Non-dialysis Chronic Kidney Disease Research Articles

Comparing Left Ventricular Diastolic Function between Peritoneal Dialysis and Non-Dialysis Patients with Stage 5 Chronic Kidney Disease: A Propensity Score-Matched Analysis.

Patients with chronic kidney disease (CKD) have a high incidence of left ventricular diastolic dysfunction (LVDD), which increases the risk of heart failure and mortality. We assessed fluid overload as an independent risk factor for LVDD in patients with decreased kidney function and compared its impact on the E/e' ratio as a parameter for assessing left ventricular diastolic functions between patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and those with non-dialysis CKD stage 5 (CKD5) using propensity score matching (PSM). After PSM, 222 patients (CAPD, n = 111; CKD5, n = 111) were included. Fluid balance was assessed using bio-impedance spectroscopy and LVDD was determined by echocardiography based on an E/e' ratio of >15. The CKD5 group had a significantly higher E/e' ratio (p = 0.002), while fluid overload (OH/ECW) did not differ significantly between the groups. In the CAPD group, there were no significant differences in OH/ECW between patients with and without LVDD (p = 0.517). However, in the CKD5 group, patients with LVDD showed a significantly higher OH/ECW (p = 0.001). In a regression analysis investigating factors associated with the E/e' ratio, OH/ECW was not significantly associated with the E/e' ratio in the CAPD group (p = 0.087), but in the CKD5 group, it was independently correlated (p = 0.047). The factors closely associated with LVDD varied depending on dialysis dependence. While fluid overload independently influenced LVDD in non-dialysis patients, it was not statistically significant in patients with CAPD. Early assessment and management of volume status are crucial in addressing LVDD in patients with advanced-stage CKD.

Effect of Recommended Dietary Intake versus Higher Doses of Supplemental Zinc on Iron and Copper Deficiency Anemia Among Patients with Chronic Kidney Diseases, A Double-Blinded, Randomized Clinical Trial

Background: Complex interplays happen in absorption and function of iron, zinc and copper. Both zinc deficiency and excess may lead to anemia. In Iran, commonly available supplements for chronic kidney disease (CKD) patients contain 25 mg-zinc (Zn). This study compared 25 mg versus 7.5 mg dose of zinc in anemia of CKD patients, the latter dose approximates to recommended dietary intake (RDI) of zinc. Methods: In this double-blinded clinical trial, 51 non-dialysis CKD patients were randomized to continue previous formulation (25 mg-Zn group) or change to a new preparation (7.5 mg-Zn group) for three months. Blood counts and serum iron, zinc and copper status were compared between and within the groups. Results: At the end of the study, serum copper and ceruloplasmin concentrations were significantly higher in 7.5 mg-Zn group compared with those in 25 mg-Zn arm (115.04± 23.05 vs. 102.48±14.98 µg/dL; P= 0.02 and 29.97±7.94 vs. 25.42±4.23 mg/dL; P= 0.01, respectively). Serum zinc levels did not differ between two groups (76.73±15.35 vs. 77.68±18.07 µg/dL for 7.5 mg-Zn and 25 mg-Zn groups, respectively; P= 0.84). After three months, patients in 7.5 mg-Zn group experienced increase in their Hb (11.11±1.17 vs. 10.72±1.03 g/dL; P= 0.04), HCT (35.28± 4.01 vs. 33.96± 3.74%; P= 0.03), MCV (86.30 (81.40-90.82) vs. 86.00 (80.35-88.77) ¦L; P= 0.01) and ferritin (202.60 (79.29-298.97) vs. 129.07 (42.25-225.87) ng/mL; P<0.001) compared to their baseline values. Conclusion: Reducing zinc content to its RDI value in supplement for CKD patients led to increased serum copper and ceruloplasmin concentrations. Moreover, patients who switched to RDI zinc-containing formula experienced a significant rise in blood hemoglobin. hematocrit, mean corpuscular volume (MCV), and ferritin concentration.

The Association between Serum Adiponectin Levels and Endothelial Function in Non-Dialysis-Dependent Chronic Kidney Disease Patients.

Adiponectin is the richest human circulating adipokine with anti-inflammatory, antioxidant, and insulin-sensitizing effects. We evaluated the association between serum adiponectin levels and endothelial function in chronic kidney disease (CKD) patients, obtaining fasting blood samples from 130 non-dialysis CKD subjects. We measured the endothelial function-represented by the vascular reactivity index (VRI)-via non-invasive digital thermal monitoring, and serum adiponectin concentrations by enzyme immunoassay kits. A total of 22 (16.9%), 39 (30.0%), and 69 (53.1%) patients had poor (VRI < 1.0), intermediate (1.0 ≤ VRI < 2.0), and good (VRI ≥ 2.0) vascular reactivity. Elevated serum blood urea nitrogen (BUN) level was negatively correlated with VRI values, but serum adiponectin and estimated glomerular filtration rate were positively associated with VRI values by univariate linear regression analysis. After applying multivariate stepwise linear regression analysis adjustment, the significantly positive association of adiponectin (p < 0.001), and the significantly negative association of log-BUN (p = 0.021) with VRI values in CKD subjects remained. In an animal study using in vitro blood-vessel myography, treatment with adiponectin enhancing acetylcholine-mediated vasorelaxation in 5/6 nephrectomy CKD mice. Our study results indicated that adiponectin concentration was positively associated with VRI values and modulated endothelial function in non-dialysis CKD patients.

