Nephrology Referral Research Articles

IgA Nephropathy: A Timeline from Hematuria/Proteinuria to Nephrology Referral and Kidney Biopsy

IgA Nephropathy: A Timeline from Hematuria/Proteinuria to Nephrology Referral and Kidney Biopsy

Analysis of Sodium in Inpatients, Outcomes, and Nephrology Engagement (ASIN-ONE): A Study on Nephrology Referral Timing in Hyponatremic Adult Patients at a Tertiary Hospital

Analysis of Sodium in Inpatients, Outcomes, and Nephrology Engagement (ASIN-ONE): A Study on Nephrology Referral Timing in Hyponatremic Adult Patients at a Tertiary Hospital

Identifying chronic kidney disease stage 3 with excess disease burden.

Chronic kidney disease (CKD) is a widely prevalent disease with heterogeneous disease progression. Prior study findings suggest that early referral to nephrologists can improve health outcomes for patients with CKD. Current practice guidelines recommend nephrology referral when patients are diagnosed with CKD stage 4. We tested whether a subset of patients with CKD stage 3 and common medical comorbidities demonstrates disease progression, cost, and utilization patterns that would merit earlier referral. Retrospective study of Medicare fee-for-service beneficiaries with CKD stages 3 through 5 and end-stage kidney disease. We identified 7 comorbidities with high prevalence in patients with progressive CKD and segmented beneficiaries with CKD stage 3 based on the presence of these comorbidities. Outcomes including costs, utilization, and disease progression were then compared across beneficiaries with different stages of CKD. We identified that beneficiaries with CKD stage 3 and at least 1 of the selected comorbidities (CKD stage 3-plus) represented 35.4% of all beneficiaries with CKD stage 3. The CKD stage 3-plus cohort had cost and utilization patterns that were more similar to beneficiaries with CKD stages 4 and 5 than to beneficiaries with CKD stage 3 without the selected comorbidities. Our findings demonstrate the use of a claims-based algorithm to identify patients with CKD stage 3 who have high costs and are at risk of disease progression, highlighting a potential subset of patients who might benefit from earlier nephrology intervention.

#1668 The 60:40 conundrum: are women with CKD discriminated against after referral to a nephrology clinic?

Abstract Background and Aims The representation of women in kidney medicine clinical trials has diffused the belief that women are discriminated although epidemiological data suggest that chronic kidney disease (CKD) is more prevalent among females than males. We aimed to test whether sex distribution varies at nephrology referral, inclusion in a clinical study or at the starting of dialysis. Method This was a retrospective, monocentric study conducted in a large non-university hospital in central France. We exploited data from patients included in the PRO-RE-RE-PRO study on the effect of diet on the progression of CKD. We evaluated patients’ characteristics and gender at the time of the first consultation in the Unit for the Care of Advanced CKD (UIRAV), at the inclusion in the PRO-RE-RE-PRO study and at the beginning of the kidney replacement therapy. Results 866 patients were included in this study as they were referred to the UIRAV, 59% males and 41% females. Female patients were older but less comorbid and were referred at the same eGFR than males. The same proportion of males/females was observed in patients included in the PRO-RE-RE-PRO study. No sex differences were observed at dialysis start. Survival was significantly higher in females. Overall, distribution across sex remained stable over time. Conclusion The main result of this study is the stability of the approximately 35-40% female to 60-65% male ratio from start of follow-up in all subsets of cases: patients referred to the unit dedicated to advanced CKD, patients recruited in the observational study, patients not included, or who refused to participate, patients on follow-up at the completion of the database. Furthermore, the same distribution is observed in dialysis patients, from dialysis start to the most recent update. Our data suggest that if a gender-selection bias exists in nephrology, it should be sought before the first nephrology referral. However, further studies are needed to ensure health equity.

#2304 Innovative approaches to nephrology referrals: unlocking the potential of artificial intelligence

