Kidney Care Research Articles

Improving kidney care for people with severe mental health difficulties: A thematic analysis of personal and family members' perspectives.

People with severe mental health difficulties (SMHDs) often have poorer access to kidney healthcare. To better understand the barriers and facilitators to kidney healthcare for this population, we conducted interviews with nine individuals with SMHDs and four family members. Through reflexive thematic analysis, we generated three themes: (1) 'One size doesn't fit all' describes the need for individualised kidney healthcare, adapted to meet the specific needs of each person with a SMHD. (2) 'You just can't say, "I'm only dealing with your kidney here"' describes how fragmentation of physical and mental healthcare services can lead to poorer outcomes for people with SMHDs, underscoring the need for coordinated care. (3) 'Just treat me with respect' describes the impact of healthcare provider attitudes. Overall, participants praised the dedication and kindness of renal clinicians. However, some participants also described experiences of stigma and discrimination, and called for additional education for healthcare providers regarding SMHDs.

Management of serum phosphorus over a 1-year follow-up in patients on peritoneal dialysis prescribed sucroferric oxyhydroxide as part of routine care: a retrospective analysis

BackgroundHyperphosphatemia is associated with increased morbidity and mortality in patients with end-stage kidney disease (ESKD). Whereas clinical and observational studies have demonstrated the effectiveness of sucroferric oxyhydroxide (SO) in controlling serum phosphorus (sP) in ESKD, data on the real-world impact of switching to SO in patients on peritoneal dialysis (PD) are limited. In this retrospective database analysis, we examine the impact of SO on sP management over a 1-year period among PD patients prescribed SO as part of routine clinical care.MethodsWe analyzed de-identified data from adults on PD in Fresenius Kidney Care clinics who were prescribed SO monotherapy between May 2018 and December 2019 as part of routine clinical management. Changes from baseline in sP levels, phosphate binder (PB) pill burden, and laboratory parameters were evaluated during the four consecutive 91-day intervals of SO treatment.ResultsThe mean age of the 402 patients who completed 1 year of SO was 55.2 years at baseline, and they had been on PD for an average of 19.9 months. SO was initiated with no baseline PB recorded in 36.1% of patients, whereas the remaining 257 patients were switched to SO from sevelamer (39.7%), calcium acetate (30.4%), lanthanum (1.2%), ferric citrate (14.0%), or more than one PB (14.8%). Mean sP at baseline was 6.26 mg/dL. After being prescribed SO, the percentage of patients achieving sP ≤ 5.5 mg/dL increased from 32.1% (baseline) to 46.5–54.0% during the 1-year follow-up, whereas the mean number of PB pills taken per day decreased from 7.7 at baseline (among patients on a baseline PB) to 4.6 to 5.4. Serum phosphorus and PB pill burden decreased regardless of changes in residual kidney function over the 12-month period. Similar results were observed for the full cohort (976 patients who either completed or discontinued SO during the 1-year follow-up).ConclusionsPatients on PD who were prescribed SO as part of routine care for phosphorus management experienced significant reductions in SP and PB pills per day and improvements in sP target achievement, suggesting the effectiveness of SO on SP management with a concurrent reduction in pill burden.

Hub and Spoke Model for Kidney Care - From Prevention to Treatment.

Hub and Spoke Model for Kidney Care - From Prevention to Treatment.

Closing the policy gap in diabetes care for individuals with advanced CKD

AbstractAimThe co‐existence of diabetes and CKD poses significant challenges to healthcare systems, current frameworks often inadequately address the complex needs of individuals with both conditions. Recognising these gaps, we introduced a new diabetes care model for people with advanced CKD in renal satellite units.This paper aims to evaluate this new diabetes model care.MethodWe conducted a prospective audit of a new integrated diabetes kidney care model. Data were presented as mean ± SD or counts/percentages, and pre‐ and post‐intervention differences were assessed using paired samples t‐tests.ResultsA total of 291 individuals with diabetes and advanced CKD stages 4 or 5, or undergoing haemodialysis, were included. The mean age was 68.5 (±13.0) years, 58.4% were males. Nearly half of the cohort had four or more long‐term conditions, while two‐thirds experienced mild/severe frailty. Only 6% were receiving ongoing diabetes care from secondary care diabetes specialist services. For patients with CKD not receiving dialysis, comparing pre‐ and post‐intervention, there were improvements in HbA1c (−13.0 mmol/mol, p < 0.001), SBP (−13.7 mm Hg, p < 0.0001), and weight (−2.9 kg, p < 0.0001). Furthermore, there was an increase in guideline‐directed therapies, with notable usage of SGLT2i (62.9%) and GLP1‐RA (28.4%), while access to diabetes technology increased to 89%.ConclusionThis new model of care resulted in improved metabolic outcomes, increased utilisation of guideline‐directed therapies, and enhanced access to diabetes technologies. However, the model also revealed significant unmet clinical needs in areas such as access to diabetes care, diabetes eye screening and foot surveillance.

