Nephrology Visits Research Articles

Nephrologist Visits Lower Rates of Hospitalization, Mortality, and ESKD Transition in Patients with CKD

Nephrologist Visits Lower Rates of Hospitalization, Mortality, and ESKD Transition in Patients with CKD

Antihypertensive Treatment Patterns in CKD Stages 3 and 4: The CKD-REIN Cohort Study

Rationale & ObjectiveBlood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP (SBP). Study DesignProspective observational cohort study Setting & Population2755 hypertensive patients with CKD stages 3–4, receiving care from a nephrologist, from the French CKD-REIN cohort study ExposurePatient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary-care physician and specialist encounters. OutcomesChanges in antihypertensive drug class prescription during follow-up: add-on, or withdrawal. Analytical ApproachHierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level, and linear mixed models to describe Systolic BP trajectory. ResultsAt baseline, median age was 69, mean eGFR, 33 ml/min/1.73m2; 66% of patients were men, 81% had BP ≥130/80 mmHg and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons and 25 per 100 for withdrawals. After adjusting for risk factors, Systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on, 1.35 (95% confidence interval, 1.01-1.80), while a shorter education level was associated with increased HR for withdrawal, 1.23 (1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 versus none) were associated with higher HRs of add-on and withdrawal (1.52; 95% CI 1.06-2.18 and 1.57; 1.12-2.19, respectively), while associations with visit frequency to other physicians varied with their specialty. Mean Systolic BPdecreased by 4 mmHg following drug add-on but tended to rise thereafter. LimitationsLack of information on prescriber, and drug dosing. Conclusions: In patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients’ tolerability. Sustainable reduction in Systolic BPafter add-on of a drug class is infrequently achieved.

#1241 Healthcare resource utilisation in adults with chronic kidney disease by KDIGO categorisation in England: 2010-2019

Abstract Background and Aims Chronic kidney disease (CKD) is associated with high clinical burden for patients and substantial economic costs for healthcare systems. Detailed estimates of healthcare resource utilization (HCRU) for patients with CKD in the UK are limited, particularly by stage of CKD. This study assessed outpatient and non-elective inpatient HCRU by stage of CKD in England. Method This non-interventional study utilised data from primary care electronic health records from Clinical Practice Research Datalink (CPRD) AURUM and Hospital Episode Statistics (HES) admitted patient care (APC). Patients aged ≥18 years registered in CPRD with eligible linkage to HES between January 1, 2010 and December 31, 2019 with 2+ eGFR measurement during the period were identified. CKD was defined by eGFR <60 ml/min/1.73 m2 and/or presence of a uACR measurement ≥3 mg/mmol, both confirmed by a second measurement 90-365 days later. Start of follow-up (index) was set to the earliest date during the study period that CKD was confirmed. Follow-up for HCRU ended at earliest of death, administrative censoring, or 31st December 2019. Patients with end-stage kidney disease (eGFR <9 ml/min/1.73 m2) at index were excluded. Number of HCRU events for each HCRU category was estimated as rates per 1,000 person years (PY) for each calendar year based on cumulative number of events. Event rates were calculated as number of outcomes/total time at risk. Confidence intervals (95%) were calculated assuming a Poisson distribution. Age- and sex-adjusted rates were calculated to compare rates across CKD stages. Results Of 6.1 million adult patients meeting study inclusion criteria, 743,945 adults (12.2%) with CKD were identified. Mean age (SD) was 76.1 (11.5) years, 55.2% were female, and 89.8% White, contributing a total of 3,055,600 years of follow-up. Most (60.9%) patients had stage 3a CKD (eGFR 45-<59 ml/min/1.73 m2). Among patients with uACR measurements (44.4%), 48.0% were A1 (<3 mg/mmol), 44.4% A2 (3-30 mg/mmol), and 7.6% A3 (>30 mg/mmol). Overall, per 1000 PY, there were 24,763 primary care visits, 475 non-elective all-cause hospitalisations, 4,950 attended (722 unattended) outpatient visits, including 308 (43 unattended) outpatient nephrology visits and 368.1 attended (61.2 unattended) cardiology visits. For all HCRU categories, greater KDIGO risk category at index was associated with higher HCRU. For example, after age and sex adjustment, patients with CKD stage 3b had a mean of 0.53/PY non-elective all-cause hospitalisations compared to 0.77/PY for patients with CKD stage 4. Additionally, a mean of 5.18 outpatient visits per PY was observed for patients with CKD stage 3b, of which 0.91 were nephrology outpatient visits compared to 8.39 outpatient visits per PY for stage 4, of which 2.65 were nephrology outpatient visits. Generally, both lower eGFR and higher uACR were individually associated with higher HCRU. Conclusion This study demonstrates high HCRU for patients with CKD, with increasing rates of HCRU with lower kidney function and greater kidney damage. Patients with more advanced CKD contribute at a disproportionally higher rate of outpatient healthcare encounters and non-elective hospitalisations. Efforts to prevent the development and progression of CKD and improving clinical outcomes will reduce frequency and cost of HCRU.