Abstract Background and Aims The widespread influence of Artificial Intelligence (AI) is evident across various sectors, including the medical field. Hospitals and healthcare systems are increasingly embracing its capabilities in order to improve clinic workflow, to save time and simplify procedures with some degree of complexity. One of those tasks is the referral process to Nephrology appointments by the Primary Care (PC) physicians. As they may face challenges in determining which patients meet the referral criteria, it would be of great help to create a tool that could assist the process. Our work aimed to understand if AI can be useful in the referral to Nephrology appointments in Portugal's National Healthcare System. Method A cross-sectional study was preformed using appointment requisitions made by PC Physicians to a single center Nephrology Department throughout 2023. An AI bot, named RefNef, was developed, incorporating referral criteria from our center, the Portuguese National Healthcare Authority, and the Kidney Disease Improving Global Outcome (KDIGO) guidelines. Stripping personal data, those requisitions were then submitted to the created bot, and the answers were analyzed. Statistical analyses, including T-student, ANOVA, and Chi-squared tests, were employed to compare different groups. Results A total of 408 referrals were analyzed (52% of them males), with a mean age of 74 ± 15 years old. Mean creatinine at referral was 1.87 ± 0.72 mg/dl, with a mean estimated Glomerular Filtration Rate using the Crockford-Gault equation of 33.23 ± 15.12 mL/min. 5.6% of them had hematuria and 15.2% had proteinuria at referral. These four criteria were lacking in the referral information in 19.37%, 56.86%, 92.9% and 61.5% of the requests, respectively, but their absence did not appear to affect the nephrologist's or the bot's rate of acceptance. 86.3% of the referrals were approved by the nephrologists, and the bot accepted 97.1% of them. The rate of acceptance was not related (χ2 (1, N = 208) = 5.038, p = 0.082). The time between the referral and the appointment differed from the PC's requirements, the bot's perspective and the actual time the appointment was scheduled. In 68.6% of the times, the bot provided the user with some useful information, as management tips or other details that should be investigated. There was a need to ask for further information to the bot in 3.18% of the cases. Conclusion While not yet poised to function as a triage system, as the information wasn't consistent with the decision of the nephrologist, the AI tool demonstrated utility in potentially aiding PC physicians in decision-making by providing useful information. Additionally, it exhibited user-friendliness, as it answers with all the needed details at the first question. Further refinement of the AI tool could enhance its alignment with nephrologist decisions, contributing to improved efficiency in the referral process. It is to be noted that the study also highlights the frequent omission of key criteria in Nephrology referrals, emphasizing the need for educational reinforcement in this aspect.

#1410 Prognosis and mortality within 90 days in community-acquired acute kidney injury in the Southwest of Sweden

Abstract Background and Aims Community-acquired acute kidney injury (CA-AKI) is common among hospitalized patients and has a poor prognosis. Research is scarce on the impact of a CA-AKI episode among patients without preexisting kidney disease and has not previously been investigated in Sweden. The aim was to describe the outcomes of patients with normal pre-hospitalization kidney function, admitted with community-acquired AKI and to investigate the association between AKI severity with outcomes. Method A retrospective population-based study was applied including patients with CA-AKI according to KDIGO classification, admitted via emergency department (ED) 2017-2019 and with a 90-day follow-up period from the ED-admission, collecting data from the Regional Healthcare Informative Platform. Age, gender and AKI stages, mortality and follow-up regarding recovery and readmission was registered. Hazard ratio (HR) and 95% confidence Interval (CI) for mortality was analyzed using Cox regression adjusted for age, comorbidities, and medication. Results There were 1646 patients included, mean age was 77.5 years. CA-AKI stage 3 occurred in 51% of patients < 65 years of age and 34% among those >65 years. In this study, 578 (35%) patients died and 233 (22%) recovered their kidney function. Mortality rate peaked within the first two weeks and among those at AKI stage 3. Nephrology referral post discharge occurred in 3% and 29% were readmitted. HRs for mortality was 1.9 (CI 1.38-2.62) for those who are > 65 years, 1.56 (CI 1.30-1.88) for atherosclerotic-cardiovascular disease. Medication with RAASi related to a decreased HR 0.27 (95% CI 0.22-0.33). Conclusion CA-AKI is associated with high mortality within 90 days, increased risk for developing chronic kidney disease (CKD) and only one fifth recover their kidney function after hospitalization with an AKI. Nephrology referral was sparse. Patient follow-up after a hospitalization with AKI should be carefully planned during the first 90 days and focused on identifying those with a higher risk of developing CKD.

#2979 Patients referred to nephrology consultation from African countries of Portuguese official language: a Portuguese single-center cohort study

