad ratio 0.98), and the largest gap was observed for women &amp;lt;19 yrs (Cat 77.4, Mad 41.5, Cat/Mad ratio 1.86). The Cat-Mad ratio increased with age in women &amp;gt;45 yrs, but not in men (Fig. 1B) The contribution of diabetes to KRT prevalence remained stable or increased slightly in both Cat (13.9-15.5%) and Mad (17.4-17.7%) between 2012 and 2021. In 2021 for most causes of KRT the prevalence adjusted for age and sex was higher in Cat, except for hypertension and miscellaneous. The largest differences were observed for unknown cause (most common cause in Cat: Cat 330.8, Mad 85.5, difference 245.3 pmp), miscellaneous (most common cause in Mad: Cat 165.9, Mad 271.5, difference −105.6 pmp), and missing (Cat 53.8, Mad 0, difference 53.8 pmp) (Fig. 1C). Prevalence of kidney transplantation in 2021 was higher in Cat than Mad (60.0% vs 54.9%), while prevalence of hemodialysis and peritoneal dialysis was higher in Mad (39.6% and 5.5%, respectively) than in Cat (36.2% and 3.9%) (Fig. 1D). Conclusion In conclusion, a stark difference in prevalence trends and in current KRT was observed for two Autonomous Communities within the same country which are broadly comparable in terms of population, life expectancy and GDP. An in-depth analysis of the drivers of these differences may bring insight into best practices for CKD prevention, treatment to slow CKD progression, timing and criteria for initiation of KRT and standard of care for KRT.

#956 Exome sequencing in adults with secondary thrombotic microangiopathy with kidney involvement

Abstract Background and Aims Currently, genetic testing is recommended in patients with thrombotic microangiopathy (TMA) and renal involvement when a complement-dependent TMA is clinically suspected. Due to a possibly poor phenotype-genotype correlation, this strategy may be suboptimal. We aimed to assess the impact of a strategy using Exome Sequencing (ES) regardless of initial suspicion. Method We conducted a prospective observational study. Data was collected in all consecutive adult patients who received a primary diagnostic ES test as part of routine care for unexplained chronic kidney disease between October 10, 2017, and December 31, 2022, at the Nephrology Department of Assistance Publique-Hôpitaux de Paris/Sorbonne University, Paris, France (Tenon and Pitié-Salpêtrière hospitals). Patients with thrombotic thrombocytopenic purpura or typical hemolytic and uremic syndrome were not included. The association between patients’ phenotypes and genotypes was explored using a validated method relying on Term Frequency-Inverse Document Frequency (TF-IDF). Results 1 413 patients underwent ES, of whom 153 (11%) had biological and/or histological indicators of TMA. ES identified a variant consistent with the renal phenotype in 20/153 (13%) cases. In 13/20 cases (65%), a genetic disorder which was not complement TMA was diagnosed: five patients had nephronophthisis (TTC21B, n = 4, NPHP3, n = 1); two had Alport's disease (COL4A4 and COL4A3, n = 1); one had Cobalamin-C deficiency (MMACHC); five had other distinct conditions (variants in SOX18, IFT140, WT1, TREX1 and UMOD). Direct clinical implications of performing ES were observed in 35/153 (23%) cases. An interactive web-app was developed to enable in-depth exploration of phenotype-genotype association, and no association between patients’ phenotypes and genotypes were observed. Conclusion First-tier ES in patients with TMA and renal involvement, irrespective of clinical suspicion, revealed diagnoses that would not have been initially obtained according to the currently recommended strategy. In patients with TMA and renal involvement, we did not find an association between patients’ phenotypes and genotypes.

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis &amp;gt;3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.

#989 Fund and incentivize multidisciplinary CKD care: what can we learn from the French CKD bundled payment program?