Patient Perspectives of Telemedicine in Outpatient Nephrology Clinics During COVID-19: A Qualitative Study.

The COVID-19 pandemic notably disrupted care for patients with chronic kidney disease (CKD) care, necessitating a rapid shift to telemedicine. Despite the growing use of telemedicine, the impact of this transition on patients' experiences, particularly in Canada and considering sociocultural factors, remains underexplored. This study aims to investigate patients with CKD perspectives on telemedicine versus in-person care and to offer recommendations for enhancing telemedicine services. The objective was to understand patients with CKD views on telemedicine clinics during the pandemic compared to traditional in-person clinics. This was a qualitative descriptive study employing semi-structured interviews. This study was conducted in general nephrology and multidisciplinary kidney care clinics in London, Canada. The study population was English-speaking patients with CKD with at least one in-person nephrology visit before March 15, 2020, and one telemedicine appointment after March 30, 2020. Interviews were conducted using a structured guide, with transcripts analyzed line-by-line by 3 independent reviewers through directed content analysis. Themes were identified and agreed upon through group consensus. Interviews with 12 participants revealed 5 key themes: (1) convenience; (2) building connection and trust; (3) necessity of in-person care; (4) role of family or caregivers; and (5) preferences for clinic types. Most participants (11/12) valued the convenience of telemedicine, noting similar levels of care compared to in-person visits. However, they found it easier to establish personal connections in face-to-face appointments. Most (8/12) preferred in-person visits if their condition worsened. Overall, a combination of in-person and telemedicine was favored, with a preference for video over telephone. The study's focus on one academic nephrology center in Ontario and predominantly white participants limits broader applicability. Additionally, recall bias may affect the findings due to the interview-based design. Telemedicine will remain integral to CKD care, with a hybrid model combining in-person and telemedicine preferred. Integrating patient feedback into future telemedicine practices is essential to enhance flexibility, access, and patient satisfaction.

The Preserving Kidney Function in Children With CKD (PRESERVE) Study: Rationale, Design, and Methods

PRESERVE seeks to provide new knowledge to inform shared decision-making regarding blood pressure (BP) management for pediatric chronic kidney disease (CKD). PRESERVE will compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; expand the National Patient-Centered Clinical Research Network (PCORnet) common data model by adding pediatric- and kidney-specific variables and linking electronic health record data to other kidney disease databases; and assess the lived experiences of patients related to BP management. Multicenter retrospective cohort study (clinical outcomes) and cross-sectional study (patient-reported outcomes [PROs]). PRESERVE will include approximately 20,000 children between January 2009-December 2022 with mild-moderate CKDfrom 15 health care institutions that participate in6 PCORnet Clinical Research Networks (PEDSnet, STAR, GPC, PaTH, CAPRiCORN, and OneFlorida+). The inclusion criteria were≥1 nephrologist visit and≥2 estimated glomerular filtration rate (eGFR) values in the range of 30 to<90mL/min/1.73m2 separated by≥90 days without an intervening value≥90mL/min/1.73m2 and no prior dialysis or kidney transplant. BP measurements (clinic-based and 24-hour ambulatory BP); urine protein; and antihypertensive treatment by therapeutic class. The primary outcome is a composite event of a 50% reduction in eGFR, eGFR of<15mL/min/1.73m2, long-term dialysis or kidney transplant. Secondary outcomes include change in eGFR, adverse events, and PROs. Longitudinal models for dichotomous (proportional hazards or accelerated failure time) and continuous (generalized linear mixed models) clinical outcomes; multivariable linear regression for PROs. We will evaluate heterogeneity of treatment effect by CKD etiology and degree of proteinuria and will examine variation in hypertension management and outcomes based on socio-demographics. Causal inference limited by observational analyses. PRESERVE will leverage the PCORnet infrastructure to conduct large-scale observational studies that address BP management knowledge gaps for pediatric CKD, focusing on outcomes that are meaningful to patients. Hypertension is a major modifiable contributor to loss of kidney function in chronic kidney disease (CKD). The purpose of PRESERVE is to provide evidence to inform shared decision-making regarding blood pressure management for children with CKD. PRESERVE is a consortium of 16 health care institutions in PCORnet, the National Patient-Centered Clinical Research Network, and includes electronic health record data for>19,000 children with CKD. PRESERVE will (1) expand the PCORnet infrastructure for research in pediatric CKD by adding kidney-specific variables and linking electronic health record data to other kidney disease databases; (2) compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; and (3) assess the lived experiences of patients and caregivers related to blood pressure management.