Abstract Background and Aims Chronic kidney disease (CKD) is a main cause of morbidity and mortality worldwide, with African population being at increased risk. Nevertheless, access to treatment for CKD is restricted in African countries resulting in premature death. The latest statistics point to an annual referral to Portugal of around 900 patients from those countries for medical reasons—of which only 5% corresponds to Nephrology referrals. However, this protocol is burdened with high social and economic impact, consuming 50% of the funds budgeted by the Portuguese government (estimated at 3 million euros annually). The aim of this study was to describe the clinical characteristics, reasons for the referral and outcomes of patients from African Countries of Portuguese Official Language (ACPOL) to a nephrology consultation in a tertiary hospital in Portugal under a cooperation protocol. Method Single-center retrospective analysis of 131 African patients referred to our nephrology department between 2014 and 2023. Results Only 84 patients (64%) ended up being evacuated from their country of origin and attended the nephrology consultation in Portugal. The mean age was 46 ± 14 years and 55% were male. Thirty-two patients were from Guinea-Bissau (38%), 24 from São Tomé and Príncipe (29%), 22 from Cape Verde (26%), and 6 from Angola (7%). The motives for referral to a tertiary center were advanced CKD in 58 patients (69%), nephrotic syndrome in 21 patients (25%), and hemodialysis (HD) vascular access dysfunction in 5 of the cases (6%). In the group of patients referred with advanced CKD the mean eGFR was 16 ± 10 ml/min, all patients had hypertension, 20% had diabetes and 9% presented heart failure. More than half (56%) needed hospitalization with urgent need of dialysis and all patients started HD with a central venous catheter. During the follow-up, four patients died (5%), two patients (2.3%) transitioned to peritoneal dialysis and 70% were on kidney transplant waiting list. Patients referred with nephrotic syndrome had a mean eGFR of 71 ± 49 ml/min/1,73 m2 and a median urine albumin/creatinine ratio (uACR) of 6.9 [IQR 4.7-8.8] g/g. Kidney biopsy was performed in 90% of the cases, with membranous nephropathy (37.5%) and focal segmental glomerulosclerosis (25%) being the two most frequent diagnosis. Only two patients returned to their origin country; the remaining prolonged their stay due to unavailability of resources for appropriate treatment in their country of origin. Conclusion These data emphasize the inequality in access to healthcare in African countries and highlights the urgent need for investment, especially in CKD, as it contributes to serious consequences in these patients’ survival and morbidity. With the cooperation protocol, Portugal provides the possibility for these patients to be evacuated and treated in specialized nephrology departments, improving their outcomes. However, our study shows that there is still a lot to be done since just over 60% of referred patients manage to reach Portugal. The entire evacuation process remains extremely delayed, a fact shown by the need for patients to start urgent HD and that more than half of them require hospitalization upon arrival at the nephrology department, with a high economic burden.

Using the Nephrology Referral Form in Italian primary care to improve the care pathway of patients with anemia or other complications related to chronic kidney disease: survey findings

Introduction: Anemia is a potentially reversible condition in early chronic kidney disease (CKD) that requires timely intervention. General practitioners (GPs) play a crucial role in recognizing CKD. A new Nephrology Referral Form (NRF) was developed and tested in the Italian setting. Methods: This mixed-methods survey, conducted between 2021 and 2022, introduced the NRF through focus group discussions involving a scientific committee. The NRF was tested in a 6-month trial involving 24 GPs each from Lazio and Puglia regions. GPs provided feedback on the use of the NRF in clinical practice through a questionnaire sent via Microsoft Form. The data were analyzed descriptively. Results: After 6 months, 41.67% of the GPs were using the NRF at least once a week. Diabetes mellitus and hypertension were common triggers for NRF assessments. GPs overwhelmingly agreed (96%) on the NRF’s utility in identifying CKD cases, with 92% citing its effectiveness in diagnosing well-defined cases. The NRF facilitated specialist referrals, with 83% of GPs reporting increased referrals compared to the prior 6 months. Feedback underscored the NRF’s positive impact, suggesting improvements such as additional referral centers, regional/national networks, enhanced GP training, and increased collaboration. Conclusion: GPs regularly used the NRF to identify and diagnose cases of CKD, streamlining the referral process and increasing referrals to specialists. Feedback emphasized the NRF’s positive impact and highlighted its potential as a valuable tool for enhancing early CKD detection, interventions, and fostering multidisciplinary management in primary care for better patient outcomes.

Nephrology referral slows the progression of chronic kidney disease, especially among patients with anaemia, diabetes mellitus, or hypoalbuminemia: A single-centre, retrospective cohort study.

The Kidney Disease Improving Global Outcomes guidelines recommend nephrology referral for patients with chronic kidney disease (CKD) stages 4 to 5, significant proteinuria and persistent microscopic haematuria. However, the recommendations are opinion-based and which patients with CKD benefit more from nephrology referral has not been elucidated. In this retrospective cohort study, patients referred to our nephrology outpatient clinic from April 2017 to March 2019 were included. We excluded patients considered to have an acute decline in kidney function (annual decline in estimated glomerular filtration rate [eGFR] >10 mL/min/1.73 m2). The slopes of eGFR before and after nephrology referral were estimated and compared by linear mixed effects models. Interaction between time and referral status (before or after referral) was assessed and effect modifications by the presence of diabetes, proteinuria (defined by urine dipstick protein 2+ or more), urine occult blood, hypoalbuminemia (defined by albumin levels less than 3.5 g/dL) and anaemia (defined by haemoglobin levels less than 11.0 g/dL) were evaluated. The eGFR slope significantly improved from -2.05 (-2.39 to -1.72) to -0.96 (-1.36 to -0.56) mL/min/1.73 m2/year after nephrology referral (p < .001). The improvement in eGFR slope was more prominent among those with diabetes mellitus, anaemia, and hypoalbuminemia (all p-values for three-way interaction <.001 after adjustment for covariates). Further adjustments for time-dependent haemoglobin levels, the use of erythropoiesis-stimulating agents, iron supplementation, anti-hypertensives and anti-diabetic medications did not change the significance of the interactions. Nephrology referral slows CKD progression, especially among those with hypoalbuminemia, diabetes or anaemia. Patients with hypoalbuminemia, diabetes or anaemia might benefit more from specialized care and lifestyle modifications by nephrologists. The inclusion of anaemia and hypoalbuminemia in nephrology referral criteria should be considered.

