Chronic Kidney Disease Clinic Research Articles

Much ado about nothing: the impact of coronary angiography on kidney function in individuals with chronic kidney disease

Abstract Background and Objectives Chronic kidney disease (CKD) is associated with premature coronary artery disease and an increased risk of cardiovascular morbidity and mortality (1). Historically, there has been a tendency to delay or even avoid coronary angiography (CA) in those with CKD due to an increased risk of contrast-induced nephropathy or concern over precipitating the need for chronic dialysis. Such "renal nihilism" may account for the poorer outcomes observed in CKD patients who present with acute coronary syndromes (2). The role of this retrospective analysis was to evaluate the impact of CA on the temporal trend in kidney function in individuals with CKD over a 24-month period. Methods The clinical details of 120 individuals under long-term local follow-up by various Nephrology clinics (CKD clinic, low creatine clearance, polycystic kidney disease, transplant and immunosuppression clinics) was collected. All underwent CA locally. Kidney function was observed at set intervals of 12-, 9-, 6- and 3-months prior to CA, immediately post-CA, and at 3-, 6-, 9- and 12-months post-CA. Only results obtained after the desired time point but within 28 days were included. All CAs regardless of either their indication (elective or urgent) or whether percutaneous intervention (PCI) was performed, were included. Patients already on dialysis at the time of the CA were excluded. Statistical analysis was performed via one-way ANOVA. Results Patient characteristics are summarised in table 1. The average age of patients was 67, with a male preponderance (72%). 22% had CKD 3, 24% had CKD 4 and 12% had CKD 5. 9% were kidney transplant recipients. 37% underwent urgent CA whilst a total of 22% had PCI. 27% progressed to requiring renal replacement therapy (RRT). The mean length to RRT was 2.8 years. The rate of decline in kidney function in the last 12 months prior to CA was 7.7% and 6.3% in the year after CA (figure 1). There was no statistically significant difference in kidney function after CA (p = 0.395). This was replicated in analyses focussing on CKD classes 3, 4 and 5 individually, within stable kidney transplant recipients, and within analysis comparing PCI vs non-intervention CAs. Conclusion The results demonstrate CA does not accelerate the decline in kidney function in those with known CKD over a 12-month period, and suggests where appropriate, an invasive treatment strategy should be consider and utilised more often in this population.Table 1:Patient characteristicsFigure 1:Trend in eGFR relative to CA

Evaluation of Drug-Related Problems in the Chronic Kidney Disease Clinic at the University Hospital in Thailand

Evaluation of Drug-Related Problems in the Chronic Kidney Disease Clinic at the University Hospital in Thailand

Estimates of eskd risk and timely kidney replacement therapy education

BackgroundKidney replacement therapy (KRT) needs preparation and its timing is difficult to predict. Nephrologists’ predictions of kidney failure risk tend to be more pessimistic than the Kidney Failure Risk Equation (KFRE) predictions. We aimed to explore how physicians’ risk estimate related to referral to KRT education, vs. the objective calculated KFRE.MethodsProspective observational study of data collected in chronic kidney disease (CKD) clinics of the Veterans Affairs Medical Center San Diego and the University of California, San Diego. The study included 257 participants who were aged 18 years or older, English speaking, prevalent CKD clinic patients, with estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m2 (MDRD equation). The exposure consisted of end stage kidney disease (ESKD) risk predictions. Nephrologists’ kidney failure risk estimations were assessed: “On a scale of 0–100%, without using any estimating equations, give your best estimate of the risk that this patient will need dialysis or a kidney transplant in 2 years.” KFRE was calculated using age, sex, eGFR, serum bicarbonate, albumin, calcium, phosphorus, urine albumin/creatinine ratio. The outcomes were the pattern of referral to KRT education (within 90 days of initial visit) and kidney failure evaluated by chart review. The population was divided into groups either by nephrologists’ predictions or by KFRE. Referral to KRT education was examined by group and sensitivity and specificity were calculated based on whether participants reached kidney failure at 2 years.ResultsA fifth were referred for education by 90 days of enrollment. Low risk patients by both estimates had low referral rates. In those with nephrologists’ predictions ≥ 15% (n = 137), sensitivity was 71% and specificity 76%. In those with KFRE ≥ 15% (n = 55), sensitivity was 85% and specificity 41%.ConclusionsAlthough nephrologists tend to overestimate patients’ kidney failure risk, they do not appear to act on this overestimation, as the rates of KRT education referrals are lower than expected when a nephrologist identifies a patient as high risk.Clinical Trial NumberNot applicable