Fostering a future of home dialysis: transforming kidney care in Europe

Fostering a future of home dialysis: transforming kidney care in Europe

Getting the most out of remote care: Co-developing a Toolkit to improve the delivery of remote kidney care appointments for underserved groups.

Telephone and video appointments are still common post-pandemic, with an estimated 25%-50% of kidney appointments in the United Kingdom still conducted remotely. This is important as remote consultations may exacerbate pre-existing inequalities in those from underserved groups. Those from underserved groups are often not represented in health research and include those with learning disability, mental health needs, hearing/sight problems, young/older people, those from ethnic minority groups. The aim was to develop a Toolkit to improve the quality of remote kidney care appointments for people from different underserved groups. A parallel mixed methods approach with semistructured interviews/focus groups and survey. We also conducted workshops to develop and validate the Toolkit. Seventy-five renal staff members completed the survey and 21patients participated in the interviews and focus groups. Patients (n = 11) and staff (n = 10) took part in the Toolkit development workshop, and patients (n = 13) took part in the Toolkit validation workshop. Four themes from interviews/focus groups suggested areas in which remote appointments could be improved. Themes were quality of appointment, patient empowerment, patient-practitioner relationship and unique needs for underserved groups. Staff reported difficulty building rapport, confidentiality issues, confidence about diagnosis/advice given, technical difficulties and shared decision making. This study is the first to explore experiences of remote appointments among both staff and those from underserved groups living with kidney disease in the United Kingdom. Whileremote appointments can be beneficial, our findings indicate that remote consultations need optimisation to meet the needs of patients. The project findings informed the development of a Toolkit which will be widely promoted and accessible in the United Kingdom during 2024.

Best practice for the selection, design and implementation of UK Kidney Association guidelines: a modified Delphi consensus approach

BackgroundDespite research into how to effectively implement evidence-based recommendations into clinical practice, a lack of standardisation in the commissioning and development of clinical practice guidelines can lead to inconsistencies and...

Advanced Care Planning in Chronic Kidney Disease: Qualitative Impact of the MY WAY Intervention

ContextDespite recommendations for shared decision-making and advanced care planning (ACP) for people with chronic kidney disease (CKD), such conversations are infrequent. The MY WAY educational and patient coaching intervention aimed to promote high-quality ACP. ObjectivesThis qualitative substudy sought to gain participant feedback on the MY WAY ACP coaching intervention, and how it impacted their wishes, perceptions of kidney care, and factors that helped them reflect on ACP. MethodsWe conducted semi-structured interviews with participants from the intervention arm of the MY WAY study about their prior experience with ACPs in the context of CKD, impressions of the MY WAY intervention, and outcomes of the MY WAY intervention. We conducted a qualitative thematic analysis of transcribed interviews. ResultsAmong 15 intervention participants, the following major themes emerged: 1) Patients with CKD approach ACP with varied experiences; 2) Patients felt the MY WAY coaching intervention supported ACP by reinforcing values; and 3) Patients found the coaching intervention focused on end of life, but not necessarily on decision making regarding CKD. ConclusionParticipants perceived the coaching intervention to have high utility in facilitating ACP, but had a limited impact on CKD-specific decision-making. These findings suggest that the coach plays a crucial role in comfort with ACP conversations and that ACP readiness and engagement may not correlate with treatment preferences or understanding of CKD treatment decisions.

Onco-Nephrology - The need of the hour for kidney care in cancer patients

Onco-Nephrology - The need of the hour for kidney care in cancer patients

Charting the future of kidney care in Brazil: insights and evolution through the Brazilian Dialysis Survey

Charting the future of kidney care in Brazil: insights and evolution through the Brazilian Dialysis Survey

#1746 Comprehensive kidney care: adopting principles of comprehensive geriatric assessment within an advanced kidney care clinic