Anemia in Patients After Stem Cell Transplantation and in Kidney Transplant Recipients

Hematopoietic stem cell transplant (HSCT) is the treatment of choice in various hematologic diseases, and kidney transplantation (KTx) is the best therapy for end-stage kidney disease. Chronic kidney disease (CKD) occurs relatively often after both types of transplantations. Anemia after both HSCT and KTx may be due to CKD and other reasons. This study aimed to assess the prevalence of anemia to CKD in 156 prevalent patients after HSCT and 80 after KTx. According to the World Health Organization's definition (hemoglobin <13 g/dL for men and <12 g/dL for women), the prevalence of anemia in the studied cohort after HSCT was 13% in women and 35% in men and for those after KTx, it was29% in men and 11%. Anemia in KTx was found in 46% of patients, whereas CKD was present in 53%. After HSCT, anemia was associated with CKD in 56% of women and 17% of men. In KTx, anemia and CKD was diagnosed in 21% of patients. Patients with anemia after KTx had significantly lower glomerular filtration rate (GFR), hemoglobin, and significantly higher creatinine levels. Age was related to the estimated GFR (eGFR; r = -0.39, P < .001) in patients who underwent HSCT and had anemia. In patients without anemia, age was negatively related to eGFR (r = -0.56, P < .001) and the hemoglobin-to-platelet count (r = 0.62, P < .001). In KTx, hemoglobin was related to eGFR (r = 0.35, P < .001), and age was related to eGFR (r = -0.20, P < .05). The type of induction therapy immunosuppressive regimen (anti-thymocyte globulin vs basiliximab vs no induction) did not affect the prevalence of anemia in the KTx population studied. Anemia is relatively common in CKD after HSCT. In both CKD and coexistent anemia, nephrology referral is to be considered to optimize therapy, including nephroprotection.

Utilizing electronic medical records alert to improve documentation of neonatal acute kidney injury

BackgroundNeonatal acute kidney injury (AKI) is a common yet underdiagnosed condition in neonates with significant implications for long-term kidney health. Lack of timely recognition and documentation of AKI contributes to missed opportunities for nephrology consultation and follow-up, potentially leading to adverse outcomes.MethodsWe conducted a quality improvement (QI) project to address this by incorporating an automated real-time electronic medical record (EMR)-AKI alert system in the Neonatal Intensive Care Unit (NICU) at Le Bonheur Children’s Hospital. Our primary objective was to improve documentation of neonatal AKI (defined as serum creatinine (SCr) > 1.5 mg/dL) by 25% compared to baseline levels. The secondary goal was to increase nephrology consultations and referrals to the neonatal nephrology clinic. We designed an EMR-AKI alert system to trigger for neonates with SCr > 1.5 mg/dL, automatically adding AKI diagnosis to the problem list. This prompted physicians to consult nephrology, refer neonates to the nephrology clinic, and consider medication adjustments.ResultsOur results demonstrated a significant improvement in AKI documentation after implementing the EMR-AKI alert, reaching 100% compared with 7% at baseline (p < 0.001) for neonates with SCr > 1.5 mg/dL. Although the increase in nephrology consultations was not statistically significant (p = 0.5), there was a significant increase in referrals to neonatal nephrology clinics (p = 0.005).ConclusionsIntegration of an EMR alert system with automated documentation offers an efficient and economical solution for improving neonatal AKI diagnosis and documentation. This approach enhances healthcare provider engagement, streamlines workflows, and supports QI. Widespread adoption of similar approaches can lead to improved patient outcomes and documentation accuracy in neonatal AKI care.Graphical A higher resolution version of the Graphical abstract is available as Supplementary information

Clinical Characteristics and Outcomes of COVID-Positive Maintenance Hemodialysis Patients: A Study from India.