Postoperative Outcomes Among Dialysis Patients Undergoing Hip Fracture Repair.

Geriatric hip fractures are strongly correlated with increased morbidity. Even so, postoperative outcomes following surgical repair of hip fractures for patients with end stage renal disease lack extensive investigation. Chronic kidney disease (CKD) poses unique risks for surgical procedures as it has been associated with several complications. Little information is available regarding the outcomes of patients whose renal function decline necessitates dialysis usage. The purpose of this study was to compare post-surgical outcomes based on dialysis usage among CKD patients requiring hip fracture repair. We used the PearlDiver database to identify hip fracture repair patients diagnosed with stages 3, 4, and 5 CKD. We matched the populations according to patient characteristics and comorbidities. We then compared patient complication rates among dialyzed and non-dialyzed CKD patients following hip fracture repair at 30days, 90days, and 1year following the procedure. Dialyzed patients were more likely to experience myocardial infarction within 30days (P = .02) and 90days (P = .002). Dialyzed patients suffered cardiac arrest at higher rates within the same time intervals (P = .02; P = .002). Furthermore, dialysis patients developed sepsis (P = .005) and pneumonia (P = .005) at higher rates within 30days of operation. Dialysis patients did not have increased risk of blood transfusion within 30days of the operation (P = .07). We found significant increases in myocardial infarction, cardiac arrest, pneumonia, and sepsis risk among dialyzed CKD patients. Blood transfusion risk failed to reach statistical significance. Our findings are consistent with previous research regarding CKD pathophysiology and associated perioperative outcomes. Given the drastic decline of renal function among patients on dialysis, our findings may be attributable to decreased glomerular filtration rate in CKD as well as dialysis itself. Regardless, multidisciplinary collaboration should be employed when performing hip fracture repair on a patient who is actively undergoing hemodialysis.

Hyperkalemia in CKD: an overview of available therapeutic strategies.

Hyperkalemia (HK) is a life-threatening condition that often occurs in patients with chronic kidney disease (CKD). High serum potassium (sKsK) is responsible for a higher risk of end-stage renal disease, arrhythmias and mortality. This risk increases in patients that discontinue cardio-nephroprotective renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after developing HK. Hence, the management of HK deserves the attention of the clinician in order to optimize the therapeutic strategies of chronic treatment of HK in the CKD patient. The adoption in clinical practice of the new hypokalaemic agents patiromer and sodium zirconium cyclosilicate (SZC) for the prevention and chronic treatment of HK could allow patients, suffering from heart failure and chronic renal failure, to continue to benefit from RAASi therapy. We have updated a narrative review of the clear variables, correct definition, epidemiology, pathogenesis, etiology and classifications for HK among non-dialysis CKD (ND CKD) patients. Furthermore, by describing the prognostic impact on mortality and on the progression of renal damage, we want to outline the strategies currently available for the control of potassium (K+) plasma levels.

Electronic Phenotype for Advanced Chronic Kidney Disease in a Veteran Health Care System Clinical Database: Systems-Based Strategy for Model Development and Evaluation.

Identifying advanced (stages 4 and 5) chronic kidney disease (CKD) cohorts in clinical databases is complicated and often unreliable. Accurately identifying these patients can allow targeting this population for their specialized clinical and research needs. This study was conducted as a system-based strategy to identify all prevalent Veterans with advanced CKD for subsequent enrollment in a clinical trial. We aimed to examine the prevalence and accuracy of conventionally used diagnosis codes and estimated glomerular filtration rate (eGFR)-based phenotypes for advanced CKD in an electronic health record (EHR) database. We sought to develop a pragmatic EHR phenotype capable of improving the real-time identification of advanced CKD cohorts in a regional Veterans health care system. Using the Veterans Affairs Informatics and Computing Infrastructure services, we extracted the source cohort of Veterans with advanced CKD based on a combination of the latest eGFR value ≤30 ml·min-1·1.73 m-2 or existing International Classification of Diseases (ICD)-10 diagnosis codes for advanced CKD (N18.4 and N18.5) in the last 12 months. We estimated the prevalence of advanced CKD using various prior published EHR phenotypes (ie, advanced CKD diagnosis codes, using the latest single eGFR <30 ml·min-1·1.73 m-2, utilizing two eGFR values) and our operational EHR phenotypes of a high-, intermediate-, and low-risk advanced CKD cohort. We evaluated the accuracy of these phenotypes by examining the likelihood of a sustained reduction of eGFR <30 ml·min-1·1.73 m-2 over a 6-month follow-up period. Of the 133,756 active Veteran enrollees at North Florida/South Georgia Veterans Health System (NF/SG VHS), we identified a source cohort of 1759 Veterans with advanced nondialysis CKD. Among these, 1102 (62.9%) Veterans had diagnosis codes for advanced CKD; 1391(79.1%) had the index eGFR <30 ml·min-1·1.73 m-2; and 928 (52.7%), 480 (27.2%), and 315 (17.9%) Veterans had high-, intermediate-, and low-risk advanced CKD, respectively. The prevalence of advanced CKD among Veterans at NF/SG VHS varied between 1% and 1.5% depending on the EHR phenotype. At the 6-month follow-up, the probability of Veterans remaining in the advanced CKD stage was 65.3% in the group defined by the ICD-10 codes and 90% in the groups defined by eGFR values. Based on our phenotype, 94.2% of high-risk, 71% of intermediate-risk, and 16.1% of low-risk groups remained in the advanced CKD category. While the prevalence of advanced CKD has limited variation between different EHR phenotypes, the accuracy can be improved by utilizing two eGFR values in a stratified manner. We report the development of a pragmatic EHR-based model to identify advanced CKD within a regional Veterans health care system in real time with a tiered approach that allows targeting the needs of the groups at risk of progression to end-stage kidney disease.