Follow-up Care of Critically Ill Patients With Acute Kidney Injury: A Cohort Study

To evaluate follow-up care of critically ill patients with acute kidney injury (AKI). Retrospective cohort study. Patients admitted to the intensive care unit (ICU) with AKI in Alberta, Canada from 2005 to 2018, who survived to discharge without kidney replacement therapy or estimated glomerular filtration rate<15mL/min/1.73m2. AKI (defined as≥50% or≥0.3mg/dL serum creatinine increase). The primary outcome was the cumulative incidence of an outpatient serum creatinine and urine protein measurement at 3 months postdischarge. Secondary outcomes included an outpatient serum creatinine or urine protein measurement or a nephrologist visit at 3 months postdischarge. Patients were followed from hospital discharge until the first of each outcome of interest, death, emigration from the province, kidney replacement therapy (maintenance dialysis or kidney transplantation), or end of study period (March 2019). We used non-parametric methods (Aalen-Johansen) to estimate the cumulative incidence functions of outcomes accounting for competing events (death and kidney replacement therapy). There were 29,732 critically ill adult patients with AKI. The median age was 68 years (IQR, 57-77), 39% were female, and the median baseline estimated glomerular filtration rate was 72mL/min/1.73m2 (IQR, 53-90). The cumulative incidence of having an outpatient creatinine and urine protein measurement at 3 months postdischarge was 25% (95% CI, 25-26). At 3 months postdischarge, 64% (95% CI, 64-65) had an outpatient creatinine measurement, 28% (95% CI, 27-28) had a urine protein measurement, and 5% (95% CI, 4-5) had a nephrologist visit. We lacked granular data, such as urine output. Many critically ill patients with AKI do not receive the recommended follow-up care. Our findings highlight a gap in the transition of care for survivors of critical illness and AKI.

#4312 CHANGES OF PATIENT CARE DURING THE COVID 19 PANDEMIC AND ITS IMPACT ON THE ADVANCED STAGE OF CKD PATIENTS

Abstract Background and Aims With the COVID-19 pandemic from the end of 2019, due to the tightening of medical care resources and intermittent lockdowns, CKD patients could not receive the full patients care or educations. However, on CKD management, patient care and education by the nephrologist and multiple professions are known to be important, especially for the late stage of CKD patients. We assessed changes of CKD patients’ management during the COVID-19 pandemic and clarify its impact on their medical conditions. Method Retrospective single center cohort study was conducted. From 2018 to 2021, CKD stage 4 to 5, non-dialyzed patients, who were followed in CKD out-patients clinic in St. Luke's International Hospital, Tokyo, Japan, were included. We definite the pre post pandemic periods as: pre-pandemic: Pre-C, from January 2018 to December 2019, and post-pandemic; Post-C, January 2020 to December 2021. The following data was compared between the 2 periods: Number of nephrology visits per patient; Rate of using telemedicine; Rate of receiving multidisciplinary educational support; Rate of drop-out patients; and Number of patients who initiate renal replacement therapy, newly. Clinical information and laboratory data were obtained from hospital medical record, eGFR were calculated according to MDRD formula modified for Japanese. This study was approved by research ethics committee in St. Lukes’ International hospital. Results Two hundreds and eighty nine individual patients were eligible for the analysis. The baseline data were as follows: mean age 67.9±14 years, 63.5% male, mean eGFR 22.2±5.9 ml/min and 40.2% comorbid DM. The number of nephrology visits and receiving multidisciplinary support was decreased in Post-C periods: Nephrology visits; Pre-C: 9.8±5.1 visits/year, Post-C 7.7±5.2 visits/year, P&amp;lt;0.001, Multidisciplinary support; Pre-C: 78%, Post-C 32%, P&amp;lt;0.001. Multi professional educational support was provided mainly for CKD stage 5 patients during the Post-C. More, the rate of using telemedicine and dropout increased in Post-C. Especially, the dropout rate of elderly patients over 70 years old was significant: 8% in Pre-C and 17% in Post-C, P&amp;lt;0.001. On the other hand, clinical indicators such RRT initiation rate remained unchanged. More, there were no difference of RRT initiation rate, between on-visit and telemedicine patients. Conclusion Frequency of nephrology visits and multidisciplinary educational care has been decreased with COVID-19, there was no difference in the short-term prognosis of CKD patients, from our study. During the pandemic of COVID-19 infection, human conversation or contact, was restricted to prevent its spread, in all over the world. In Japan, a national survey reported that the number of outpatient hospital visits in 2020 was on average 70% of those in 2019. Our clinic also recognized the phenomenon. Some patients switched their visit to telemedicine. Telemedicine has some evidence which has equivalent value to face to face education. From our study, needs for more IT-based, contact-less device-based medical treatment and care in the future was suggested. On the other hand, the dropout rate in the elderly was increased, and these population could no easily use telemedicine. The prognosis of these patients needs to be followed up and verified.