#2188 Challenges in lipid control in the advanced chronic kidney disease clinic: findings from a cross-sectional study

Abstract Background and Aims Chronic kidney disease (CKD) is associated with lipid metabolism disruptions and heightens cardiovascular (CV) risk. International guidelines categorize CKD patients into high CV risk (LDL target &amp;lt; 70 mg/dL and a reduction &amp;gt;50% from baseline) for CKD G3b A1, CKD G3a A2, and CKD G2 A3; and very high CV risk (LDL target &amp;lt; 55 mg/dL and a reduction &amp;gt;50% from baseline) for CKD G4 and G5, CKD G3b A2-3, and those with type 2 diabetes and G3a A2-3, G3b regardless of UACR, or UACR &amp;gt; 300 mg/g regardless of eGFR. This cross-sectional study aims to evaluate the challenges of achieving LDL targets in advanced CKD patients, focusing on statin use. Method A cross-sectional study enrolled 312 patients with advanced CKD. Collected data included demographics, renal function stage, albuminuria/proteinuria, diabetes, and cardiovascular history. Documented statin use specified type and potency. Statistical analysis employed descriptive measures. Results Of the 312 patients, 207 were males, with a mean age of 69.18 ± 10.26 years, mean eGFR of 27.54 ± 12.22, and LDL of 86.64 ± 32.9. The majority had a history of diabetes (158) and previous cardiovascular disease (100). 69.6% used statins, with atorvastatin being the most common (165), followed by simvastatin (26), pravastatin (11), rosuvastatin (10), and pitavastatin (5). Statin potency varied, with high potency in 49.4%, moderate in 49.2%, and low in 1.4%. Only 19.6% of patients achieved adequate lipid control per guidelines. Conclusion This study underscores the high prevalence of dyslipidemia and the challenges in achieving LDL targets in advanced CKD patients. Despite the presence of cardiovascular risk factors, including a history of cardiovascular events, the majority did not attain adequate lipid control, highlighting the imperative to address therapeutic inertia to prevent LDL detrimental consequences. Specific strategies are warranted, focusing on mitigating statins’ underutilization and low potency. Additionally, consideration of adjunct therapies such as ezetimibe and bempedoic acid is crucial. Exploring novel agents like iPCSK9 or inclisiran emerges as promising avenues for safer and more effective alternatives in this population at high cardiovascular risk.

Analysis of dry and wet season water quality in the municipality of La Gomera, Guatemala

Abstract There is a need for access to clean potable water worldwide. However, almost every source of surface water in Guatemala is contaminated. This study assesses the potential exposure to water contaminants in proximity to Medecins Sans Frontieres's (MSF) chronic kidney disease clinic population in La Gomera, Guatemala during wet and dry seasons. Five municipal wells and four artisanal wells (servicing approximately 18.9% of La Gomera) were selected for their proximity to MSF La Gomera clinic to determine the presence of coliforms, physicochemical parameters, heavy metals, and pesticide residues. Water samples were collected over 3 consecutive days during La Gomera's wet season and again during the dry season. Wet season 2022: Total coliforms and Escherichia coli exceeded the acceptable limits for several artisanal wells but were not detected in municipal wells. Mercury and arsenic were detected in all wells during at least one sampling period. Dry season 2023: Total coliforms exceeded the acceptable limits for all wells and E. coli was detected in all four artisanal wells. Lead and arsenic were detected in all wells. Our results suggest that water from artisanal wells does not meet COGUANOR or WHO microbiological criteria for human consumption.