Abstract Background and Aims Chronic Kidney Disease (CKD) is increasingly prevalent among older people, a trend that presents significant healthcare challenges. This project introduces the Comprehensive Kidney Care (CKC) clinic model which incorporates elements from Comprehensive Geriatric Assessment within the Advanced Kidney Care clinic. By focusing on a holistic care, this model aims to enhance symptom management, facilitate appropriate referrals, improve documentation, and offer advance care planning (ACP), ultimately to improve care quality for older people with advanced CKD. Method We evaluated 27 patients ≥65 years old with CKD stage 4 and 5, attending the CKC clinic between 23/11/2022 and 22/11/2023. Demographics and clinical characteristics were recorded, including Charlson Comorbidity Index (CCI). Individual symptoms and total score were screened in each clinic using the Integrated Palliative Outcome Score (IPOS)-Renal Symptom Survey. Geriatric impairments were assessed including frailty (Clinical Frailty Scale [CFS]), mobility, polypharmacy (≥5 medications), activities of daily living (ADLs), falls and cognition. Actions were documented, including initiation of ACP discussions and other relevant interventions. Results Patients’ average age was 82 (SD 5.8), they were predominantly male (20 patients, 74%) and had a median eGFR of 18 ml/min/1.73 m2 (IQR 10). They exhibited a high burden of comorbidities (CCI mean 8.4, SD 2) and a high prevalence of geriatric impairments: 74% (20 patients) had a CFS score ≥4, 63% (17) required mobility aids, 26% (7) reported falls, 30% (8) required assistance with ADLs, and all had polypharmacy. IPOS was recorded for 20 patients. Mean total score was 10.25 (IQR 8). Fig. 1 demonstrates the symptoms reported as experienced ‘moderately’ or worse at first IPOS completion. Thirteen patients had more than one IPOS completed, allowing each symptom to be compared at two consecutive clinic attendances 239 times. Symptom improvement was more common than worsening (37 [15.5%] versus 11 [4.6%]). Most times symptoms remained stable (43, 18%) or were absent (132, 55.2%), with a minority appearing 16 times (6.7%). Seventeen relevant actions were identified, including symptom management (14 patients, 51.9%), physical activity advice (7, 25.9%), referrals to other teams (12, 44.4%; 2 referred to more than one), including dietitian (4), psychology (3), frailty team (2), physiotherapy (2), memory assessment clinic, social care, falls clinic and palliative care (1 each). Preferred kidney management was discussed with 9 patients (33%); 9 patients had documented preferences before attending the CKC clinic. Ten (37%) preferred conservative care, 4 (15%) haemodialysis and 13 (48%) remained undecided. Undecided patients had a significantly higher eGFR (median 21 [IQR 4] versus 12 ml/min/1.73 m2 [IQR 6.75], p-value 0.012). ACP was discussed with 8 patients; these patients had higher CFS scores (median 6 versus 4, IQR 1.25, p-value 0.005) and higher ADL dependence (Odds ratio 8.9, p-value 0.026). Conclusion The CKC clinic model shows promise as an effective approach for assessing and managing older people with advanced CKD. Most times symptoms improved or remained unchanged, suggesting actions were effective at managing symptom burden. ACP discussions were more commonly initiated in patients with higher frailty severity and ADL dependence; obtaining geriatric impairment information may help prompt ACP discussions.

#857 How low can we go with dialysate flow? Does that mean we can make nephrology green?

Abstract Background and Aims Green nephrology encompasses all initiatives in kidney care that have a positive impact on the climate and environment. We know that environmental impact of dialysis is particularly high, considering water consumption and disposable waste production during each session. All that suggests a great opportunity where many improvements should be made. To prepare the dialysate 240 liters of water are needed for one four-hour session with a dialysate flow (Qd) set at 500 ml/min. Including additional water needed to rinse and sterilize the system, this gives approximately 500 liters of water used for one hemodialysis. Lower dialysate flow rate is associated with a significant reduction in the amount of water used for the hemodialysis procedure. An increase in Qd from 500 ml/min to 800 ml/min has been recommended to increase dialysis efficiency. It's benefit was not confirmed in in vivo studies which suggested that increasing the dialysate flow rate offers no benefit in terms of delivered Kt/V. Similarly, studies with a Qd of 400 ml/min showed comparable efficiency. If hemodialysis could be performed equally effectively with less dialysate consumption, water could be significantly saved. The aim of this study was to check whether change of dialysate flow from 500 ml/min to 300 ml/min has a significant impact on dialysis adequacy (measured by Kt/V). Method The study was a retrospective analysis. During the COVID19 surge in January 2022 due to administrative issues in a satellite dialysis center the dialysate flow was reduced to 300 ml/min. The center again increased Qd to 500 ml/min in February 2022. We analyzed laboratory data from 3 months before dialysate flow reduction, in the month with reduced Qd to 300 ml/min, and from 3 months thereafter with Qd set at 500 ml/min. Results 26 patients (10 men and 16 women – all dialysis patients from a satellite dialysis center) were enrolled in the study. Two of them died during observation, therefore 24 people were included in final analysis. Their median age was 72 (66-78) years. ANOVA with repeated measures showed lack of differences between three time points in terms of Kt/V (Qd 500 ml/min - 1.285±0.202, Qd 300 ml/min - 1.275±0.192 and Qd 500 ml/min - 1.337±0.199; p=0.093). Change in serum potassium during hemodialysis did not depend on dialysate flow (ΔK Qd 500ml/min - 1.5±0.5 mmol/l, Qd 300 ml//min - 1.7±0.5 mmol/l, Qd 500 ml/min - 1.6±0.4 mmol/l; p=0.197). Serum phosphorus was comparable between three time points (Qd 500 ml/min - 5.99±1.68 mg/l, Qd 300 ml/min - 5.65±1.4mg/l, Qd 500 ml/min - 6.01±1.67 mg/l; p=0.066). Conclusion Reduction in dialysate flow rate to 300 ml/min is safe for the patients and probably does not cause any short-term negative effects. Thus we can achieve the same therapeutic effect saving water consumption. Larger, long-term studies are needed to confirm the efficacy of this approach.