Correction to "Association between urinary chloride excretion and progression of coronary artery calcification in patients with non-dialysis chronic kidney disease: results from KNOW-CKD study".

Correction to "Association between urinary chloride excretion and progression of coronary artery calcification in patients with non-dialysis chronic kidney disease: results from KNOW-CKD study".

Bone marrow macrophage iron content and sideroblast count in iron- and ESA-naïve patients with CKD-related anemia

Background Since in chronic kidney disease (CKD) iron deficiency anemia (IDA) can coexist with inflammation-induced immobilization of iron in macrophages (anemia of chronic disorders – ACD), we assessed the utility of ferritin, transferrin saturation (TSAT), and hepcidin for differentiation of mixed IDA-ACD from ACD, using bone marrow (BM) examination as reference. Methods This cross-sectional, single-center study analyzed 162 non-dialysis iron and epoietin-naïve CKD patients (52% males, median age 67 years, eGFR 14.2 mL/min 1.73 m2, hemoglobin 9.4 g/dL). BM aspiration, serum hepcidin (ELISA), ferritin, TSAT, and C-Reactive protein (CRP) were the main studied parameters. Results ACD was seen in 51%, IDA-ACD in 40%, while “pure” IDA in only 9%. In univariate and binomial analyses, IDA-ACD differed from ACD by lower ferritin and TSAT, but not by hepcidin or CRP. Correspondingly, in receiver operating curve analysis, ferritin and TSAT differentiated IDA-ACD from ACD, at cutoffs of 165 ng/mL and 14%, but with moderate precision (sensitivity and specificity of 72%, and 61%, respectively). Conclusion The mixed pattern IDA-ACD could be more prevalent than estimated in non-dialysis CKD. Ferritin and, to a lesser degree, TSAT are useful in the diagnosis of IDA superimposed on ACD, while hepcidin, although reflecting BM macrophages iron, seems to have limited utility.

Priorities for peer support delivery among adults living with chronic kidney disease: a patient-oriented consensus workshop.

Peer support can address the informational and emotional needs of people living with chronic kidney disease (CKD) and enable self-management. We aimed to identify preferences and priorities for content, format and processes of peer support delivery for patients with non-dialysis CKD and their loved ones. Using a patient-oriented research approach, we conducted a half-day, virtual consensus workshop with stakeholder participants from across Canada, including patients, caregivers, peer mentors and clinicians. Using personas (fictional characters), participants discussed and voted on preferences for delivery of peer support across format, content and process categories. We analyzed transcripts from small- and large-group discussions inductively using content analysis. Twenty-one stakeholders, including 9 patients and 4 caregivers, participated in the workshop. In the voting exercise on format, participants prioritized peer mentor matching, programming for both patients and caregivers, and flexible scheduling. For content, participants prioritized informational and emotional support focus, and for process, they prioritized leveraging kidney care programs and alternative sources (e.g., social media) for promotion and referral. Analysis of workshop transcripts complemented prioritization results and emphasized tailoring of peer support delivery to accommodate the diversity of people living with CKD and their support needs. This concept was elaborated in 3 themes, namely alignment of program features with needs, inclusive peer support options and multiple access points. We identified preferences for peer support delivery for people living with CKD and underscore the importance of tailored, flexible programming in this context. Findings could be used to develop, adapt or study CKD-focused peer support interventions.

Evaluation of Iron Status in Non-dialysis Chronic Kidney Disease Patients

Background: Iron deficiency is very common in non-dialysis chronic kidney disease (CKD) patients. It plays a significant role in the causation of anemia. Both the absolute and functional iron deficiency are associated with increased cardiovascular hospitalization and overall mortality in these group of patients. Objectives: This study was conducted to evaluate the iron status in non-dialysis CKD patients. Methods: This cross-sectional study was carried out in the Department of Biochemistry, Dhaka medical college, Dhaka from the period of July 2018 to June 2019. In this study, thirty non-dialysis CKD patients were taken from the Department of Nephrology, Dhaka Medical College Hospital, Dhaka. For better assessment another age and sex matched thirty healthy individuals were also taken. Hemoglobin, serum creatinine, iron, total iron binding capacity (TIBC), transferrin saturation (TSAT) and ferritin levels of all participants were measured and all values were analyzed statistically. Results: Mean age of the non-dialysis CKD patients was 48.07 ± 12.42 years in this study. All of them were anemic with hemoglobin concentration &lt;11gm/dl. 44% of them had iron deficiency and absolute iron deficiency was predominant which was 27% of the CKD patients. Hypertension was the most common etiology of CKD followed by diabetes mellitus. Serum creatinine and ferritin level were significantly raised in non-dialysis CKD patients than the control group while hemoglobin, serum iron and TSAT were significantly low in non-dialysis CKD patients. Hemoglobin level was negatively correlated with serum creatinine in CKD patients which was significant. Conclusion: Iron deficiency is common in non-dialysis CKD patients where absolute iron deficiency is predominant. Early evaluation of iron deficiency should be done in every CKD patient.