This study describes to the clinical features and outcomes of patients on maintenance hemodialysis infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) delta variant. This was a retrospective analysis of case records of patients on maintenance hemodialysis admitted for management of coronavirus disease (COVID) infection. Our teaching hospital, being a state-designated referral center, had COVID admissions from March 2020 till December 2020. Epidemiological and clinical data were collected and analyzed. Factors influencing survival and the survival curve analysis were assessed. Of a total of 21,228 admissions during the period, 400 patients were referred for nephrology services. Of the 400 referrals, 226 were maintenance hemodialysis patients. Mean age of the group was 50 years, and fever was the most common presenting symptom. On multivariate analysis, factors influencing mortality were found to be older age, presence of diabetes, leukopenia, thrombocytopenia, hypoxemia, need for support, and a higher qSOFA score. The probability of survival of dialysis patients at the end of 19 days was 60%. During the pandemic by SARS-CoV-2 delta variant, majority of the nephrology referrals were for maintenance hemodialysis patients. Mortality was 38% in the study group, and the factors associated with mortality with a significant hazard ratio were older age and diabetes.

Risk Prediction and Management of Chronic Kidney Disease in People Living with Type 2 Diabetes Mellitus.

People with type 2 diabetes mellitus have increased risk of chronic kidney disease and atherosclerotic cardiovascular disease. Improved care delivery and implementation of guideline-directed medical therapy have contributed to the declining incidence of atherosclerotic cardiovascular disease in high-income countries. By contrast, the global incidence of chronic kidney disease and associated mortality is either plateaued or increased, leading to escalating direct and indirect medical costs. Given limited resources, better risk stratification approaches to identify people at risk of rapid progression to end-stage kidney disease can reduce therapeutic inertia, facilitate timely interventions and identify the need for early nephrologist referral. Among people with chronic kidney disease G3a and beyond, the kidney failure risk equations (KFRE) have been externally validated and outperformed other risk prediction models. The KFRE can also guide the timing of preparation for kidney replacement therapy with improved healthcare resources planning and may prevent multiple complications and premature mortality among people with chronic kidney disease with and without type 2 diabetes mellitus. The present review summarizes the evidence of KFRE to date and call for future research to validate and evaluate its impact on cardiovascular and mortality outcomes, as well as healthcare resource utilization in multiethnic populations and different healthcare settings.

Impact of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Chronic Kidney Disease: A Middle East and Africa Perspective.

Chronic kidney disease (CKD) is a major public health concern in the Middle East and Africa (MEA) region and a leading cause of death in patients with type 2 diabetes mellitus (T2DM) and hypertension. Early initiation of sodium-glucose cotransporter - 2 inhibitors (SGLT-2i) and proper sequencing with renin-angiotensin-aldosterone system inhibitors (RAASi) in these patients may result in better clinical outcomes due to their cardioprotective properties and complementary mechanisms of action. In this review, we present guideline-based consensus recommendations by experts from the MEA region, as practical algorithms for screening, early detection, nephrology referral, and treatment pathways for CKD management in patients with hypertension and diabetes mellitus. This study will help physicians take timely and appropriate actions to provide better care to patients with CKD or those at high risk of CKD.

A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics

Rationale & ObjectiveThe study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving of CKD care in adults. Study DesignCluster randomized trial. Setting & Participants32 midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined GFR categories of CKD Stage G3 and G4, as well as one or more of six CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure (BP) or glycated hemoglobin (A1C) levels, indication for angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) but not prescribed, a nonsteroidal anti-inflammatory agent (NSAID) on the active medication list, or an indicated nephrology referral. InterventionThe CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters. OutcomesWe assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after18 months. ResultsThe adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs. 21.8%; RR 1.17, CI 0.91-1.51); ACEi/ARB prescribed (15.9% vs.16.1%;RR 0.95, CI 0.76-1.18); BP control (20.4% vs. 20.2%;RR 0.98, CI 0.84-1.15); A1C control (21.4% vs. 22.1%;RR 1.00, CI 0.80-1.24); NSAID not on the active medication list (51.5% vs. 50.4%;RR 1.03, CI 0.90-1.17); referral or visit to a nephrologist (38.7% vs. 36.1%;RR 1.02, CI 0.79-1.32). LimitationsWe encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization due to the COVID-19 pandemic. ConclusionThe CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the COVID-19 pandemic likely influenced these results.