ASSESSMENT OF QUALITY OF LIFE OF CHRONIC KIDNEY DISEASE PATIENT ATTENDING IN SELECTED HOSPITALS, WEST BENGAL

Introduction: Chronic Kidney disease (CKD) is still a health problem in India &amp; increasing number of new cases. profound physiological, psychological, social effect due to CKD hurt the quality of life.Aim: This study aims to find out quality of life of CKD patient and association between quality of life with demographic variables.Method: The investigator conducted a descriptive study on assessment of quality of life (QOL)among chronic kidney disease patients attending selected Nephrology and Medicine OPD of West Bengal with the objective to assess quality of life and to find out the association between quality of life and selected demographic variables. The conceptual framework adopted for the study was based on Sr. Callista Roy’s adaptation model (1989). Non-probability convenience sampling technique was adopted to select 173 respondents. The tools used for the study were semi-structured interview schedule and WHOQOL-BREF.Result: The study findings revealed that the majority of the respondents (69.37%) had an average quality of life. The result also showed that respondents had maximum quality of life in social domain and minimum quality of life in psychological domain. A significant association found between quality-of-life score and addiction as chi- square value was 4.782=3.841] at 0.05 level of significance. The study has several implications in Nursing education, practice, administration, and research. The study concluded with recommendations for future intervention and improve policy implementation regarding CKD clinics for improving the quality of life among this population.

The Use of Kidneys With Lower Longevity From Deceased Donors to Improve Access to Preemptive Renal Transplantation for Elderly Patients: A Qualitative Study.

There is a gap between the number of patients waiting for a transplant and the number of kidneys available. Some deceased donor kidneys are currently nonutilized, as medical teams fear that they will experience suboptimal graft survival. However, these organs could provide an acceptable therapeutic option if they were allocated for preemptive kidney transplantation in elderly candidates. This project aims to gather patients' perspectives on the allocation of kidneys with lower longevity for preemptive kidney transplantation in elderly patients. Individual interviews. The Center hospitalier de l'Université de Montréal (CHUM) chronic kidney disease (CKD) clinic. Patients aged between 64 and 75 years with CKD G4-5 ND, followed at the CHUM and who have not initiated dialysis yet. Between March and July 2023, we conducted 14 individual interviews with patients aged between 64 and 75 years who had CKD G4-5 ND and were followed at the CHUM. The interviews were digitally recorded and transcribed. Thematic analysis was conducted. Most participants were in favor of using kidneys with lower longevity to increase their access to transplantation, improve their quality of life, enable accelerated transplantation, and avoid dialysis. Patients also wanted to be engaged in the decision-making process, underlining the importance of informed consent. Although the use of kidneys with lower longevity offers the hope of returning to "normal" life, some patients were concerned about the risk of reduced graft survival and the need for a subsequent kidney transplant. In these cases, patients were interested in using mitigation strategies, such as prioritization for kidney transplantation from standard donors in case of early graft loss associated with receiving kidneys with lower longevity. They also recommended the development of a separate waiting list for patients consenting to preemptive transplantation with kidneys with lower longevity. This study was conducted in only 1 nephrology clinic in the province of Quebec with French-speaking patients. Consequently, the results may not be generalizable to other populations, including ethnic minorities. The use of kidneys with lower longevity for preemptive kidney transplantation appears to be an interesting option for elderly kidney transplant candidates. However, patient information and participation in the decision-making process are essential. Moreover, organ donation organizations and transplant programs should develop a separate waitlist for transplant candidates who have preconsented to receive organ offers of deceased donor kidneys with lower longevity. Not registered.

Oral Nutritional Supplement Prescription and Patient-Reported Symptom Burden Among Patients With Late-Stage Non-Dialysis Chronic Kidney Disease.