The Relationship of Iron Stores Biomarkers with Chronic Heart Failure in Nondialysis Chronic Kidney Disease Patients

The Relationship of Iron Stores Biomarkers with Chronic Heart Failure in Nondialysis Chronic Kidney Disease Patients

A retrospective view of the relationship of soluble Fas with anemia and outcomes in chronic kidney disease.

Anemia is common in chronic kidney disease (CKD) and is associated with outcomes. In addition, serum soluble Fas (sFas) levels are related to anemia and erythropoietin (EPO) resistance. Firstly, to compare clinical data and serum levels of sFas, EPO, and pro-inflammatory markers between patients with non-dialytic CKD (NDD-CKD) and healthy subjects. Subsequently, to compare and evaluate the relationship of serum EPO, sFas levels with anemia, and outcomes in patients with NDD-CKD over a long follow-up period. We performed a retrospective study in 58 NDD-CKD patients compared with 20 healthy subjects on complete blood count, kidney function, serum EPO, sFas, and inflammatory markers (CRP, IL- 6, and IFN-γ) at baseline. We then compared the same baseline data between patients with NDD-CKD who evolved to anemia and those who did not have anemia over the follow-up. We also evaluated the frequency of outcomes in patients with CKD with higher sFas levels. Finally, we performed a multivariate analysis of factors associated with CKD anemia. There were lower eGFR and Hb but higher serum inflammatory markers, sFas levels, sFas/eGFR, and EPO/Hb ratios in patients with NDD-CKD. Comparatively, on the other hand, NDD-CKD patients with anemia had lower eGFR but were older, had more diabetes, and had higher sFas/ eGFR, EPO/Hb ratios, and serum levels of IL-6 and sFas than NDD-CKD without anemia for an extended period. In addition, there was an association in a multivariate analysis of diabetes, age, and sFas levels with kidney anemia. Furthermore, there were higher frequencies of outcomes in increased serum sFas levels. As an elective risk factor, serum sFas levels, in addition to age and diabetes, were independently associated with kidney anemia for an extended period. Thus, more studies are necessary to analyze the proper relationship of sFas with kidney anemia and its outcomes and therapy in CKD.

Decreased levels of perfluoroalkyl substances in patients receiving hemodialysis treatment

Perfluoroalkyl substances (PFAS) have been reported to be harmful to multiple organs in the human body. Based on a previous study suggesting that hemodialysis (HD) may be a means of eliminating PFAS from the human body, we aimed to compare the serum PFAS concentrations of patients undergoing regular HD, patients with chronic kidney disease (CKD) and controls. Additionally, we also investigated the correlation between PFAS and biochemical data, as well as concurrent comorbidities. We recruited 301 participants who had been on maintenance dialysis for >90 days, 20 participants with stage 5 non-dialysis CKD, and 55 control participants who did not have a diagnosis of kidney disease, with a mean creatinine level of 0.77 mg/dl. Eight different PFAS, namely perfluorooctanoic acid (PFOA), total and linear perfluorooctanesulfonic acid (PFOS), perfluoroheptanoic acid (PFHpA), perfluorohexanesulfonic acid (PFHxS), perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), and perfluoroundecanoic acid (PFUnDA), were measured using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Spearman correlation and multivariable linear regression with 5 % false discovery rate were used to evaluate the relationships between PFAS and clinical parameters in HD patients and controls. Circulating concentrations of seven PFAS, including total and linear PFOS (T-PFOS and L-PFOS) PFDA, PFNA, PFHxS, PFOA, and PFUnDA, were significantly lower in the HD group compared to the CKD and control group. For the interplay between biochemical data and PFAS, all of the studied PFAS were positively correlated with aspartate aminotransferase, alanine aminotransferase, glucose, blood urea nitrogen, ferritin, and vitamin D in the controls, while in HD patients, the PFAS were all positively correlated with albumin, uric acid, iron, and vitamin D. These findings may offer valuable insights for future studies seeking to eliminate PFAS.