Longitudinal Estimated Glomerular Filtration Rate Trajectories in Children with Type 1 Diabetes

Although children with type 1 diabetes (T1D) are at risk for developing diabetic kidney disease (DKD), clinical practice guidelines do not uniformly recommend routine serum creatinine (SCr) monitoring, and data describing changes in renal function from diagnosis are lacking. As part of a quality improvement initiative, the Diabetes Clinic at British Columbia Children’s Hospital in Vancouver, Canada, implemented routine serum SCr monitoring. This study describes estimated glomerular filtration rate (eGFR) trajectories and prevalence of decreased eGFR, hypertension, and albuminuria and their relationship to patterns of nephrology referral in a cohort of children aged ≤18 years (n = 307) with T1D recruited between December 2016 and February 2019. Annualized eGFR (ml/min/1.73 m2 per year) was calculated using the CKiD U25 formula and categorized as declining (&lt;−3), stable (−3 to +3), and inclining (&gt;+3). eGFR was categorized as normal (≥90), mildly decreased (60 to &lt;90), and chronic kidney disease (CKD, &lt;60). In this cohort, 54% were male; the median age at diagnosis and duration of T1D was 6.2 years and 6.9 years, respectively. Over a median follow-up of 2.3 years, declining, stable, and inclining trajectories were observed in 33%, 32%, and 35%, respectively. During their follow-up, 32% had mildly decreased eGFR, elevated blood pressures (≥90th percentile), and/or abnormal urine albumin-creatinine ratios (≥2 mg/mmol), with &lt;10% referred for nephrology assessment. Twenty-three percent of subjects had an eGFR &lt;90; this subgroup was more highly represented in the declining trajectory group (vs. stable and inclining). Logistic regression analysis found female sex and higher baseline eGFR to be associated with a declining eGFR trajectory. In conclusion, these data challenge the commonly held paradigm that renal function remains stable in childhood T1D and supports systematic monitoring of renal function in children with T1D, as well as collaboration across disciplines, particularly endocrinology and nephrology, to provide evidence-based individualized care.

#5902 KIDNEY INVOLVEMENT IN HAEMATOLOGICAL MALIGNANCIES: THE IMPORTANCE OF EARLY NEPHROLOGICAL REFERRAL

Abstract Background and Aims Kidney is often injured in the setting of hematological malignancies. Although, kidney involvement negatively influences the prognosis of these patients, often the referral to clinical nephrology is late. The aims of this study were to investigate the long-term outcomes of haematological diseases with renal involvement demonstrated by kidney biopsy and the association between nephrological referral earliness and survival. Method Monocentric retrospective study evaluating overall survival (OS) (time to death) and renal free survival (RFS) (time to renal replacement therapy) in patients affected by hematologic malignancies with renal involvement demonstrated by kidney biopsy. Data have been collected by January 1st 2009 to December 30th 2021. Results reported as median (min-max) and percentage (%). Results 46 patients; M/F = 1.3; age: 70 years (39.5-91.2). Follow-up: 17,8 months (0.13-125.4). Data at kidney biopsy: creatinine was 3.13 mg/dL (0.6-14), eGFR was 20 ml/min/1.73 m2 (3-110), proteinuria was 5.1 g/24h (0.15-38.6), Bence-Jones proteinuria detected in 74% of patients. Clinical presentations: AKI (63.1%), Nephrotic syndrome (36.9%). Patient referral by Nephrologist (28.2%), Hematologist (26.1%), General Practitioner (21.7%); Emergency Department (17.4%), Others (6.6%). The most frequent histological diagnosis was amyloidosis (32.7%), followed by cast nephropathy (19.2%). Renal Replacement Therapy was required in 41.3% patients. Treatment: 38 patients underwent chemotherapy (56.4% complete/very good hematologic response; 12.8% partial and 30.6% without response). Overall Survival at 24 months was 63.8% and it was reduced in patients with AKI at presentation (Fig. 1) and in patients without treatment response (Fig. 2). RFS was shorter in patients who presented with AKI and affected by Myeloma Cast. Early Nephrological referral was associated with a better RFS (Fig. 3). Conclusion Haematological malignancies with renal involvement causing AKI have the worst prognosis. Kidney biopsy has a prognostic significance and early nephrological referral associated with haematological treatment response correlate with a better renal outcome. These data point to the central role of a multidisciplinary team aimed to the detection and treatment of renal damage due to hematologic malignancies.