Malnutrition and protein-energy wasting (PEW) are nutritional complications of advanced chronic kidney disease (CKD) that contribute to morbidity, mortality, and decreased quality of life. No previous studies have assessed the effect of oral nutritional supplements (ONSs) on patient-reported symptom burden among patients with non-dialysis CKD (CKD-ND) who have or are at risk of malnutrition/PEW. The objective of this study was (1) to quantify the associations between baseline nutritional parameters and patient-reported symptom scores for wellbeing, tiredness, nausea, and appetite and (2) to compare the change in symptom scores among patients prescribed ONS with patients who did not receive ONS in a propensity-score-matched analysis. This study conducted observational cohort analysis using provincial registry data. This study was done in multidisciplinary CKD clinics in British Columbia. Adult patients >18 years of age with CKD-ND entering multidisciplinary CKD clinics between January 1, 2010-July 31, 2019 who had at least 2 Edmonton Symptom Assessment System Revised: Renal (ESASr:Renal) assessments. The measurements include nutrition-related parameters such as body mass index (BMI), serum albumin, serum phosphate, serum bicarbonate, neutrophil-to-lymphocyte ratio (NLR), and ESASr:Renal scores (overall and subscores for wellbeing, tiredness, nausea, and appetite). Multivariable linear regression was applied to assess associations between nutritional parameters and ESASr:Renal scores. Propensity-score matching using the greedy method was used to match patients prescribed ONS with those not prescribed ONS using multiple demographic, comorbidity, health care utilization, and temporal factors. Linear regression was used to assess the association between first ONS prescription and change in ESASr:Renal overall score and subscores for wellbeing, tiredness, nausea, and appetite. Of total, 2076 patients were included. Higher baseline serum albumin was associated with lower overall ESASr:Renal score (-0.20, 95% confidence interval [CI] = -0.40 to -0.01 per 1 g/L increase in albumin), lower subscores for tiredness (-0.04, 95% CI = -0.07 to -0.01), nausea (-0.03, 95% CI = -0.04 to -0.01), and appetite (-0.03, 95% CI = -0.06 to -0.01). Higher BMI was associated with higher overall ESASr:Renal score (0.32, 95% CI = 0.16 to 0.48 per 1 kg/m2 increase in BMI), higher symptom subscores for wellbeing (0.02, 95% CI = 0.00 to 0.04) and tiredness (0.05, 95% CI = 0.02 to 0.07). Higher baseline NLR was associated with higher overall score (0.21, 95% CI = 0.03 to 0.39 per 1 unit increase in NLR), higher symptom subscores for wellbeing (0.03, 95% CI = 0.01 to 0.05) and nausea (0.03, 95% CI = 0.02 to 0.05). In the propensity-score-matched analysis, there were no statistically significant associations between ONS prescription and change in overall ESASr:Renal (beta coefficient for change in ESASr:Renal = 0.17, 95% CI = -2.64 to 2.99) or for subscores for appetite, tiredness, nausea, and wellbeing. Possible residual confounding. The ESASr:Renal assessments were obtained routinely only in patients with G5 CKD-ND and/or experiencing significant CKD-related symptoms. This exploratory observational analysis of patients with advanced non-dialysis CKD demonstrated BMI, serum albumin, and NLR were modestly associated with patient-reported symptoms, but we did not observe an association between ONS use and change in ESASr:Renal scores.