Association of Longitudinal B-Type Natriuretic Peptide Monitoring With Kidney Failure in Patients With CKD: A Cohort Study

Both hypervolemia and hypovolemia are associated with chronic kidney disease (CKD) progression. Although longitudinal monitoring of B-type natriuretic peptide (BNP) may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. This study assessed the association between BNP monitoring and the risk of incident kidney replacement therapy (KRT). Retrospective cohort study. A total of 2,998 outpatients with stages 3-5 of nondialyzed CKD referred to the department of nephrology at an academic hospital. BNP monitoring. KRT, acute kidney injury (AKI), and heart failure hospitalization. Marginal structural models, which create a balanced pseudo population at each time point, were applied to account for potential time-dependent confounders. Inverse probability weighted pooled logistic regression models were employed to estimate hazard ratios. At baseline, the median age and estimated glomerular filtration rate were 66 years and 38.1mL/min/1.73m2, respectively. During the follow-up period (median, 5.9 [IQR, 2.8-9.9] years), 449 patients required KRT, 765 had AKI, and 236 were hospitalized for heart failure. After adjustment for time-updated clinical characteristics and physician-specific practice styles, BNP monitoring was associated with lower risks of KRT (HR, 0.44 [95% CI, 0.21-0.92]), AKI (HR, 0.36 [95% CI, 0.18-0.72]), and heart failure hospitalization (HR, 0.37 [95% CI, 0.14-0.95]). The association between BNP monitoring and KRT was attenuated after additional adjustment for AKI or heart failure hospitalization as a time-varying covariate. Residual confounding by measured and unmeasured variables or indications for BNP measurements. BNP monitoring was associated with a lower risk of KRT among patients with CKD that did not require dialysis. This association is potentially mediated through a reduced risk of AKI or heart failure hospitalization. Both volume overload and volume depletion are deleterious to kidney function. B-type natriuretic peptide (BNP) is a biomarker that reflects volume status not only in heart failure but also in nondialysis chronic kidney disease (CKD). Although longitudinal BNP monitoring may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. In this cohort study analyzing 2,998 patients with nondialyzed CKD, BNP monitoring was associated with a lower risk of kidney replacement therapy, acute kidney injury, and heart failure hospitalization over the follow-up period. The association with kidney replacement therapy may be mediated through a reduced risk of acute kidney injury or heart failure hospitalization. BNP monitoring may aid physicians in optimal fluid management, potentially conferring better kidney outcomes.

#5529 RED BLOOD CELL TRANSFUSION RATES IN THE INTERNATIONAL DOPPS PROGRAM (2012–2022): HEMODIALYSIS, PERITONEAL DIALYSIS, AND NON-DIALYSIS CKD POPULATIONS

Abstract Background and Aims Anemia is a common complication of chronic kidney disease (CKD), and affects the majority of patients on hemodialysis (HD) and peritoneal dialysis (PD). Consequences of anemia include lower quality of life, increased healthcare utilization, and greater mortality risk. Current international guidelines recommend treating patients with iron and erythropoiesis-stimulating agents (ESAs) to a target hemoglobin (Hb) range, and avoiding red blood cell transfusions (RBCT) when possible, given the associated short- and long-term adverse consequences including hyperkalemia and allosensitization. A description of contemporary RBCT rates – after the 2012 KDIGO guideline changes – across the spectrum of CKD and different geographies is lacking. In this analysis, we estimated RBCT rates in non-dialysis CKD (ND-CKD), PD, and HD patients in a multinational setting, overall and stratified by Hb levels. Method We used data from 3 ongoing prospective cohort studies from the Dialysis Outcomes and Practice Patterns Study (DOPPS) Program: 2443 Stage 3–4 ND-CKD patients from 2 countries in CKDopps phases 1–2 (2013–2022), 3557 PD patients from 6 countries in PDOPPS phase 1 (2014–2018), and 22,771 HD patients from 20 countries in DOPPS phases 5–7 (2012–2022). Within each study, patients were randomly selected from stratified national samples of clinics, representative of a snapshot in time at study entry. Prospective information on RBCT receipt (yes/no) was captured at the patient-month level; thus, multiple events per patient were considered in the rate calculation, if they occurred in different months. RBCT rates were calculated as a count of the total patient-months with an RBCT event divided by the total patient-months with RBCT data available. Rates (per patient-month) were converted to per 100 patient-years, with 95% confidence intervals estimated by Poisson regression. RBCT rates are presented in each population (ND-CKD, PD, HD) across strata of interest, including CKD stage, country/region, and baseline Hb levels. Results Mean age (years) of the cohort was 68.6 for ND-CKD, 59.1 for PD, and 63.2 for HD. Mean (std dev) baseline Hb levels (g/dL) were 12.1 (1.9) in ND-CKD compared to 10.9 (1.7) in PD and 10.9 (1.5) in HD. Median [IQR] months of follow up (with RBCT data available) was 17 [6, 27] for ND-CKD, 16 [9, 20] for PD, and 8 [4, 19] for HD. Table 1 shows crude RBCT rates (per 100 patient-years) in the ND-CKD, PD, and HD populations, overall, by CKD stage and country/region. For ND-CKD, the RBCT rate was 6.7 (95% CI: 5.9, 7.6) overall, including 7.0 in the US and 5.5 in Brazil. RBCT rates increased with ND-CKD stage, from 2.2 in Stage 3a to 4.5 in Stage 3b to 8.5 in Stage 4. For PD, the RBCT rate was 20.3 (95% CI: 19.1, 21.6), higher than in ND-CKD, with substantial variation across countries, from 7.3 in the UK to 45.6 in Thailand. For HD, the RBCT rate was 23.9 (95% CI: 23.3, 24.5), also higher than in ND-CKD, with international variation observed. In the HD cohort, RBCT rates were lower in China (6.3) compared to the US (21.9), Canada (34.4), and the Gulf Cooperation Council region (34.8). Within HD-Europe, RBCT rates were highest in Belgium (48.1) and Sweden (42.4), and lowest in Germany (15.4), France (19.0), and Italy (20.4). Table 2 shows crude RBCT rates by baseline Hb levels. In all 3 cohorts (ND-CKD, PD, HD), RBCT rates appeared higher among patients with lower versus higher baseline Hb levels. In the PD and HD populations, patients with baseline Hb &amp;lt;8 g/dL had RBCT rates &amp;gt;100. Conclusion Our multinational study used uniform and standardized data collection tools, procedures, and processes to estimate RBCT rates in the post-2012 era following the revision of international guidelines. As expected, we observed higher RBCT rates in the PD and HD (vs. ND-CKD) populations, and higher RBCT rates among patients with lower baseline Hb levels. Interestingly, we also observed substantial international variation in RBCT rates in all 3 cohorts (ND-CKD, PD, HD). Further research is needed to better understand the reasons why RBCT use is higher or lower in certain countries, and to investigate predisposing and modifiable risk factors for RBCT. Funding: GSK (study 218930)