Implementation and Feasibility of Clinical Genome Sequencing Embedded Into the Outpatient Nephrology Care for Patients With Proteinuric Kidney Disease

The diagnosis and management of proteinuric kidney diseases such as focal segmental glomerulosclerosis (FSGS) are challenging. Genetics holds the promise to improve clinical decision making for these diseases; however, it is often performed too late to enable timely clinical action and it is not implemented within routine outpatient nephrology visits. We sought to test the implementation and feasibility of clinical rapid genome sequencing (GS) in guiding decision making in patients with proteinuric kidney disease in real-time and embedded in the outpatient nephrology setting. We enrolled 10 children or young adults with biopsy-proven FSGS (9 cases) or minimal change disease (1 case). The mean age at enrollment was 16.2 years (range 2-30). The workflow did not require referral to external genetics clinics but was conducted entirely during the nephrology standard-of-care appointments. The total turn-around-time from enrollment to return-of-results and clinical decision averaged 21.8 days (12.4 for GS), which is well within a time frame that allows clinically relevant treatment decisions. A monogenic or APOL1-related form of kidney disease was diagnosed in 5 of 10 patients. The genetic findings resulted in a rectified diagnosis in 6 patients. Both positive and negative GS findings determined a change in pharmacological treatment. In 3 patients, the results were instrumental for transplant evaluation, donor selection, and the immunosuppressive treatment. All patients and families received genetic counseling. Clinical GS is feasible and can be implemented in real-time in the outpatient care to help guiding clinical management. Additional studies are needed to confirm the cost-effectiveness and broader utility of clinical GS across the phenotypic and demographic spectrum of kidney diseases.

Long-Term Kidney and Cardiovascular Complications in Pediatric Cancer Survivors

The objective of this study was to describe the burden of adverse kidney and hypertension outcomes in patients evaluated by pediatric nephrology in a multidisciplinary survivorship clinic. Retrospective chart review of all patients followed up by nephrology in our multidisciplinary survivorship clinic from August 2013 to June 2021. Data included clinic blood pressure, longitudinal ambulatory blood pressure monitoring (ABPM), echocardiography, serum creatinine, and first-morning urine protein/creatinine ratios. For patients with multiple ABPMs, results of initial and most recent ABPMs were compared. Of 422 patients followed in the multidisciplinary cancer survivorship clinic, 130 were seen by nephrology. The median time after therapy completion to first nephrology visit was 8years. The most common diagnoses were leukemia/myelodysplastic syndrome (27%), neuroblastoma (24%), and Wilms tumor (15%). At the last follow-up, 68% had impaired kidney function, 38% had a clinical diagnosis of hypertension, and 12% had proteinuria. There were 91 ABPMs performed in 55 (42%) patients. Patients with multiple ABPMs (n=21) had statistically significant reductions in overall median blood pressure loads: systolic initial load 37% vs most recent 10% (P=.005) and diastolic load 36% vs 14% (P=.017). Patients with impaired kidney function were more likely to have received ifosfamide. Patients with hypertension were more likely to have received total body irradiation or allogeneic stem cell transplant. History of leukemia/myelodysplastic syndrome, neuroblastoma, and Wilms tumor was frequent among survivors seen by nephrology. There was significant improvement in cardiovascular measures with increased recognition of hypertension and subsequent treatment.