#5815 INTERNATIONAL VARIATIONS IN TRANSITION OF CARE PRACTICES AND TWO-YEAR OUTCOMES IN ADVANCED CHRONIC KIDNEY DISEASE

Abstract Background and Aims The transition to kidney failure is the period of the highest risk for adverse outcomes in chronic kidney disease (CKD). A smooth and timely transition of care, assuring informed and patient-centric decision-making, is paramount to fostering better kidney care. We described the two-year incidence of clinical outcomes and nephrology practices among advanced CKD patients in CKDopps. Method CKDopps is a prospective cohort study designed to describe and evaluate variations in CKD practices and outcomes in nephrologist-led CKD clinics. For this analysis, we included CKDopps participants who reached a three-month average estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73 m2 in the US, France, and Brazil. Time at risk for outcomes started at the end of the first three-month window in which the average eGFR was lower than 20 mL/min/1.73 m2 during study follow-up. Education was defined as participation in at least one educational session about KRT modalities. They were considered to have been referred to vascular access (VA) creation if reported in medical records. Education or VA referral happening before the start of follow-up were classified as occurring at baseline. Patients were considered waitlisted if they had been registered on a pre-emptive kidney transplant waiting list. Cumulative incidence functions adjusting for the competing risk of mortality or KRT were used to estimate the 2-year probability of clinical outcomes and planning events. Results 2,645 patients were included – 51% from France, 36% from the US, and 14% from Brazil. Overall, 56% of patients were male, the mean age was 66 ± 14 years, approximately 50% had diabetes, 27% had coronary artery disease, and 16% had heart failure. Patients in Brazil tended to be younger (63 years) than those in France (67) and the US (67); patients in the US had the greatest burden of cardiovascular comorbidities. The mean eGFR at the study baseline was 16.6 mL/min/1.73m² (15.4 in Brazil, 15.9 in the US, and 17.3 in France). Over a median follow-up of 15.7 [7.2–24] months, 1140 patients (43.1%) started KRT, whereas 377 (14.3%) died before KRT. The 2-year cumulative incidence of KRT was 32% in Brazil, 33% in France, and 44% in the US (Figure 1). The median eGFR at KRT initiation was 11.7 in Brazil, 9.0 in France, and 10.3 in the US. Pre-KRT death risk in two years was 7.3% in Brazil, 10.9% in France, and 16.4% in the US. In two years, approximately one-third of patients had a VA created across countries (Table 1). The probability of transplant waitlisting was higher in France and the US, while patient-reported KRT education was more common in Brazil (Table 1). Conclusion In this international analysis of advanced CKD patients, we found important variations in nephrology practice and outcomes across countries. Patients in the US have a higher risk of both pre-KRT death and KRT. Patient-reported education was far more common in Brazil than in the US and France. Although patients in Brazil are referred for VA creation earlier in the course of advanced CKD, 2-year cumulative incidences for such are similar across countries. The 2-year probability of pre-emptive kidney transplant listing was higher in France and the US. Further international studies evaluating risk factors for adverse outcomes and barriers to KRT planning among advanced CKD patients are warranted.

#5059 EXTERNAL VALIDATION OF THE KFRE AND GRAMS PREDICTION MODELS FOR DEATH AND KRT IN A SPANISH POPULATION WITH ADVANCED CHRONIC KIDNEY DISEASE

Abstract Background and Aims The Kidney Failure Risk Equation (KFRE) is used to predict the risk of kidney replacement therapy (KRT) initiation in the following 2 and 5 years, in patients with chronic kidney disease (CKD) stages G3-G5. The Grams model is applied exclusively to stage G4-G5 patients who have a higher risk of dying or requiring KRT. This model predicts both events, KRT and death, at 2 and 4 years, but unlike the KFRE, it considers the patient's death as a competing event with respect to the start of RRT. It has been suggested that the Grams model makes a more accurate prediction of the onset of KRT in the long term, since by including mortality as a competing event it does not overestimate the risk of KRT. However, there are few external validations of the Grams model to predict mortality in patients with CKD G4+. We performed an external validation of both models with respect to the start of KRT and mortality in a Spanish population with CKD G4+, followed up prospectively during 4-9 years. Method We conducted a prospective cohort analysis of incident patients followed in the Advanced Chronic Kidney Disease clinic of the Hospital Universitario Fundación Alcorcón, Spain between 1-1-2014 and 31-12-2018 who had CKD G4-G5. Clinical data was registered prospectively in a database at each visit to the clinic. Follow-up ended on 31-12-2022. For each patient, the follow-up time ranged from 4 to 9 years. The outcomes were: observed incidence of KRT (haemodialysis, peritoneal dialysis, or pre-emptive kidney transplantation) by 2, 4 and 5 years and death at 2 and 4 years before starting KRT. The predictors used in the study were calculated at the time of initial clinic referral and included the 2-year and 4-year Grams’ calculator risk scores (Grams-2 and Grams-4, respectively) for KRT and death and the 2-year and 5-year 4-variable KFRE scores for KRT (KFRE-2 and KFRE-5 respectively). We performed calibration and discrimination analyses to evaluate the performance of both predictive models. Discrimination was assessed by calculating the area under the ROC curve (C-statistic with 95% confidence interval). Calibration was assessed by using the Hosmer-Lemeshow test, through calculation of the slope and intercept, and visually by generating a calibration plot, evaluating the level of agreement between predicted probabilities versus observed outcomes. Overall model performance was evaluated using the Brier score as a composite measure of both model discrimination and calibration. Results We studied 347 patients, 31.1% were women, with a mean age of 72.1 ± 12.7 years, 52.4% with cardiovascular disease and 58.8% diabetics. At the start, the mean eGFR was 20.7 ± 5.0 ml/min and the median urine albumin-creatinine ratio was 327 (IQR 52-1118) mg/g. At 2, 4 and 5 years the percentage of patients who required KRT was 20.2%, 38.3% and 45.7% respectively, while 12.7% and 23.6% died at 2 and 4 years respectively, before starting KRT. For KTR both models had an excellent discrimination. For KFRE-2 and Grams-2 the AUC was 0.896 (95% CI 0.858-0.933) and 0.904 (95% CI 0.866-0.941) respectively, for Grams-4 the AUC was 0.842 (95% CI 0.801-0.884), and for KFRE-5 the AUC was 0.805 (95% CI 0.751-0.859). For death before KTR the Grams model demonstrated an acceptable discrimination, with an AUC of 0.726 (95% CI 0.646-0.806) and 0.749 (95% CI 0.690-0.809) for Grams-2 and Grams-4 respectively. There was excellent calibration for KRT for both models, the Hosmer-Lemeshow test presented a p&amp;gt;0.05 in all cases, the Brier score was less than 0.20. The adjustment was very precise and only in the event of estimated risks greater than 70% at 2 and 4 years is the observed risk overestimated. The calibration of the Grams model to estimate mortality before starting KTR was also excellent, although for estimated risks greater than 50% at 4 years the observed risk is underestimated. Conclusion In a Spanish cohort of patients with CKD G4+, the Grams and KFRE models adequately estimate the risk of KRT. The Grams model provides an acceptable estimate of the risk of death before starting KRT at both 2 and 4 years. It can be considered for treatment planning and information for patients with CKD G4+.