#4016 MENTAL HEALTH OF PEOPLE WITH KIDNEY DISEASE AND THEIR SIGNIFICANT OTHERS BEFORE AND AFTER THE COVID-19 VACCINE PROGRAMME

Abstract Background and Aims The COVID-19 pandemic resulted in widespread psychological distress, including depression, anxiety, and stress, especially in clinically vulnerable people such as those with chronic kidney disease (CKD). In the UK, high rates of infection, severe illness and death, and profound changes to usual activities and healthcare delivery imposed by social distancing and isolation persisted throughout 2020 and only began to abate after the introduction of the COVID-19 vaccination programme early in 2021. We conducted a survey to assess levels of general depression, anxiety, stress and health anxiety in people with non-dialysis CKD (ND-CKD), kidney transplant recipients (KTRs), and their significant others (SOs) at two timepoints: during the Autumn of 2020 when COVID-19 levels and social restrictions were high, and in May 2021 after the majority of the population had been vaccinated. We hypothesised that the mental health status of people affected by CKD would improve after receiving the vaccine. Method 11 hospital sites in England invited local patients and their SOs to complete an online survey in Autumn 2020, and a follow-up in May 2021. The survey included two validated mental health questionnaires: the Depression, Anxiety and Stress Scale (DASS-21) and the Short Health Anxiety Index (SHAI). Higher scores are indicative of higher levels of depression, stress and anxiety, and health anxiety respectively. One-way ANOVA was used to compare questionnaire scores between the three participant groups, and paired sample t-tests were used to assess changes between the two timepoints for each group. Results 381 participants completed the Autumn 2020 survey: 123 ND-CKD (61% male, mean age 64[SD:14] years), 150 KTRs (51% male, 59[SD:12] years), and 108 SOs (39% male, 60[SD:13] years). 318 completed the May 2021 follow-up survey. 174 participants completed both surveys. In Autumn 2020, people with ND-CKD had significantly higher DASS-21 anxiety scores than SOs (p = 0.029). Both ND-CKD and KTRs had significantly higher health anxiety scores than SOs at baseline (P&amp;lt;0.001), and at follow-up (ND-CKD, P = 0.006; KTR, P = 0.010). In May 2021, 95% of participants had received the COVID-19 vaccine. There were no significant changes in DASS-21 subscale scores or SHAI scores between the Autumn 2020 and May 2021 timepoints for any of the participant groups. Conclusion Our results show that during the COVID-19 pandemic, people living with ND-CKD and KTRs had higher levels of health-related anxiety than their SOs. As the COVID-19 vaccine programme reduced health risks and allowed relaxation of social restrictions, it may be expected to result in improved population mental health. However, in May 2021, we found no improvement in depression, anxiety, stress, or health anxiety among people living with CKD or their SOs despite nearly all the participants having received the vaccine. It is likely that increased social mixing and marked reduction in public mask-wearing led to persistently high anxiety levels in clinically vulnerable people and those who live with them. Today, the majority of the public have returned to “normal” social behaviour and masks are rarely worn, but COVID-19 remains a threat to people with CKD. There is an urgent need for better mental health support among the kidney community.