#5542 THE ITALIAN REGISTRY OF POLYCYSTIC KIDNEY DISEASE (RIRP): DESIGN, PATIENT CHARACTERISTICS AND INITIAL RESULTS

Abstract Background and Aims ADPKD is the most common form of inherited renal disease worldwide. ADPKD care has advanced over the past decade by the identification of several clinical/genetic risk factors of progression and approval of first disease-modifying drug. Further clinical outcomes research is needed to improve patient-centered clinical care; in addition new disease-modifying therapies are in pipeline, requiring a growing need for patient enrolment in clinical trials. To advance these goals, the Italian Society of Nephrology, supported by the Italian PKD Foundation (AIRP) established in 2020 the creation of a National web-based ADPKD Registry. Here we present the design of this Registry and the preliminary results. Method Adult patients with clinical or genetically confirmed diagnosis of ADPKD have been enrolled in the Registry, hosted by a secure online platform including both a clinical and genetic database. Databases have modular design collecting clinical features, including demographic data, type of diagnosis, e-GFR at onset and at time of first and last nephrological referral, age at onset of hypertension (HTN) and major urological complications (UC), Total Kidney Volume (hTKV) and Mayo Imaging Classification of ADPKD, age at ESRD, use of aspecific renal-protective and disease-modifying drugs, additional risk factors for CKD progression (smoke, diabetes, NSAID), extra-renal manifestations. Genetic data collected include type of PKD1/2 variant with ACMG classification and pathogenic prediction tools, testing method, results of segregation analysis. Statistics included estimation of eGFR slope using linear-mixed modelling. Results By January 2023, the Registry had recruited 985 ADPKD patients across 21 Italian Nephrology Unit; 513 (52,1%) were females; 967 (98,2%) Caucasians. Familiar history of ADPKD was reported in 738 patients (79%). All CKD stages were represented and 105 (14,1%) patients reached ESRD (median age 57y ± 11,5). hTKV was available for 353 (35,9%) patients, with a median value of 1100 ± 996 ml/m; a Mayo class of 1C or higher was found in 221 (70,4%). PROPKD score was evaluated in 162 patients, and in 50% of them it was associated with low risk of progression. A total of 191 (21,6%) were receiving Tolvaptan. Demographic and clinical characteristics are summarized in Table 1. Genetic testing was performed in 288 patients; 111 (38,5%) had PKD1 truncating (T) variants; 67 (23,3%) PKD1 non truncating variants; 69 (24%) PKD2 variants. In 41 patients (14,2%) no pathogenic variants were detected. In our cohort deterioration of renal function over time, estimated using eGFR slope was significantly associated with Mayo Imaging classes, high-medium PROPKD score, PKD1-T variant, HTN onset before 35 yo (Figure) and early UC (−2,3 vs. −1,9 ml/min/1.73m2/y, p = 0.014). Conclusion The Italian ADPKD National Registry is an important research tool collecting clinical and genetic information. Our preliminary data confirm that in the Italian population genotype, early onset HTN or UC, Mayo Imaging classification and PROPKD score are able to predict deterioration of GFR in ADPKD. The future empowerment of the Registry will provide a comprehensive description of clinical features and genetic variants related to ADPKD in a large cohort of Italian patients, enabling us to better understand genotype-phenotype correlation. Furthermore, the Registry could be an opportunity to identify patients suitable for future clinical trials or observational studies concerning specific aspects of the disease.

#6663 PRIMARY SJöGREN SYNDROME WITH BIOPSY PROVEN RENAL INVOLVEMENT: A SINGLE CENTER EXPERIENCE

Abstract Background and Aims Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune disease, characterized by inflammation and destruction of the exocrine glands and the involvement of multiple organs. A wide variety of kidney manifestations associated with pSS have been described. The prevalence of kidney involvement is not clear. Our aim was to describe the renal involvement of patients with pSS diagnosed by kidney biopsy (KB). We also analyzed the clinical manifestations, laboratory and immunological characteristics, clinical outcomes and treatments received in patients with pSS referred to a specialized kidney centre. Method Observational, retrospective study of adult patients (age &amp;gt; 18 years) diagnosed with pSS (EULAR criteria) referred and treated at a kidney referral centre (Fundació Puigvert) in Barcelona, Spain. We collected data from the clinical records registry including demographic variables, laboratory parameters, biopsy results and adverse outcomes, defined by the need of renal replacement therapy (RTT) and/or death. Absolute frequencies, percentages, means and standard deviations were used for statistical analysis. Multivariate analysis was performed as appropriate in SPSS V28.0 Results A total of 27 patients with pSS underwent KB from January 1994 to July 2022; all patients were female, with a median age of 58.4 years (SD ±12.4); 85% were Caucasian. The mean baseline glomerular filtration rate (eGFR) was 65.9 mL/min (SD ±16) (before nephrologist referral), with 8 of 27 patients (29.6%) having eGFR less than 60 mL/min at baseline. The main indication for nephrological evaluation was acute kidney injury (AKI) (63%), followed by the presence of non-nephrotic proteinuria with dysmorphic haematuria (29.6%). The most common finding in KB was acute interstitial nephritis (AIN) (55.6%), as an isolated AIN kidney lesion in twelve patients (44.4%). Mild interstitial nephritis was noted in the context of a predominant glomerular lesion in three other patients (one membranoproliferative glomerulonephritis, one IgA nephropathy and one AA amyloidosis). Nine patients (33.3%) had glomerular lesion (see Table 1). In 18.5% of patients, the diagnosis of pSS was made after the renal biopsy. The percentage of patients receiving ACEI/ARB was 77.8%. A total of 25 patients received some type of immunosuppression (IS). Corticosteroids being the most frequently used (77.8%), followed by the combination IS treatment (44%) and rituximab (33.3%). At the time of the KB, the mean eGFR was 46.3 mL/min (SD ±24), compared to eFGR of 45.2 mL/min (SD ±22) one-year after KB. During follow-up, seven patients (25.9%) required RRT and three (11.1%) died from non-renal causes, mainly by infections associated with immunosuppression. Factors associated with adverse renal outcomes were AKI (p = 0.01), baseline eGFR CKD-EPI less than 60 mL/min (p = 0.005), presence of anti-Ro60 antibodies (p = 0.046), use of plasmapheresis (p = 0.013), use of cyclophosphamide (p = 0.013) and the presence of tubulointerstitial atrophy with glomerular sclerosis on kidney biopsy (p = 0.010). Conclusion Our study included a larger cohort than previously reported before in a single centre. In our cohort of patients with pSS who were evaluated by KB, AIN was the leading cause of renal involvement, as has been seen in other studies. The presence of eGFR below 60 mil/min at baseline and the finding of chronicity in the KB are associated with an adverse outcome, as well as is the presence of AKI. Early referral to nephrologist may be important for prognosis, and KB is necessary for accurate diagnosis of kidney involvement to allow targeted treatment.