Effectiveness of Multidisciplinary Care Team on Improving the Stages of Chronic Kidney Disease in Thailand

Background: Because of the high prevalence of chronic kidney disease (CKD) in Thailand, the Ministry of Public Health implemented a policy with the concept of multidisciplinary care team (MDC) approach. Objective: To evaluate the effectiveness of MDC in patients who received health service in CKD clinics. Materials and Methods: The present study was a retrospective cohort study carried out among 1,059 CKD patients from 140 hospitals in 12 regional health districts of Thailand between April and July 2017. McNemar test was used to compare laboratory results and the stage changing of CKD before and after patients received the service by multidisciplinary care teams in CKD clinics. Results: Seventy-four percent of subjects were aged more than 60 years. The average duration between the first and the last visit was 28.74 (range of 1 to 210) months. Mean estimated glomerular filtration rate (eGFR) on diagnosis CKD and last follow-up were 32.08±13.58 and 29.19±16.60 mL/minute, respectively. Mean systolic blood pressure on diagnosis CKD and last follow-up were 136.27±20.19 and 133.10±17.64 mmHg, respectively. Of the 1,059 patients, 15.5% improved the stage of CKD and 52.4% was stable. Stage of CKD, eGFR, blood pressure, creatinine, total cholesterol, triglyceride, and low-density lipoprotein cholesterol had statistically significant differences between before and after receiving health service from MDC in the CKD clinic. Conclusion: MCD in CKD clinic had shown the effectiveness in improving the CKD stage and laboratory examination results among the CKD patients. Keywords: Chronic kidney disease; CKD clinic; Multidisciplinary care team; Effectiveness of care

Preparing for kidney replacement therapy in pediatric advanced CKD: a review of literature and defining a multi-disciplinary clinical approach to patient-caregiver education.

Pediatric patients with progressive chronic kidney disease (CKD) approaching kidney replacement therapy (KRT) make up a small population but carry significant morbidity and mortality. Patients and caregivers require comprehensive kidney failure education to ensure a smooth start to KRT. Choice of KRT modality can be influenced by medical comorbidities, patient/caregiver comprehension, and comfort with a particular modality, social and economic factors, and/or implicit bias of the health care team. As KRT modality can influence morbidity, mortality, and quality of life, we created a pediatric advanced CKD clinic to provide comprehensive KRT education and to promote informed decision-making for our advanced CKD patients and their caregivers.