LBSUN208 Patient Education And Addressal Of Social Determinants Of Health: Key To Improvement In Diabetes Care

Abstract As per American Diabetes Association, diabetes is a 'complex chronic illness requiring continuous medical care with multifactorial risk reduction strategies beyond glycemic control'. In 2018, the prevalence of diabetes mellitus in the US population was 10.5% (34.2 million people). It is the seventh leading cause of death in the United States. The average healthcare expenditure is 2.3 times higher for diabetics than non-diabetics. The goal of diabetes care as per the American Diabetes Association and the American College of Cardiology is HbA1c less than 7%, blood pressure less than 140/90mmHg, and LDL cholesterol less than 100mg/dl. Only 19.2% of diabetic population meet all these criteria. At the Guthrie-Robert Packer Hospital, we use the 'Diabetic Bundle' as a quality metric for the standard of care for diabetic patients. It is a metric with diabetic patients seen in the past 2 years who have an active Guthrie PCP, with A1C less than 8 in the past 6 months, LDL less than 70 mg/dl (or currently prescribed a moderate or high dose statin) in the past year and age 40-75, and medical attention for nephropathy (a microalbumin test in the past year, or a nephrology visit, or are on an ACE/ARB, or have ESRD/CKD Stage 4) as a system numerator and total diabetes patients seen in the last 2 years who have an active Guthrie PCP as a system denominator. For the past few years, the resident's clinic has had lower compliance with the diabetic bundle. Multiple factors were responsible. Lack of awareness about the quality metric, discontinuity of care, failure to educate patients, poor patient involvement in diabetes care, socio-economic barriers like lack of insurance, poor family and social support, lack of transportation, poor patient compliance, and low health literacy were some of the identified factors. We conducted the prospective study to improve diabetes care by assessing 'diabetic bundle' compliance. Key interventions were focused on creating a multidisciplinary care team of the clinic director, care coordinator, informatics, nurse, resident, and faculty. Resident education regarding the diabetic bundle, patient education and involvement in diabetes care, outreach calls and mails to the non-compliant, involving the care coordinator in addressing social needs, and regular updating of the diabetes registry were some of the main interventions done during the study period. All these interventions contributed to improvement in the diabetic bundle but we believe that the most important factor in improving diabetes care was educating the patients, involving them in their diabetes care, and addressing their social determinants of health. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Enhanced Telemedicine With Trained Medical Assistants Using Augmented Reality Glasses for Inpatient Nephrology Visits

Enhanced Telemedicine With Trained Medical Assistants Using Augmented Reality Glasses for Inpatient Nephrology Visits

Submaximal Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Dosing Among Persons With Proteinuria

For persons with proteinuria, angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) are treatment mainstays for reducing kidney disease progression. Guidelines for managing hypertension and chronic kidney disease recommend titrating to the maximum ACEi/ARB dose tolerated. Using deidentified national electronic health record data from the Optum Labs Data Warehouse, we examined ACEi/ARB dosing among adults with proteinuria—defined as either a urine albumin to creatinine ratio of 30 mg/g or greater or a protein to creatinine ratio of 150 mg/g or greater—who were prescribed an ACEi/ARB medication between January 1, 2017, and December 31, 2018. Among 100,238 included patients (mean age, 65.1 years; 49,523 [49.4%] female), 29,883 (29.8%) were taking maximal ACEi/ARB doses. Among 74,287 patients without potential contraindications to dose escalation (systolic blood pressure <120 mm Hg, estimated glomerular filtration rate <15 mL/min per 1.73 m2, serum potassium level greater than 5.0 mEq/L, or acute kidney injury within the prior year), the frequency of maximal ACEi/ARB dosing was 32.3% (24,025 patients). In adjusted analyses, age less than 40 years, female sex, Hispanic ethnicity, lower urine albumin to creatinine ratio, lack of diabetes, heart failure, lower blood pressure, higher serum potassium level, and prior acute kidney injury were associated with lower odds of maximal ACEi/ARB dosing. Having a prior nephrologist visit was not associated with maximal dosing. Our results suggest that greater attention toward optimizing the dose of ACEi/ARB therapy may represent an opportunity to improve chronic kidney disease care and reduce excess morbidity and mortality associated with disease progression.

Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

Identification of patients with chronic kidney disease (CKD) with high risk of progression to kidney failure can help ensure they receive appropriate and effective nephrology care. To examine whether patients with CKD at various levels of kidney failure risk receive nephrology care within 1 year of established risk. This population-based, retrospective cohort study collected nationwide administrative health claims data from 156 733 adult patients who met the Kidney Disease: Improving Global Outcomes initiative CKD diagnostic criteria between January 1, 2012, and December 31, 2019, and had an available urine albumin to creatinine ratio within 90 days of a serum creatinine laboratory test. Patients with a history of dialysis or kidney transplant, a prior visit with a nephrologist in the past year, or palliative care billing codes or those who died or disenrolled within 1 year of the albumin to creatinine ratio measurement were excluded. Data analysis was performed from September 10, 2022, to February 14, 2022. Kidney failure risk computed with the 5-year Kidney Failure Risk Equation. The main outcome was nephrology care rates across tiers of kidney failure risk, estimated as the proportion of individuals having a nephrologist visit within 1 year after index time. The study population consisted of 156 733 patients with CKD (mean [SD] age, 74.6 [8.4] years; 91 906 [58.6%] female; 86 457 [55.2%] White). A total of 106 004 patients (67.6%) had a low (≤1%) 5-year risk of kidney failure. Nephrology visit rates increased with higher kidney failure risk. Among the 137 highest-risk patients, 79 (57.7%; 95% CI, 48.4%-64.7%) had a nephrology visit. Among 7730 patients with risk above a 10% threshold, 3208 (41.5%; 95% CI, 40.3%-42.4%) had a nephrology visit. This study's findings suggest that nearly half of patients with CKD at high risk of progressing to kidney failure do not have a nephrologist visit within 1 year of established risk. These findings have implications in the design of risk-based guidelines for referral and in the practice of delivering nephrology care to patients with CKD.

Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study.

IntroductionInformation on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD).MethodsRetrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m2, persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m2).ResultsOf 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63).ConclusionsA significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.

MO520: Prevalence of Anemia in Patients With Stage 3 or 4 Chronic Kidney Disease in Portugal–The Nefropor Study

Abstract BACKGROUND AND AIMS Anemia is a highly prevalent and modifiable comorbidity in patients with chronic kidney disease (CKD), which tends to aggravate as the disease progresses. The economic burden of anemia in CKD is high, and quality of life issues (e.g. fatigue, reduced productivity) is common in these patients. Data on the prevalence and treatment of anemia in CKD stages 3 and 4 (based on the estimated glomerular filtration rate according to KDIGO classification) in Portugal are lacking. The NEFROPOR study aimed to estimate the prevalence of anemia in patients with CKD stage 3 or 4 admitted to a Nephrology consultation between 1 January and 31 March 2017 and characterize anemia treatment in this patient population. METHODS NEFROPOR was a retrospective, multicentric study carried out in 10 Portuguese centers. All patients aged ≥18 years with stage 3 or 4 CKD admitted to a Nephrology consultation in one of those centers between 1 January and 31 March 2017 were invited to participate, and data for up to 24 months after admission were collected from patients’ clinical files. Retrieved data included age, body mass index (BMI), anemia status according to the World Health Organization (WHO) diagnostic criteria, and anemia treatment type and duration. Three assessments of the prevalence anemia were performed: at the time of the first Nephrology visit (presentation), at the first analytical results and the overall prevalence in the study cohort. Statistical analysis was performed in SPSS Statistics (v26) and a 0.05 significance level was adopted. RESULTS A total of 176 patients were included in this study, mostly (61.9%) male, with a median age of 76 years (range, 26–97) and a mean BMI indicative of pre-obesity (28.2; standard deviation, 4.2). CKD stage 3b was predominant (43.2%), followed by stage 4 (32.4%) and stage 3a (24.4%). The most frequent CKD etiologies in this cohort were diabetes (39.8%), followed by arterial hypertension (27.8%) and unknown cause (25.6%). Arterial hypertension was largely the most frequent comorbidity, present in 90.3% of patients, followed by diabetes (54.0%). Although less prevalent, coronary artery disease (18.2%) and congestive heart failure (14.8%) were also identified in this patient population. A total of 44.9% of patients [95% confidence interval (CI), 37.7%–52.3%] had anemia at presentation, which was significantly associated with CKD stage, diabetes, peripheral vascular disease and myocardial infarction comorbidities, and diabetes and unknown CKD etiology. The overall prevalence of anemia in the study cohort was 61.9% (95% CI 54.6%–68.9%), and it was significantly associated with diabetes and peripheral vascular disease comorbidities and with diabetes and primary glomerulonephritis as CKD etiologies. The prevalence of anemia at the first analytical results was 49.4% (95% CI 42.1%–56.8%), and it was significantly associated with CKD stage, diabetes, non-skin cancer, peripheral vascular disease and myocardial infarction comorbidities, and diabetes as CKD etiology. Figure 1 shows the evolution of anemia treatment in this cohort over 24 + months. CONCLUSION The three estimates of the prevalence of anemia in this study were consistent with each other, particularly those for the first visit and first analytical results. The latter were also consistent with evidence in the literature reporting a prevalence of anemia in the population of patients with CKD stages 3 and 4 between 40% and 60%. The overall prevalence of anemia in this study was 12%–15% higher than first visit and first analytical results estimates, in agreement with the fact that this refers to a cumulative prevalence. These data support the need for optimized and individualized treatment strategies for patients with CKD stages 3 and 4, maximizing the efficiency of health-care resource use.