#520 Trends in kidney replacement therapy in Central and Eastern Europe—data from the ERA Registry

Abstract Background and Aims Despite huge efforts to accomplish equitable access to high-quality healthcare, large disparities in kidney care delivery remain across Europe. Economic factors are considered to be the driving force behind differences in access to kidney replacement therapy (KRT), with lower access in lower-income countries. There is a sparsity of epidemiological data on KRT in Central and Eastern Europe. Therefore, we aimed to examine time trends in incidence and prevalence of KRT in Central and Eastern Europe from 2010 to 2021. Method We included incidence and prevalence data on patients starting or receiving KRT between the years 2010 and 2021 from 18 Central and Eastern European countries participating in the ERA Registry. Albania, Belarus, Bulgaria, Cyprus, Czech Republic, Latvia, Lithuania, Northern Macedonia, Poland, Russia, Slovakia, Turkey, and Ukraine provided data on aggregated level, whereas Bosnia and Herzegovina, Estonia, Greece, Romania and Serbia provided individual patient data. General population data were reported by the collaborating registries or extracted from Eurostat. Most registries had full coverage of the general population. We expressed incidence and prevalence per million population (pmp) and time trends were studied with Joinpoint regression and expressed as Annual Percentage Changes (APCs). Results Incidence of KRT varied largely across Central and Eastern European countries (Fig. 1). In 2010, it ranged from 23.0 pmp in Ukraine to 190.5 pmp in Greece, and in 2021 from 53.0 pmp in Ukraine to 283.0 pmp in Cyprus. In 7 countries the KRT incidence increased significantly between 2010 and 2021 (APC; 95% CI): Albania (+8%; 5-10%), Cyprus (+6%; 4-9%), Greece (+3%; 3-4%), North Macedonia (+4%; 3-5%), Romania (+3%; 1-5%), Russia (+9%; 7-10%), and Ukraine (+7%; 4-9%). Serbia was the only country in which KRT incidence decreased: from 188.6 pmp in 2010 to 65.9 pmp in 2021 (APC: −8%; −10 to −6%), whereas for other countries KRT incidence remained stable over the study period. Except for the Baltic States, the age of incident KRT patients increased in all countries during the study period, also reflected by a temporal increase in the proportion of patients initiating KRT at ages of 65 years and older. The KRT prevalence also showed large variation across countries, ranging from 123.6 pmp to 1080.0 pmp in 2010 in Ukraine and Greece (Fig. 1). In 2021 it ranged from 303.6 pmp (Ukraine) to 1445.4 pmp (Greece). In all, but five countries (Belarus, Bosnia and Herzegovina, Czech Republic, North Macedonia, and Serbia) the prevalence of KRT increased annually with 2-9% between 2010 and 2021. This increase was mainly driven by an increase in prevalent patients with a functioning kidney transplant. If, however, the period prior to the COVID-19 pandemic was considered (2010 to 2019) there was also an increasing trend in the KRT prevalence for Bosnia and Herzegovina, Czech Republic, and North Macedonia. In all countries, prevalent KRT patients became older during recent years. Conclusion Large variation exists in the number of incident and prevalent patients treated with KRT across Central and Eastern Europe. In the majority of countries the incidence of KRT remained stable between 2010 and 2021, whereas in about one third of countries the incidence of KRT significantly increased. On the other hand, in most countries the number of prevalent KRT patients significantly increased over the study period, especially prior to the COVID-19 pandemic. This increase was mainly driven by an increase in prevalent kidney transplant recipients. Patients on KRT tended to become older in the entire region, reflecting both the aging population, as well as the increasing willingness and capacity to treat elderly patients. Nevertheless, large country variations in the epidemiology of KRT remain and this study is a first important step to define country-specific priorities for the optimization of kidney care and to create further public awareness for kidney diseases in the Central and Eastern European region.

