Pre-dialysis Clinic Research Articles

#1648 Chronic kidney disease-mineral bone disorder and fractures in predialysis patients

Abstract Background and Aims Chronic Kidney Disease (CKD) patients have a complex physiopathology of bone fragility given the development of mineral bone disorder (CKD-MBD) and are at increased fracture risk [1]. Bone turnover, mineralization, and volume (TMV) classification, as proposed by Kidney Disease Improving Global Outcomes (KDIGO), defines different subtypes of renal osteodystrophy (ROD), and is evaluated through bone biopsies and respective histomorphometric analysis. The impact of these parameters and of different ROD subtypes in fracture occurrence has not been evaluated. We aim to evaluate the incidence of fractures in patients with predialysis CKD and the relationship of ROD subtypes and the impact of bone volume with the occurrence of fractures. Method We conducted a retrospective study that enrolled 54 patients (40-89 years old) followed in a predialysis clinic between 2014-2023. Blood tests, bone biopsies and histomorphometric analysis were performed at the beginning of follow-up. Data from dual x-ray absorptiometry (DXA) scan were collected if available. Information regarding clinical evident fractures was recorded from analysis of clinical registries. Radiographies of the thoracic and/or lumbar spine were evaluated to detect asymptomatic vertebral fractures. Results Median follow-up time was 7.5 ± 3 years. Mean age at the time of bone biopsy was 65.4 ± 9.8 years old and most patients were male (n = 43, 79.6%). The majority had CKD stage 4 (53.7%). During follow-up, 20 (37%) patients progressed to kidney replacement therapy and 5 (9.3%) died. DXA scan was performed in 19 patients (35.2%). Of these, 5 had osteoporosis (T-score ≤-2,5). The histomorphometric analysis showed that 40.7% (n = 22) patients had normal bone histology, 37% (n = 20) low bone turnover with normal mineralization (adynamic bone disease) and 22.3% (n = 12) high bone turnover with normal mineralization (hyperparathyroid bone disease). Two patients sustained clinical evident fractures. Radiographies of 51 patients were reviewed and asymptomatic vertebral fractures were identified in 3 (5.9%). The group that suffered fractures had higher phosphorus levels and these differences were statistically significant (4.1 mg/dL vs 3.5 mg/dL, p = 0.047). None of the patients with osteoporosis diagnosed by DXA scan fractured and bone mineral density (BMD) by DXA was similar between the groups (−1.05 vs −1.04, p = 0.530). The different histomorphometric subtypes and circulating biomarkers did not correlate with the incidence of fractures. Patients with fractures had more frequently low bone volume (40%) than patients who do not sustained fractures (25.5%) but this difference was not significant (p = 0.579). BV/TV was lower in the group that sustained fractures during follow-up (16.1 (11.9-17.2) vs 19.0 (16.2-23.6)) and this achieved borderline significance (p = 0.052). Femoral neck BMD measures in the patients who had an available DXA scan did not show any correlation with BV/TV (r = 0.039, p = 0.874). Conclusion No relationship was found between different ROD subtypes and the incidence of fractures. However, when considering bone volume isolated (but not BMD assessed by DXA), a marginally significant association was found between a low BV/TV value and the occurrence of fractures. High phosphorus levels also associated with fractures and have been previously described as a possible risk factor for fractures not only in CKD patients but also general population [2, 3]. Further studies with a larger population are needed to validate these conclusions with statistical power.

#3054 The hospital frailty risk score lacks service planning and decision-making utility in end stage kidney disease

Abstract Background and Aims Survival time for patients commencing dialysis is poor (median 2.0 years in our data) and treatment is invasive. While the age of patients commencing dialysis has increased significantly, the survival advantage diminishes with increasing comorbidity and frailty. The Hospital Frailty Risk Score (HFRS) is a recently-described score derived from ICD-10 codes which has been shown to correlate with outcomes in patients aged >75 years admitted to acute hospital settings. As part of a wider initiative to improve service planning and patient decision-making in the renal setting, we investigated the utility of the HFRS in modelling the survival time of dialysis patients with chronic kidney disease (CKD) both prior to reaching end-stage kidney disease (ESKD), and at dialysis start date. Method A secondary care dataset was obtained of all patients who attended pre-dialysis clinic at a single renal unit in the north of England between 2006–2019 (n = 2,573). Patients choosing dialysis and conservative management were included in the cohort; 1,081 eventually underwent dialysis including 329 patients who were aged ≥70 years when they commenced dialysis. 62.9% were male. Retrospective survival analysis was conducted using the HFRS prior to, and at, dialysis start date and estimates compared using the log-rank test. Results HFRS on dialysis start date was associated with survival time in patients aged ≥70 years (Low frailty Median = 2.5 years; CI = [2.1–3.0 years] vs. Intermediate frailty Median = 1.5 years; CI = [1.0–2.0 years] vs. High frailty Median = 1.3 years; CI = [0.2–2.2 years]; p = 0.005). No association was found between HFRS and survival in the same patients (aged ≥70 on dialysis start date), at any of 3 timepoints prior to dialysis: eGFR level of 20, 15, or 12 (p = 0.18, p = 0.63, p = 0.38 respectively). However, only 150/329 patients (46%) had HFRS recorded prior to eGFR level so sample size was limited. 60 patients’ HFRS had also worsened by dialysis start date (8 had improved). Additional analyses including all age groups found a weaker association between HFRS on dialysis start date and survival (Low frailty Median = 2.1 years; CI = [1.9–2.3 years] vs. Intermediate frailty Median = 1.7 years; CI = [1.5–2.0 years] vs. High frailty Median = 2.1 years; CI = [1.3–2.4 years]; p = 0.04). HFRS and survival were associated at eGFR 15 for all ages (p = 0.02) but not eGFR 20 or 12. Conclusion We identified issues with the HFRS and its implementation that present challenges to its utility for treatment decision-making or service planning in a renal setting. While the HFRS has previously been shown to be predictive of 30-day outcomes in an acute admissions unit, it performed poorly in our cohort of patients with CKD, a long-term condition where HFRS may worsen or improve between treatment choice and dialysis start. Although HFRS did predict outcome from dialysis start in patients aged ≥70 years, this is of limited use given the abundance of validated tools that predict outcome at ESKD. More work is needed to refine the HFRS for pre-ESKD decision-making in a renal setting.