Abstract Background and Aims Multidisciplinary care (MDC) is crucial to slow down the progression of Chronic Kidney Disease (CKD) and prevent or post-pone kidney replacement therapy. To incentivize the development of that care, France launched a nationwide bundled payment program (CKD-BP) targeted to patients with CKD G4 and G5. In this study, we review the implementation of the program, 3 years into its launch. Method First, using the CKD-BP program data collected by participating facilities, we described the characteristics and trajectories of patients enrolled from 2020 through 2022. Second, from exploratory interviews with medical and management staff, we performed a thematic analysis to identify the obstacles encountered during implementation and the changes introduced by the program. Results Since 2020, 157,863 patients were reported by 408 facilities (median age 75 y-o, 40% women, 77% G4). Missing data frequencies were high for comorbidities. Each year, around 4200 dialysis start (5% of patients) and 2600 deaths (3% of patients) were reported. On average, 47% and 40% of patients visited nurses and dietitians at least once a year respectively. From 22 interviews across 7 facilities, we identified challenges of implementation: adapting information systems, gathering the support of facility management and organizing the care in a context of workforce shortage, specifically nurses. Despite those challenges, facilities welcomed positively the new model, notably with increased time between nurses and patients and affirmation of dietitian's role. Conclusion We estimate the exhaustiveness of the CKD-BP program at 40% of all French patients with G5 CKD (around 4,600 dialysis start reported in 2021, compared to 11,000 from the national exhaustive REIN registry data). The results of this study suggest that interventions to accompany facilities in adapting their information systems are a priority to ensure efficient allocation of medical time and quality of the data. The results also suggest the need for increased flexibility regarding what professional is considered in the CKD-BP program, beyond nurses and dietitians. These challenges remain to be addressed in order to complete a successful shift from fee-for-service to assessable value-based care for CKD in France.

#1381 Economic evaluation of an integrated care program versus conventional care for chronic kidney disease patients in rural communities of Thailand

Abstract Background and Aims This study evaluates an integrated care program for chronic kidney disease (CKD), which has demonstrated effectiveness in delaying kidney function decline in the rural population of Thailand. Efficacy of the program was initially established through the ESCORT-1 study, a cluster-randomized controlled trial (doi: 10.1186/s12882-016-0414-4), and further demonstrated the effectiveness by the larger-scale prospective cohort study, ESCORT-2 (doi: 10.1111/nep.13849). The aim of this study is to assess the cost-effectiveness of incorporating this program into Thailand's public health benefit package, with the goal of establishing it as a model for similar rural areas in resource-limited settings. Method Following the Thailand's guideline for health technology assessment, a cost-utility analysis utilizing data from the ESCORT studies, local databases, and literatures. The integrated care program was tailored to primary healthcare system by using preexisting workforces. It involved a collaboration between Multi-Disciplinary Care Teams (MDCT) at district hospitals and Community Care Network (CCN) teams at Sub-District Health Centers (SDHC). The MDCT, comprising general practitioners, CKD nurse managers, pharmacists, a nutritionist, and a physical therapist, provided key patient education on diet, medication adherence, exercise, and avoiding certain medications and herbal remedies. The CCN teams, including community nurses and village health volunteers, conducted home visits for health monitoring and lifestyle guidance. Both MDCT and CCN personnel received training in CKD care based on the NKF-K/DOQI and KDIGO Clinical Practice Guidelines. A decision-analytic Markov model and Monte-Carlo simulation were applied to quantify and compare the lifetime costs and quality-adjusted life years (QALY) outcomes of the intervention and conventional-care from a societal perspective considering both direct and indirect costs. The analysis included extensive sensitivity analyses, incorporating a probabilistic model and scenario-analyses based on patient ages, CKD stages, and varying program efficacy. Additionally, a budget impact analysis from the payer's perspective assessed the financial impact and affordability over a five-year period. Results The integrated care program was found to dominate conventional care. The results indicated an incremental cost-effectiveness of (-)278,000 Thai Baht (∼7,267 EUR) per QALY for the base case analysis. Probabilistic analysis demonstrated consistent outcomes, with the integrated care program being cost-effective at almost 100% of the time during analysis at the 160,000 Thai Baht (∼4,182 EUR) willingness-to-pay threshold (Fig. 1). These results are driven by significant cost savings due to reduced time and overall costs in dialysis before death. The program is most cost-effective when provided early to patients, in terms of both age and CKD stages (Fig. 2). The budget impact analysis showed that introducing the intervention could save the payer 184 billion Thai Baht (4.76 billion EUR) over five years. (The exchange rate; 1 Thai Baht = 38.26 EUR) Conclusion The integrated care program for patients with stage 3-4 CKD is cost-effective and suitable for inclusion in Thailand's health benefit package, mainly due to its significant cost savings and enhanced health outcomes. The program's design, focusing on sustainability and feasibility by utilizing existing workforces, positions it as a viable model for similar economic and healthcare contexts, especially in resource-limited countries.