#2924 Comparison of large language models and traditional natural language processing techniques in predicting arteriovenous fistula failure

Abstract Background and Aims Large language models (LLMs) have gained significant attention in the field of natural language processing (NLP), marking a shift from traditional techniques like Term Frequency-Inverse Document Frequency (TF-IDF). We developed a traditional NLP model to predict arteriovenous fistula (AVF) failure within next 30 days using clinical notes. The goal of this analysis was to investigate whether LLMs would outperform traditional NLP techniques, specifically in the context of predicting AVF failure within the next 30 days using clinical notes. Method We defined AVF failure as the change in status from active to permanently unusable status or temporarily unusable status. We used data from a large kidney care network from January 2021 to December 2021. Two models were created using LLMs and traditional TF-IDF technique. We used “distilbert-base-uncased”, a distilled version of BERT base model [1], and compared its performance with traditional TF-IDF-based NLP techniques. The dataset was randomly divided into 60% training, 20% validation and 20% test dataset. The test data, comprising of unseen patients’ data was used to evaluate the performance of the model. Both models were evaluated using metrics such as area under the receiver operating curve (AUROC), accuracy, sensitivity, and specificity. Results The incidence of 30 days AVF failure rate was 2.3% in the population. Both LLMs and traditional showed similar overall performance as summarized in Table 1. Notably, LLMs showed marginally better performance in certain evaluation metrics. Both models had same AUROC of 0.64 on test data. The accuracy and balanced accuracy for LLMs were 72.9% and 59.7%, respectively, compared to 70.9% and 59.6% for the traditional TF-IDF approach. In terms of specificity, LLMs scored 73.2%, slightly higher than the 71.2% observed for traditional NLP methods. However, LLMs had a lower sensitivity of 46.1% compared to 48% for traditional NLP. However, it is worth noting that training on LLMs took considerably longer than TF-IDF. Moreover, it also used higher computational resources such as utilization of graphics processing units (GPU) instances in cloud-based services, leading to higher cost. Conclusion In our study, we discovered that advanced LLMs perform comparably to traditional TF-IDF modeling techniques in predicting the failure of AVF. Both models demonstrated identical AUROC. While specificity was higher in LLMs compared to traditional NLP, sensitivity was higher in traditional NLP compared to LLMs. LLM was fine-tuned with a limited dataset, which could have influenced its performance to be similar to that of traditional NLP methods. This finding suggests that while LLMs may excel in certain scenarios, such as performing in-depth sentiment analysis of patient data for complex tasks, their effectiveness is highly dependent on the specific use case. It is crucial to weigh the benefits against the resources required for LLMs, as they can be significantly more resource-intensive and costly compared to traditional TF-IDF methods. This highlights the importance of a use-case-driven approach in selecting the appropriate NLP technique for healthcare applications.

#1018 Profiles of medication use in dialysis patients globally

Abstract Background and Aims Global patterns of medication use in dialysis have not been defined so far. This project aims to provide a real-world view of medication use in dialysis and to characterize therapeutic classes and types of medications. An anonymized dialysis dataset of a global kidney care network called Apollo Dial DB was used. The most common prescribed medications administered at home by the patients were assessed. Method This is a multi-center, retrospective study using real-life data from adult dialysis patients captured in the first version of the Apollo Dial DB dataset. This dataset contains anonymized dialysis data (longitudinal observation level data) on more than 540,000 unique dialysis patients in 40 countries from Jan 2018-Mar 2021. Home medications were analyzed based on Anatomical Therapeutic Chemical (ATC) codes. Top (most common) 5 ATC codes for home medication are presented, once as 4-digit ATC code classes (e.g., A12A for Calcium) and once as full/exact ATC code (e.g., A12AA04 as 7-digit code for Calcium carbonate). Results In Apollo Dial DB 497,723 patients had 10,538,324 documented home medication entries (on average 21 medication prescriptions per patient outside the dialysis clinic), thereof 114,978 patients had 1,607,168 ATC code entries. Each ATC code entry represents a documented prescription of individual length. All percentages shown below are related to 1,607,168 ATC code entries (not to patients). The top 4-digit ATC code classes of home medication were Calcium (8.60%), Vitamin A and D, including combinations (7.33%), All other Therapeutic Products (6.84%), Antithrombotic Agents (5.89%) and Selective Calcium Channel Blockers with mainly vascular Effects (5.39%) (Fig. 1). Out of the ATC class Calcium, Calcium carbonate (4.89%) and Calcium acetate (3.22%) are listed as number 1 and 3 of the top 5 ‘full’ ATC codes. Alfacalcidol (3.36%) of ‘Vitamin A and D, including combinations’ is also number 2 of the ‘full’ ATC code list. Amlodipine (3.07%), number 4 of the full ATC code list, represents the majority of ‘Selective Calcium Channel Blockers with mainly vascular Effects’. Sevelamer of ‘All other Therapeutic Products’ is listed as number 5 in the ATC code list with 2.91% (Fig. 2). Conclusion The top 5 home ATC classes of medications account for 34% of all home prescriptions in dialysis patients. They largely represent phosphate binders, vitamin A & D, antithrombotics, and antihypertensives/antiarrhythmic medications. Although, outside the dialysis clinic each patient has on average 21 medication prescriptions, a lot of these prescriptions represent the major medication classes. It is worthwhile to mention the presented data are related to prescriptions and not to duration of use, e.g., both a medication prescribed for 6 months and a prescription for 1 week are documented only once, even if time on drug varies. Further research is needed to explore global patterns, including further ATC code groups particularly on a patient level, accounting for duration of use and medication formulations, real-world application of various drugs (e.g., GLP1 drugs, HIF PH inhibitor) and accounting for US data with NDC codes.