#5103 VASCULAR ACCESS AT HEMODIALYSIS INITIATION: A REPORT FROM THE ROMANIAN RENAL REGISTRY

Abstract Background and Aims Vascular access (VA) type used at hemodialysis (HD) initiation varies greatly across countries and dialysis providers, and central venous catheters (CVC) usage is associated with poor survival. Since middle 2019, the Romanian Renal Registry (RRR) imposed compulsory reporting for VA. Therefore, we aimed to evaluate at a national level the VA at HD initiation and its impact on survival. Method We examined the outcome on September 30, 2022, in incident patients starting HD between January 1, 2020 and December 31, 2021. RRR records data on patient age, sex, primary kidney disease (PKD), history of kidney replacement therapy (KRT) and VA, date and cause of death. Results A total of 6153 patients (median age 65 (IQR 54, 72) years, 60% male) started HD in the study period. Glomerulonephritis, diabetic kidney disease (DKD) and tubulointerstitial disease were the main PKD (12, 11 and 9%); the diagnosis was unknown in almost half of the patients (47%). Only 15% of the patients started HD on arterio-venous fistula (AVF); CVC was used in most of the patients: 63% temporary and 22% tunnelled. As in the first 90 days of the study 1674 patients died (74%), recovered the kidney function (17%), received a kidney transplant (2%) or were lost to follow up (7%), the final cohort for survival analysis (i.e. patients that survived more than 90 days) included 4479 patients. The proportion of VA type at HD initiation was similar in this cohort: only 20% AVF, 58% temporary and 23% long-life CVC. A total of 664 (15%) patients died after the first 90 days. They were older, had more often DKD and more frequently started HD on CVC. Cardiovascular disease (56%) was the main cause of death, followed by infectious (14%), cancer (6%), neurological (5%) and gastroenterological (2%) causes. There were no differences in the causes of death between patients who started HD on AVF or CVC. The mean survival time for the entire cohort was 25.3 (95%CI, 25.0-25.6) months. Survivals at 6, 12 and 24 months were 93%, 88% and 80%. In univariate analysis, patients who started HD on AVF had a significantly better mean survival time than those starting on temporary or on tunnelled CVC: 26.6 (95%CI, 26.2-27.1) vs. 25.1 (95%CI, 24.8-25.5) and 24.6 (95%CI, 24.0-25.2) months. In the multivariate Cox proportional hazard model, higher age at HD initiation, DKD, and CVC as initial VA were significantly associated with a poorer survival (Table 1). We reexamined the VA at 6 months after HD initiation - on December 31, 2021, or at the last treatment recorded – in 5654 patients. At six months from HD initiation, 33% were using an AVF, 39% a tunnelled, and 28% a temporary CVC. Conclusion In this nationwide, registry-based study we observed a high rate of CVC usage (80%) among incident HD patients. Also, there was a low conversion from CVC to AVF, with only 33% of patients having a patent AVF six months after HD initiation. HD initiation on a CVC was independently associated with a higher mortality. Furthermore, close to a half of the studied patients had unknown PKD. Taken together, these data point to late nephrology referral of patients in stage 4 CKD, and deficient predialysis nephrology care. A national strategy should be implemented to improve CKD care, aiming to increase both the rate of AVF usage at HD, and the conversion from CVC to AVF in the six months.