Feminizing care pathways: Mixed-methods study of reproductive options, decision making, pregnancy, post-natal care and parenting amongst women with kidney disease.

To identify the needs, experiences and preferences of women with kidney disease in relation to their reproductive health to inform development of shared decision-making interventions. UK-wide mixed-methods convergent design (Sep 20-Aug 21). Online questionnaire (n = 431) with validated components. Purposively sampled semi-structured interviews (n = 30). Patient and public input throughout. Kidney disease was associated with defeminization, negatively affecting current (sexual) relationships and perceptions of future life goals. There was little evidence that shared decision making was taking place. Unplanned pregnancies were common, sometimes influenced by poor care and support and complicated systems. Reasons for (not) wanting children varied. Complicated pregnancies and miscarriages were common. Women often felt that it was more important to be a "good mother" than to address their health needs, which were often unmet and unrecognized. Impacts of pregnancy on disease and options for alternates to pregnancy were not well understood. The needs and reproductive priorities of women are frequently overshadowed by their kidney disease. High-quality shared decision-making interventions need to be embedded as routine in a feminized care pathway that includes reproductive health. Research is needed in parallel to examine the effectiveness of interventions and address inequalities. We do not fully understand the expectations, needs, experiences and preferences of women with kidney disease for planning and starting a family or deciding not to have children. Women lack the knowledge, resources and opportunities to have high-quality conversations with their healthcare professionals. Decisions are highly personal and related to a number of health, social and cultural factors; individualized approaches to care are essential. Healthcare services need to be redesigned to ensure that women are able to make informed choices about pregnancy and alternative routes to becoming a parent. The original proposal for this research came from listening to the experiences of women in clinic who reported unmet needs and detailed experiences of their pregnancies (positive and negative). A patient group was involved in developing the funding application and helped to refine the objectives by sharing their experiences. Two women who are mothers living with kidney disease were co-opted as core members of the research team. We hosted an interim findings event and invited patients and wider support services (adoption, fertility, surrogacy, education and maternal chronic kidney disease clinics) from across the UK to attend. We followed the UK national standards for patient and public involvement throughout.

Preferences of Patients With Chronic Kidney Disease for Invasive Versus Conservative Treatment of Acute Coronary Syndrome: ADiscrete Choice Experiment.

Background Patients with chronic kidney disease (CKD) can experience acute coronary syndromes (ACS) with high morbidity and mortality. Early invasive management of ACS is recommended for most high-risk patients; however, choosing between an early invasive versus conservative management approach may be influenced by the unique risk of kidney failure for patients with CKD. Methods and Results This discrete choice experiment measured the preferences of patients with CKD for future cardiovascular events versus acute kidney injury and kidney failure following invasive heart procedures for ACS. The discrete choice experiment, consisting of 8 choice tasks, was administered to adult patients attending 2 CKD clinics in Calgary, Alberta. The part-worth utilities of each attribute were determined using multinomial logit models, and preference heterogeneity was explored using latent class analysis. A total of 140 patients completed the discrete choice experiment. The mean age of patients was 64 years, 52% were male, and mean estimated glomerular filtration rate was 37 mL/min per 1.73 m2. Across the range of levels, risk of mortality was the most important attribute, followed by risk of end-stage kidney disease and risk of recurrent myocardial infarction. Latent class analysis identified 2 distinct preference groups. The largest group included 115 (83%) patients, who placed the greatest value on treatment benefits and expressed the strongest preference for reducing mortality. A second group of 25 (17%) patients was identified who were procedure averse and had a strong preference toward conservative management of ACS and avoiding acute kidney injury requiring dialysis. Conclusions The preferences of most patients with CKD for management of ACS were most influenced by lowering mortality. However, a distinct subgroup of patients was strongly averse to invasive management. This highlights the importance of clarifying patient preferences to ensure treatment decisions are aligned with patient values.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting. Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes. Population-based descriptive cohort study. Alberta Kidney Care South. Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019. Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations. We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios. Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting. The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics. Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events. Not applicable.

Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic.

Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two. To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics. Qualitative evaluation. British Columbia, Canada. Patients and health care providers associated with multidisciplinary kidney care clinics. Development and delivery of semi-structured interviews of patients and health care providers. 11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session. Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC. A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery. Not registered.

ANTICOAGULATION FOR ATRIAL FIBRILLATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGES 4 AND 5, NOT ON DIALYSIS

ANTICOAGULATION FOR ATRIAL FIBRILLATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGES 4 AND 5, NOT ON DIALYSIS

POS-116 ADVERSE OUTCOMES AFTER TUNNELLED HEMODIALYSIS CATHETER ASSOCIATED BLOODSTREAM INFECTIONS: IMPACT OF THE INFECTING MICROORGANISM

The utilization of tunnelled central catheters (TCC) is steadily increasing, partly due to late referral to chronic kidney disease (CKD) clinics, combined with suboptimal arteriovenous fistula maturation and failure rates The incidence of catheter-related blood stream infection (CRBSI) after TCC contributes to substantial morbidity in patients on hemodialysis. The present study was designed to evaluate a spectrum of adverse outcomes after CRBSI and association with microorganism isolated from the blood cultures

Effects of a nutrition education program on self-care behavior and kidney functions in pre-dialysis chronic kidney disease patients

The kidneys play a vital role in eliminating wastes and maintaining electrolyte and acid balance in the human body. Chronic kidney disease (CKD) is a condition in which the kidney functions irreversibly decline and eventually requires hemodialysis or renal transplantation. This present study aimed to investigate the effects of an 8-week nutrition education program on self-care behavior and kidney functions in pre-dialysis CKD patients. Twenty-one patients diagnosed with pre-dialysis CKD in the CKD Clinic were appointed to the 8-week nutrition education program on basic kidney functions, CKD etiology, CKD delaying strategies, and dietary counseling. Primary outcomes were the knowledge, attitude, and behavior scores on pre-dialysis self-care. Secondary outcomes were the estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), serum creatinine (sCr), sodium, potassium, and phosphorus. Baseline and post-intervention scores of all outcomes were measured. Results show that most of the participants were female and aged ≥ 60. The nutrition education program significantly improved post-intervention knowledge, attitude, and behavior scores. Moreover, laboratory results of BUN, sCr, eGFR, and serum sodium levels were stable. Even though the mean potassium and phosphorus levels increased, there were improvements in the post-intervention measurements.

Association between urinary sodium excretion and hard outcomes in non-dialysis chronic kidney disease patients

BackgroundRestriction of sodium intake is routinely recommended for patients with chronic kidney disease (CKD). Whether or not sodium intake is associated with the progression of CKD and mortality remains uncertain. We evaluated the association between urinary sodium excretion (as a surrogate for sodium intake) with the occurrence of renal failure and mortality in patients with non-dialytic CKD.MethodsWe conducted a retrospective study of patients followed at a CKD clinic care hospital from October 2006 to March 2017. Adult patients with non-dialytic CKD were included. Using a time-to-event analysis, we examined the association of urinary sodium excretion as a categorical variable (categorized as quintiles: 1st quintile: 0.54–2.51 g; 2nd quintile: 2.52–3.11 g, 3rd quintile: 3.12–3.97 g, 4th quintile: 3.98–5.24 g and 5th quintile: 5.26–13.80 g) and the outcomes of interest. The primary outcome was defined as progression to end-stage renal disease requiring any type of renal replacement therapy. The secondary outcome was mortality.ResultsTwo hundred five patients were included in the study (mean follow up of 2.6 years) with a mean eGFR of 26 (19–41) ml/min/1.73m2. 37 patients (18%) required renal replacement therapy and 52 (25,3%) died. There was association between urinary sodium excretion and need for renal replacement therapy (adjusted HR 0.245; 95%CI 0.660–0.912). There was no association between urinary sodium excretion and mortality in adjusted models.ConclusionModerate sodium intake was associated with a lower risk of renal failure.