#2121 The Kidney-specific Psychosocial ASSessment and support (Kidney PASSPORT) feasibility trial

Abstract Background and Aims Psychosocial interventions for depressive and anxiety symptoms are effective in CKD, but studies mainly focus on people on dialysis. Little is known about the role of screening and prevention of common mental health difficulties in early CKD. This trial assessed the research feasibility of an intervention to screen for psychological distress in CKD and deliver prevention approaches for sub-threshold symptoms. The intervention was facilitated by an Assistant Wellbeing Practitioner (AWP), a Band 3 healthcare assistant familiar with renal services and upskilled with specific competency-based training. Method We conducted a mixed-methods, one-year, single-centre, prospective, single-blind, wait-list, randomised controlled feasibility trial. We anticipated screening 250 individuals to identify 100 eligible, with a 40% screening positivity rate, a 45% participation rate and 20% attrition rate, to give 36 participants in the feasibility study. Primary outcomes are shown in Table 1. Potential participants were screened using an online self-completion questionnaire. Participants were randomised to 6 months of immediate or wait-list intervention. Data was collected using online self-report surveys, clinical research forms and semi-structured qualitative interviews. The trial was overseen by a steering committee and received the relevant ethics approvals. Funders included Kidney Care UK, the British Renal Society, the Royal Devon and Exeter Research Capacity Awards and the Exeter Kidney Unit development fund. Results We approached n = 233 people. Feasibility outcomes are shown in Table 2. Due to logistical issues an extension was obtained and in total n = 24 participants were recruited, agreed by the steering committee. All clinical research forms were completed. The most common intervention components were self-management and liaison with the clinical team. The median (interquartile range) difference in baseline and post intervention PHQ-9 score was −5 (−7, 0), n = 19, p = 0.003) and GAD-7 score was −7 (−8, −2), n = 19, p = 0.0002). Qualitative findings showed the AWP was seen as filling in the gaps left by other parts of the service. Key themes were accessibility, time availability, empathy, patient empowerment, and ability to empower the individual. Balance—especially family, work and health—was noted to be a challenge for participants. Importantly, the AWP was able to help participants overcome previous negative experiences. The trial provided valuable learning regarding role implementation, including recruitment, training, work patterns, everyday practicalities, and supervision arrangements. Conclusion We propose a novel intervention for screening and addressing early mental health problems in people with CKD. A single-centre feasibility design was appropriate. The screening positivity rate was lower than anticipated, informing samples for future trials. Outcome data collection via self-report surveys was not feasible. The intervention was well received, with the AWP being valued and self-help and clinical liaison being core elements. Significant reductions in depression and anxiety screening scores were observed. Despite the rigorous design, limitations included slow initial recruitment impacting the sample size and AWP role vulnerability. Future work includes adapting the AWP training and role based on trial learning and considering suitability for other long-term conditions. In conclusion, the AWP role shows promise in routine screening for and prevention of common mental health difficulties in CKD.

#1325 Patients reporting not “sleeping normally” are more likely to transition to in-center hemodialysis within 90 days of peritoneal dialysis start