MO375: The Health Economic Impact of Accurately Diagnosing CKD With and Without a UACR Test at Different Points in the Pathway of Disease Progression

Abstract BACKGROUND AND AIMS In the Kidney Disease Improving Global (KDIGO) guidelines, it is recommended that an accurate chronic kidney disease (CKD) diagnosis is based on repeated positive test results for estimated glomerular filtration rate (eGFR) and urine albumin-to-creatine ratio (UACR). While eGFR indicates kidney function decline, UACR identifies kidney damage, predicts CKD progression, and indicates risk for cardiovascular events. UACR testing is, therefore, a critical component of identifying CKD patients early. There is a lack of evidence that demonstrates the economic impact of early CKD diagnosis; hence, a cost-effectiveness model was built to demonstrate the potential clinical and economic benefit of undertaking UACR tests in those with early-stage CKD. METHOD The KDIGO heatmap quadrants were organised into a Markov model with three levels of severity (moderate, high, and very high CKD risk) over a lifetime horizon, for a cohort of 60-year-old patients in the base-case. Costs, life-years (LYs), quality adjusted life-years (QALYs), and the associated incremental cost-utility ratios (ICURs) were calculated (discounted at 3.5%). Costs consisted of testing, general practitioner (GP) visit, nephrologist visit, and treatment costs. Data inputs were based on published data from the literature and validated by clinicians. RESULTS Hypothetical comparisons between a 1000-patient cohort who had UACR tests undertaken in the early stages of CKD, predicted higher LYs and QALYS for patients in the KDIGO heatmap quadrants of G3aA1, G1A2, G2A2, G3aA2, G1A3, G2A3 and G3aA3 compared with a 1000-patient cohort who did not have UACR tests. By identifying individuals in the early stages of CKD, treatment can be initiated earlier, reducing the number of patients progressing to late-stage CKD and ultimately offsetting the more expensive treatment costs associated with late-stage CKD. Overall, ICURs for all quadrants were less than the UK's willingness to pay threshold of £20 000 per QALY. CONCLUSION Preliminary results suggest that undertaking regular UACR tests early in patients with CKD is a cost-effective strategy, as this allows an individual to initiate the appropriate treatment, resulting in slower disease progression. This is an important consideration for clinicians and policymakers due to the suboptimal UACR testing rates globally. Funding: Bayer AG

Prescribing Patterns of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD: A Cross-Sectional Registry Analysis.

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduce kidney disease progression and mortality in patients with chronic kidney disease (CKD), regardless of diabetes status. However, the prescribing patterns of these novel therapeutics in the CKD population in real-world settings remain largely unknown. This cross-sectional study included adults with stages 3-5 CKD included in the Mass General Brigham (MGB) CKD registry in March 2021. We described the adoption of SGLT-2i therapy and evaluated factors associated with SGLT-2i prescription using multivariable logistic regression models in the CKD population, with and without diabetes. A total of 72,240 patients with CKD met the inclusion criteria, 31,688 (44%) of whom were men and 61,265 (85%) White. A total of 22,653 (31%) patients were in the diabetic cohort, and 49,587 (69%) were in the nondiabetic cohort. SGLT-2i prescription was 6% in the diabetic cohort and 0.3% in the nondiabetic cohort. In multivariable analyses, younger Black men with a history of heart failure, use of cardiovascular medications, and at least one cardiologist visit in the previous year were associated with higher odds of SGLT-2i prescription in both diabetic and nondiabetic cohorts. Among patients with diabetes, advanced CKD stages were associated with lower odds of SGLT-2i prescription, whereas urine dipstick test and at least one subspecialist visit in the previous year were associated with higher odds of SGLT-2i prescription. In the nondiabetic cohort, CKD stage, urine dipstick test, and at least one nephrologist visit in the previous year were not significantly associated with SGLT-2i prescription. In this registry study, prescription of SGLT-2i was low in the CKD population, particularly among patients without diabetes.

Diagnostic value of reticulocyte indices for the assessment of the iron status of cats with chronic kidney disease.