#2449 Prevalence and determinants of chronic kidney disease among older community-dwelling adults in Ireland

Abstract Background and Aims Chronic Kidney Disease (CKD) is a major global health challenge with substantial morbidity and mortality. In Ireland, a comprehensive understanding of the determinants of CKD is lacking, with limited data on the combined impact of socioeconomic and traditional risk factors. While the Irish Longitudinal Study on Ageing (TILDA) has offered insights into CKD burden, a detailed examination of its determinants remains unexplored. The goal of this study was to explore the prevalence and determinants of CKD at the community level within the Irish population. Method This is a retrospective cohort study that utilised cross sectional data from the first wave of TILDA conducted between 2009 and 2011. Participants aged 50 years and older who had health assessment and kidney function tests performed were included. The 2012 and 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations were employed to calculate estimated glomerular filtration rates (eGFR) based on cystatin C and creatinine levels. CKD was classified as eGFR &amp;lt; 60 ml/min/1.73 m². We determined the weighted prevalence of CKD using sample weights. Stepwise multivariable logistic regression models were used to identify correlates of CKD and models’ performance were assessed using AUC-ROC curves and the Akaike Information Criterion (AIC). Associations were expressed using adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Results Among the 5 386 participants tested for cystatin C and serum creatinine, the weighted CKD prevalence was 11.3% based on the 2021 CKD-EPI definition (excluding race) and 13.9% using the 2012 definition. Prevalence was significantly higher in women than men, and increased with age, reaching about 45% in women over 71 years versus 29% in men. Burden of comorbid conditions in CKD individuals varied from 11% (for cancer) to 89% (for hypertension) and were significantly higher than non-CKD individuals (P&amp;lt; 0.001). Adjusting for age, sex, education, and employment, the adjusted odds of CKD were significantly higher for individuals with hypertension AOR 2.15 (95% CI: 1.58–2.96), diabetes AOR 2.00 (95% CI: 1.50–2.66), cardiovascular disease AOR 1.72 (95% CI: 1.43–2.21), cancer AOR 1.64 (95% CI: 1.16–2.30), and obesity AOR 2.18 (95% CI: 1.61–2.96). The likelihood of CKD was also higher for patients with a hospital admission in the previous year AOR = 1.50 (95% CI: 1.14–1.96), possession of a medical card AOR 1.41 (95% CI: 1.06–1.89), and unemployed individuals AOR 1.61, (95% CI: 1.06–2.50), while the likelihood was significantly lower for individuals with a tertiary education (versus primary) AOR 0.73 (95% CI: 0.54–0.98). With further adjustment for medications, the magnitude of these associations was greatly attenuated with increasing odds of CKD for those receiving higher medication burden: 2-3 drugs AOR 2.02, (95% CI: 1.29–3.29), 3-4 drugs AOR 2.52 (95% CI: 1. 59–4.11), and &amp;gt; 5 drugs AOR 4.49 (95% CI: 2.81–7.39) (see Fig. 1). The AUC score ranged from 0.84 to 0.88, indicating strong model performance. Conclusion This study brings renewed attention to observed variation in national estimates of CKD prevalence (11.3% vs 13.9%) that are derived from current prediction equations with important implications for the strategic planning and resourcing of CKD care. This study emphasises the impact of socioeconomic factors, such as health coverage and financial barriers to heath care, education attainment, and employment, on CKD beyond traditional risk factors. Furthermore, the attenuation of known risk factors with increasing medication use highlights the influence of these treatments on CKD dynamics. These findings provide valuable insights for targeted public health strategies and awareness programs in Irish communities to address the increasing burden of CKD.

Navigating challenges: insights into chronic kidney disease care in South Auckland.

The burden of chronic kidney disease is increasing throughout New Zealand, resulting in growing strain on patients, families and the healthcare system. The population of South Auckland is the most diverse in New Zealand and it is particularly vulnerable to the effects of chronic kidney disease due its demography and its many communities that endure significant hardships. This article explores the prevailing challenges identified by renal physicians and nurse specialists over 35 years of caring for patients with chronic kidney disease in South Auckland.

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario.

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

A Community-Based Nephrology and Palliative Care Partnership to Improve Advanced Chronic Kidney Disease Care

A Community-Based Nephrology and Palliative Care Partnership to Improve Advanced Chronic Kidney Disease Care