Abstract Background and Aims Although there are many advantages to home dialysis therapies such as peritoneal dialysis (PD), many patients drop out of PD and transition to in-center hemodialysis (ICHD). Reasons for this transition are varied and may be multifactorial. The current analysis aims to assess whether self-reported abnormal sleep is associated with transition to ICHD within 90 days of starting automated peritoneal dialysis (APD). Method Patients initiating APD at any Fresenius Kidney Care dialysis clinic between 2017-2019 were eligible for inclusion in this retrospective database analysis (n = 11 668). Monthly, various health-related questions are asked to patients as part of routine care through a home therapy nursing assessment (HTNA). One question asks if the patient is “sleeping normally”. After removing patients without completed HTNA questions on sleep, there were 11 449 patients included. We assessed patients for the first 90 days of PD for transition to ICHD through survival analysis with other reasons for discontinuing PD treated as competing events. Results On average, patients were aged 57 (15) years with BMI of 31 (14.5) and 42% were female. Approximately 5% of patients described their sleep as not normal (553/11449) in their first HTNA. Patients who reported abnormal sleep had 4.4 times the rate of switching to ICHD when compared to patients who reported normal sleep (Hazard Ratio (HR): 4.4; 95% CI: 3.5-5.5, p < 0.0001). After controlling for case mix variables, the HR was 3.7 (95% CI: 2.9-4.7, p < 0.0001). Case mix variables included gender, dialysis vintage, age, race, ethnicity, body size, residual renal function, Charlson Co-morbidity Index, diabetes status, geographic region, size of PD program, insurance primary payor, relationship status, and primary language spoken. Conclusion Among patients dialyzing at home with APD, abnormal sleep may be a risk factor for transitioning from home therapy to ICHD. Identifying root causes of sleep disturbances may help to prevent modality change.

#1635 In hemodialysis patients, COVID-19 vaccination mitigates the variability of clinical and laboratory variables

Abstract Background and Aims Despite prior studies on the clinical impact of COVID-19 and the documented efficacy of COVID-19 vaccinations in hemodialysis (HD) patients, the exact effects of COVID-19 vaccinations on various clinical biomarkers before and after the diagnosis of COVID-19 have not been established. In particular, the longitudinal trajectories of clinical and laboratory parameters remain unknown. We aim to investigate clinical and laboratory variables around the time of COVID-19 diagnosis and how vaccination impacts population trajectories. Method We studied 53,223 HD patients from Fresenius Kidney Care, a large U.S. dialysis organization, who received COVID-19 vaccination between January 1, 2021 and August 2, 2021. Depending on whether or not COVID-19 diagnosis happened after the first dose of vaccination for Johnson & Johnson or after the second dose for all other vaccines, we created two patient cohorts comprising patients infected before (N = 47,443) and after (N = 5780) full vaccination. A nonparametric cubic spline model for flexibility was fitted to the patient data averaged for each day between 60 days before and 60 days after the COVID-19 diagnosis. Clinical parameters include ones that are recorded at each HD treatment (pre-HD temperature, TEMP; pre-HD systolic blood pressure, SBP; pre-HD weight, WT; pre-HD pulse rate, PULSE; intradialytic weight gain, IDWG) and ones that are recorded less frequently (hemoglobin, HGB; white blood cell, WBC; neutrophil-lymphocyte ratio, NLR; platelet count, PLA; albumin, ALB). Results All longitudinal trajectory patterns undergo changes in the days before and after the diagnosis of COVID-19. In both the vaccinated and unvaccinated cohorts, there is an initial increase in TEMP, PULSE, and NLR up to 14 days preceding the diagnosis of COVID-19, followed by a subsequent decrease. Conversely, WT and IDWG exhibit a decline up to 14 days before the diagnosis of COVID-19 and an increase thereafter. ALB maintains a decreasing trend from 14 days prior until 20 days after before increasing again. In the unvaccinated cohort, SBP and WBC start decreasing up to 20 days ahead of diagnosis of COVID-19, whereas the unvaccinated cohort maintains a steady trend, increasing for SBP and decreasing for WBC. The lasting effects of COVID-19 can be found up to 60 days after diagnosis, e.g., WT, PULSE, and HGB. Variations in trend shapes are evident between the vaccinated and unvaccinated cohorts across all variables. Notably, all variables in the vaccinated cohort demonstrate smaller changes around the days of COVID-19 diagnosis. Conclusion We discovered trend changes in multiple variables in the days leading up to COVID-19 diagnosis, corroborating earlier findings. This finding lays the foundation for early detection ahead of regular COVID-19 tests. Prior COVID-19 vaccination mitigates the effect of COVID-19 on several important clinical and laboratory indicators, supporting the need for continued vaccination efforts. Lasting effects from infection are prevalent, extending beyond 60 days after confirmation. Further research is warranted to understand their long-term impact.