#4292 PATIENT-REPORTED MENTAL HEALTH PROBLEMS, SUICIDE IDEATION, AND CLINICAL OUTCOMES IN ADULTS WITH NON-DIALYSIS CKD: RESULTS OF THE KNOW-CKD STUDY

Abstract Background and Aims Mental health is important for health and well-being at every stage of life and disease. Mental health problems are common and bothersome in chronic kidney disease (CKD). Mental health problems of CKD are poorly understood and evaluated. To address the importance of mental health in CKD, we analyzed a prospective cohort database from prospective CKD cohort. Method We analyzed 1897 participants from the KNOW-CKD cohort. We evaluated 4 items as indicators of patient-reported mental health: sleep duration, perceived stress, depressive symptoms, and suicidal ideation. To facilitate interpretation of the mental health problems in CKD, we measure a scaled effect size (ES) for the Kidney Disease Quality of Life Short Form (KDQOL-SF) differences among the groups of mental health problems. We investigated the association between patient-reported mental health problems and clinical outcomes of incident end-stage kidney disease (ESKD) all-cause death in non-dialysis CKD. Results The mean age was 53 ± 12 years and 62% were male. The participants had mental health problems of inadequate sleep duration (17.4%), subject distress (27.3%), experience of depression (13.2%), and suicide ideation (16.8%), but had not well taken care (psychiatric counselling 1.9%, antidepressant therapy 2.8%). The 4 item indicators of mental health showed large effect size between-groups KDQOL mental component summary (ES = 1.67). In the fully adjusted Cox proportional model, poor mental health (≥2 mental health problems) was associated with high risk of ESKD [HR = 1.46; 95% CI (1.18∼1.08)] and death [HR = 1.55; 95% CI (1.04∼2.32)] compared to good mental health (no mental health problems). Among 4 item indicators of patient-reported mental health, suicide ideation was the most predictive indicator of clinical outcomes. Conclusion Mental health problem is common and undertreated in CKD. Poor mental health is associated with high risk of ESKD and death in non-dialysis CKD and the single question of suicide ideation is significantly associated with high risk of ESKD and death. It suggests that the evaluation and management of mental health problem is important to the clinical outcomes in CKD.

#4820 RISK FACTORS FOR INPATIENT MORTALITY IN PATIENTS WITH NON-DIALYSIS CHRONIC KIDNEY DISEASE ADMITTED FOR COVID-19 USING A US NATIONAL SAMPLE

Abstract Background and Aims Several studies reported that the COVID-19 pandemic has disproportionately affected socioeconomically vulnerable populations. No study evaluated risk factors for inpatient mortality in patients with non-dialysis chronic kidney disease (CKD) admitted with the diagnosis of Covid-19, using a US nationwide sample. This study aimed to elucidate risk factors for mortality in patients with CKD during Covid-19 admissions. Method We extracted data from the National Inpatient Sample year 2020, the largest nationally representative inpatient-care database in the US. We created a cohort of all adults with CKD hospitalized for Covid-19 by ICD-10 codes. The outcome was inpatient mortality. We excluded patients with end stage kidney disease on maintenance dialysis and transplant patients. We compared baseline characteristics and used multiple logistic regression to determine risk factors for inpatient mortality in this cohort. Results Total of 201,460 admissions with a diagnosis of Covid-19 were detected in patients with non-dialysis CKD. Table 1 showed the baseline characteristics. The mean age was 72.8±0.2 years and females accounted for 43.6%. Of all, White accounted for 52.3%, followed by Black (26.1%) and Hispanic (14.6%). Inpatient mortality was 20.9%. Table 2 showed the results of the multivariable logistic model. Older patients, Males, higher Charlson Comorbidity Index scores were associated with a higher risk of inpatient mortality. White patients had a higher risk compared to Black patients and Native Americans had the highest risk, followed by other ethnic minorities, Hispanic, and Asians. Those from the lowest income households had the highest risk. Admission to a rural, publicly owned hospital and those located in the West and Northeast had higher odds of inpatient mortality. Conclusion Our study showed males, race, commercial payment type, lower income, and hospital settings such as regions and location were risk factors for inpatient mortality in patients with non-dialysis CKD. Further studies are needed to evaluate whether differences in clinical practice underly some of these risks.

#4023 FEELINGS OF SAFETY AND SOCIAL BEHAVIOURS AFTER COVID-19 VACCINATION IN PEOPLE LIVING WITH KIDNEY DISEASE AND THEIR SIGNIFICANT OTHERS