BackgroundReticulocyte indices have been suggested as alternatives to transferrin saturation (TSAT) for iron status assessment in humans and dogs but they have not been evaluated thoroughly in cats.ObjectivesTo assess the value of the reticulocyte indices for the diagnosis of iron deficiency in cats with chronic kidney disease (CKD) and chronic hematuria associated with subcutaneous ureteral bypasses (SUBs).AnimalsSixty‐four cats: 16 healthy, 14 CKD without SUB, and 34 CKD with SUB.MethodsProspective observational cross‐sectional study of cats presented for routine nephrology visits. Primary outcomes included assessment of the diagnostic values of erythrocyte indices (mean corpuscular volume, hemoglobin, and hemoglobin concentration: MCV, MCH, and MCHC) and reticulocyte indices (mean corpuscular volume, MCVr; corpuscular hemoglobin, CHr), using TSAT as reference.ResultsIron deficiency was diagnosed in 9/64 cats (14%). A receiver‐operating characteristic curve analysis yielded a moderate discriminatory value for CHr in this diagnosis: area under the curve [AUC] = .75 (95% confidence interval, 0.48‐0.89); P = .006; sensitivity 67%, specificity 82% for a cutoff of 15.9 pg. This compared favorably to MCVr (AUC = .63; P = .29), MCV (AUC = .58; P = .45), MCH (AUC = .64; P = .19), and MCHC (AUC = .7; P = .03).Conclusion and Clinical ImportanceCHr added moderate value to the diagnosis of iron deficiency in cats with CKD.

Comparison of a Kidney Replacement Therapy Risk Score Developed in Kaiser Permanente Northwest vs Estimated Glomerular Filtration Rate in Advanced Chronic Kidney Disease Using Decision Curve Analysis

Introduction:Use of kidney replacement therapy (KRT) prediction models for guiding arteriovenous fistula (AVF) referrals in advanced chronic kidney disease (CKD) is unknown. We aimed to compare a hypothetical approach using a KRT prediction model developed in Kaiser Permanente Northwest to estimated glomerular filtration rate (eGFR) for AVF referrals.Methods:Our retrospective cohort consisted of patients with stage G4 CKD in Kaiser Permanente Northwest followed by nephrology. Two-year KRT risk was calculated at each nephrology visit up to 2 years from entrance into cohort based on a previously published model. We calculated sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) based on several 2-year KRT risk and eGFR cutoffs for outcome of hemodialysis at 18 months. We compared an approach of AVF referral using 2-year KRT risk and eGFR cutoffs using decision curve analysis.Results:Two-year KRT risk better discriminated progression to hemodialysis compared to eGFR < 15 mL/min (AUC 0.60 vs 0.69 at 2-year KRT risk > 20% and 0.69 at 2-year KRT risk > 40%, p = 0.003 and 0.006, respectively) but not to eGFR of 20 mL/min (AUC 0.64, p = 0.16 and 0.19, respectively). Decision curve analysis showed that AVF referral guided by 2-year KRT risk score resulted in higher net benefit compared to eGFR at low thresholds for referral.Conclusion:In stage G4 CKD, a 2-year KRT risk model better predicted progression to KRT at 18 months compared to an eGFR of 15 mL/min but not to 20 mL/min and may improve timely referral for AVF placement in patients at lower thresholds for referral.

The effect of pre-ESRD care program on potentially inappropriate medication in advanced CKD patients

Abstract Background Due to the multiple comorbidities and the associated complications among advanced CKD population, assessing potentially inappropriate medications (PIM) in these patients is an important task for physicians and multidisciplinary care team members. This study aimed to investigate the impact of the national pre-ESRD pay-for-performance (P4P) program on prescribing quality in Taiwan. Methods We conducted a retrospective cohort study using data from National Health Insurance Research Database (NHIRD) maintained by the Health and Welfare Data Science Center, Ministry of Health and Welfare (HWDC, MOHW). The incidents of CKD in year 2010 were observed until the end of 2017. Adult patients who initiated maintenance dialysis therapy were enrolled. To identify the use of PIM that should be avoided in advanced CKD patients, the Beers 2019 criteria and latest Taiwan Manual of Renal Injury Prevention and Drug Safety were applied. We measured PIM use in one year before starting long-term dialysis. Results Among 7,828 participants underwent continuous dialysis treatment, 2,119 (27.1%) were P4P patients. Most (90.4%) participants were prescribed one or more PIMs before ESRD initiation. After adjusted age, sex, Charlson Comorbidity Index (CCI) and the number of nephrologist visits, the logistic regression showed lower probability of PIM use in the P4P enrollees (OR = 0.56, 95% CI = 0.47-0.66). The effect of P4P on PIM was more prominent in the subgroups of patients who were female and CCI≤3. Conclusions The implementation of the pre-ESRD P4P program might reduce PIM use among CKD patients. Our results underline the strategy of financial incentives in the payment design to improve prescribing patterns. Key messages Prescribing potentially inappropriate medications is common among patients who were approaching ESRD. The study highlights the importance of implementing the pre-ESRD P4P program to reduce PIM use in advanced CKD patients.