#1857 Difelikefalin experience in a large dialysis organization in the US: one year follow-up on patients after completion of 12 weeks

Abstract Background and Aims Chronic kidney disease associated pruritis (CKD-aP) is a common disorder that negatively impacts a patient's quality of life. Itch can be self-reported using the Worst Itching Intensity Numerical Rating Scale (WI-NRS) where higher numbers indicate more severe itch. Difelikefalin (DFK) has been shown to reduce itch in hemodialysis (HD) patients with moderate to severe CKD-aP in clinical trials. Previously, we reported the real-world results of patients who completed 12 weeks of DFK treatment as part of routine clinical care. This current analysis describes the long-term treatment of these 295 patients. Method Fresenius Kidney Care (FKC) in-center HD patients aged 18-89 who received at least 1 dose of DFK before 15 Nov 2022 and were administered a WI-NRS before first DFK administration were assessed. Patients who received 30+ DFK administrations within 74-84 days were classified as complete and are the focus of this analysis. The current analysis focuses on the 3- to 12-month follow-up after first DFK administration to monitor for DFK discontinuation and severity of itch when DKF therapy is discontinued. Results Eighty-one percent of patients (238/295) were administered DFK doses beyond 90 days. These patients treated included 167 patients who received DFK continuously (doses between days 91-101) and 71 who restarted DFK after day 101. Most patients (62%, 148/238) were treated with DKF between days 354 and 365 and 90 (38%, 90/238) stopped before 354 days. Out of those not treated with DFK beyond 90 days (19%, 57/295), 26 patients died or were transferred outside of FKC and 1 received a kidney transplant. Out of the 84 patients previously reported with WI-NRS measured before DFK and during DFK WI-NRS, 29 had follow up WI-NRS scores during times without DFK doses. We observed a decrease in mean itch severity from 8.0 before DFK to 3.2 during DFK and then a return to higher itch severity after DFK was discontinued (7.3). Conclusion In a real-world analysis of patients who completed 12 weeks of DFK therapy, 81% of patients received further DKF administrations. Most patients were treated with DFK between days 354 and 365, although not all patients received continuous DFK therapy. In a subset 29 patients with WI-NRS scores before DFK, during DFK, and after discontinuation, improvements in itch were noted during DFK treatment and a return to severe itch after DFK discontinuation.

#559 Validation of the Kidney Failure Risk Equation (KFRE) in individuals with chronic kidney disease and multimorbidity

Abstract Background and Aims Increasing numbers of individuals with chronic kidney disease (CKD) experience multiple long-term conditions (multimorbidity). Clinical guidance recommends the use of validated risk prediction equations, such as the kidney failure risk equation (KFRE), to guide referral to specialist kidney care services. However, multimorbidity may impact the accuracy of creatinine-based eGFR and bias the prognostic utility of KFRE. Equations with alternative filtration markers, such as Cystatin C eGFR (eGFRcys) or the combined creatinine and Cystatin C eGFR (eGFRcrcys), may improve KFRE's risk stratification and discrimination of future kidney failure risks. This study aimed to validate the four-variable KFRE in individuals with CKD, with and without multimorbidity in a research-based cohort (UK Biobank) and a population-based cohort (Stockholm Creatinine Measurements project (SCREAM)). The study also assessed the performance of KFRE when using eGFRcr, eGFRcys and eGFRcrcys. Method Individuals from both cohorts were included if they had CKD, defined as eGFR<60 mL/min/1.73 m2 by any of the three eGFR equations (eGFRcr, eGFRcys and eGFRcrcys), and had available proteinuria measurement at time of testing or within the previous 12 months. Multimorbidity was defined as the presence of two or more long-term conditions in addition to CKD and was grouped into multimorbidity clusters based on previous research. The outcome was kidney failure, defined as the need for long-term dialysis or kidney transplantation. KFRE performance at 2- and 5-years was assessed using the area under the receiver operating characteristic curve and c-index for discrimination and calibration curves for calibration. Results We included 24 489 individuals from UK Biobank and 42 902 individuals from SCREAM (mean age 62.8 (SD 5.6) and 70.1 (SD14.1), 54% and 66% female, respectively). In UK biobank, 14 998 individuals had multimorbidity, of which 5 375 had cardiometabolic multimorbidity. In SCREAM, 30 147 had multimorbidity and 17 854 cardiometabolic multimorbidity. Overall, there were 252 and 312 kidney failure events and 1 108 and 1 471 death events in UK Biobank and 918 and 1 098 kidney failure events and 8 785 and 10 152 death events in SCREAM within 2- and 5-years respectively. Model performance was consistent across both cohorts. Discrimination power of KFRE was good in individuals with and without multimorbidity and across the 2-year and 5-year models (Table 1). Calibration plots revealed over-estimation of risk at 2-years in both cohorts and under-estimation of risk at 5-years in patients with multimorbidity in UK Biobank. There was no improvement in model performance when using eGFRcys or eGFRcrcys compared to eGFRCr. There was a higher cumulative incidence of both kidney failure and death in the multimorbidity group, with a prominent increase in risk of death over time compared to the no multimorbidity group. This was most evident in the SCREAM cohort (Fig. 1). Conclusion KFRE adequately predicts kidney failure in individuals with multimorbidity and either creatinine or cystatin C can be used. Given the high rates of mortality amongst people with multimorbidity, exploration of models that account for the competing risk of death is warranted.