Abstract Background and Aims Throughout the majority of 2020, the COVID-19 pandemic forced the UK population, and especially clinically vulnerable people such as those with chronic kidney disease (CKD), to isolate and cease their usual activities outside the home. The COVID-19 vaccine became available in early 2021, with the aim of protecting against COVID-19 infection, reducing the risk of serious illness or death, and consequently allowing a return to more normal social behaviours. In May 2021 we conducted a survey to explore perceptions of increased COVID-19 safety and resultant changes in social mixing behaviour in people with non-dialysis CKD (ND-CKD), kidney transplant recipients (KTRs), and their significant others (SOs) after receiving the COVID-19 vaccination. Method ND-CKD, KTR and SO participants from 11 hospital sites across England were invited to complete an online survey in May 2021. The survey included items asking about changes to their feelings of COVID-19 risk and safety, and their social behaviours after receiving the COVID-19 vaccine. Participants ranked questions on 7-point Likert scales (perceived COVID-19 safety, 1: feel not safe at all to 7: feel completely safe; changes in social behaviour, 1: no change to 7: complete change), and provided free-text explanations for their ranked responses. Question ratings were analysed by ANOVA, and free-text responses by content analysis to identify common themes. Results 114 ND-CKD (mean age 65.5 (±1.2) years, 59% male), 120 KTR (60.95 (±9.9) years, 51% male), and 77 SO (63 (±11.08) years, 62% male) participants completed the survey. In total, 109/114 (96%) ND-CKD, 116/120 (97%) KTR, and 71/77 (92%) SO participants had received the COVID-19 vaccine. There were no significant differences between the groups for perceived COVID-19 safety, with all three groups reporting feeling safe from the virus (mean perceived safety rating 6.0 [±1.3] out of a maximum of 7). However, all groups reported limited changes in behaviour after receiving the vaccine (scale rating 3.6 [±1.3]/7). Common reasons identified for perceived feelings of safety were ‘risk perception’ e.g. reduced risk of severe illness, death and hospitalisation and ‘availability of vaccine evidence’ e.g. data that supported the safety of the vaccine being available to the public as well as trust in science and health care professionals. ‘Relaxed shielding’, ‘compliance with government guidance’, and ‘using own discretion’ were common reasons underlying changes in social behaviour. Conclusion These results show that the majority of participants had received at least one dose of the COVID-19 vaccine by May 2021. Participants did report feeling safer from COVID-19, but despite this, changes to isolation and social mixing behaviour were limited. The free text responses provided explanations for this: participants stated they felt safer after receiving the vaccine due to reduced risk of severe illness and hospitalisation, and new variants. However, despite feeling safer, changes in social behaviour were limited. This may be partly explained by the continuation of some government restrictions at the time of the survey. However, increased social mixing and abandonment of mask-wearing by the general public potentially increased risk for the clinically vulnerable. Together with uncertainty around vaccine efficacy in clinical populations, this resulted in ongoing social avoidance behaviour. These factors persist in today's environment and highlight the need for communication of high-quality research evidence to encourage uptake of booster COVID-19 and flu vaccines, and effective public education campaigns, to allow clinically vulnerable people to confidently return to pre-pandemic social activity.

#3213 PATIENT ACTIVATION STATUS AND PATIENT PERCEIVED FUNCTION IMPAIRMENT IN CKD: A ROUTE TO OPTIMISING LIFE PARTICIPATION THROUGH ENHANCED SELF-MANAGEMENT?

Abstract Background and Aims Chronic kidney disease (CKD), even at earlier stages where kidney replacement therapy is not required, is associated with significant health and symptom burdens which negatively impact on an individual's functional status and ability to fully engage with work, leisure, and social activities. Life participation can be maximized with optimal day-to-day management of CKD. A strong partnership between the healthcare team and patient is required to support effective self-management. Central to this partnership is patient activation, defined as the knowledge, skills, and confidence to manage one's own health. Individuals who are highly activated take an active role in their health, whilst those with low activated have a more passive role. Higher activation is associated with better clinical outcomes. As part of a wider survey in people living with non-dialysis CKD (ND-CKD), we explored the relationship between patient activation and perceived functional impairment as a result of CKD. Method 14 hospital sites across England invited patients with ND-CKD to complete a survey on health and lifestyle factors including demographic and clinical information, the SF-12 health-related quality of life (QoL) questionnaire, Chalder Fatigue Scale, Patient Activation Measure (PAM-13), and Work and Social Adjustment Scale (WSAS). Participants were classified as having ‘low’ or ‘high’ activation based on their PAM-13 level (Levels 1&amp;2 ‘low’; 3&amp;4 ‘high’). Higher WSAS scores indicated greater perceived functional impairment due to CKD. To compare perceived impairment in WSAS domains between low and high activated participants, Mann-Whitney tests were conducted. To determine the relationship between participant characteristics (i.e., age, gender, ethnicity, eGFR, patient activation, fatigue, physical and mental QoL) and WSAS score, linear regression was performed. Results 828 ND-CKD patients completed the survey [mean age 67.9 (±13.8) years, 60% (n = 501) male, 92% White British (n = 771), eGFR 33.1 (±19.7) ml/min/1.732, total number of additional comorbidities 2.0 (±1.5)]. 64% (n = 529) of participants were classified as having ‘low’ activation. The mean WSAS score was 7.8 (±9.9) indicating mild functional impairment. Both high and low PAM groups perceived social and leisure activities (with other people e.g., outings/dating/parties) to be their most impaired functional activities, and close relationships with others as least impaired. Low activated participants perceived greater impairment on work (P = 0.035), home management (P&amp;lt;0.001), social leisure activities (P&amp;lt;0.001), private leisure activities (P&amp;lt;0.001) and close relationships (P&amp;lt;0.001) as a result of their CKD compared to those with higher activation. Individuals who perceived greater functional impairments were younger (P&amp;lt;0.001), had lower levels of activation (P = 0.036), poorer physical (P&amp;lt;0.001) and mental (P = 0.043) QoL, and greater levels of fatigue (P = 0.001). Conclusion People with lower patient activation perceived greater functional impairment to work, leisure, and social activities as a result of their CKD. Younger people may have greater expectations as to what they can functionally achieve and the marked impact in comparison to their peers without CKD may be greater and more prominent. Conversely, older individuals may be more likely to attribute functional impairments to other age-associated comorbidities or to the effects of aging itself than to CKD. Interventions designed to increase patient activation and improve psychosocial adjustment have the potential to help individuals manage their CKD and reduce the perceived impairment on life participation.