Real-Time Use of SGLT2i Verified in Pre-dialysis: The RSVP Cross-sectional Study.

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in nephrology practice is increasingly becoming standard of care in patients with diabetes or those with proteinuria. The primary outcome was to identify the proportion of pre-dialysis patients with chronic kidney disease (CKD) G3a, G3b, or G4 prescribed an SGLT2i and describe their characteristics. This was a retrospective, multicentric, cross-sectional study of patients with CKD followed at 4 pre-dialysis clinics in the province of Quebec, Canada. We collected data of multiple covariates associated with prescribing SGLT2i in patients over 18 years of age with CKD G3a, G3b, or G4. We then performed a multivariate logistic regression to assess their associations. Of the 874 patients included, 22.7% were prescribed an SGLT2i. Factors most strongly associated included male sex (odds ratio [OR] = 4.88, 95% CI = 2.38-10.03), being prescribed metformin (OR = 4.30, 95% CI = 2.23-8.31), having type 2 diabetes (OR = 4.00, 95% CI = 1.86-8.62), or having an albumin-to-creatinine ratio greater than 300 mg/g (OR = 1.84, 95% CI = 1.08-3.14). The majority of patients (60.4%) had their SGLT2i initiated by the pre-dialysis clinic and the most frequent adverse event was an initial increase in serum creatinine 1 week after starting treatment (33.9%). An increasing number of patients with CKD are being prescribed SGLT2i. Nonetheless, significant disparities in sex, severity of disease, and comorbidities remain. We suggest that specific strategies be put in place to promote prescribing of SGLT2i in women and other at-risk populations, in particular among nephrology teams, to improve patient care.

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

MO416: Predicting Serum Bicarbonate in Non-Dialysis Dependent CKD Patients

Abstract BACKGROUND AND AIMS Metabolic acidosis (HCO3 < 22 mmol/L) is associated with an increased hazard of death in patients with chronic kidney disease (CKD) [1, 2]. It is further associated with muscle wasting, bone disease, hypoalbuminemia, increased inflammation, protein malnutrition, and progression of CKD [3]. Hospital Civil de Guadalajara is an urban public hospital serving a population of low socioeconomic status for whom HCO3 measurements are not included in their healthcare services and create costs around 70% of which our population cannot afford. We aimed to develop a model allowing us to predict HCO3 in CKD patients and tested its diagnostic performance. METHOD Patients at CKD stage 3–5 from our pre-dialysis clinic were included in this retrospective, cross-sectional study which served as a model development. Creatinine, weight, height, calcium, phosphorus, sodium, potassium, chloride, urea, presence of diabetes, total body water calculated by the Watson equation and eGFR calculated with the CKD-EPI formula were utilized. We performed uni- and multivariate linear regression between measured serum HCO3 and the available variables. A hypothesis-driven step-wise approach for parameter inclusion based on the Akaike Information criterion and optimization of the coefficient of determination was employed to construct the final model predicting serum HCO3. Diagnostic performance for detecting metabolic acidosis using the estimated HCO3 (eHCO3) was evaluated by receiver operating characteristics curve (ROC) analysis and computation of sensitivity, specificity and the positive and negative predictive values (PPV, NPV). Post-test probabilities at different pre-test probabilities (prevalence) were assessed using Bayes’ theorem. RESULTS We screened 1089 patients and included 284 patients [62 (21 IQR), 56% male, 69±14kg, 27% at CKD stage 3 and 34% and 40% at stage 4 and 5, respectively] in the analysis. The final model [eHCO] = 21.47 + 0.61 Ca + 0.43 Na + 0.95 TBW-0.61 Pi-0.51 K-0.53 Cl-0.008 Urea + 0.95 If diabetic had an adjusted R2:0.57, RMSE 2.4 on 275df, P-value: <0.001. The mean difference between HCO3 and eHCO was 0 (95% CI −4.9 to 4.9). Diagnostic performance quantified as AUC ROC 0.87 (95% CI 0.83–0.91). At a prevalence of metabolic acidosis of 56% with a chosen threshold of 20 mEq/L, the model has a sensitivity of 56% and specificity of 95% and a PPV of 94% and NPV of 63%, at a prevalence of 56%. Simulation of the post-test probabilities using Bayesian analysis is shown in Figure 1. CONCLUSION At a considerably high specificity of 95%, we can make predictions with a relatively low risk of treating subjects without metabolic acidosis with bicarbonate. Given the cost saving for the patients and the added insights and diagnostic capability, we believe that the prediction of serum HCO3 by biochemical parameters as done in our model will prove useful in settings with limited resources such as our uninsured urban population in Mexico. Validation of our model is the next step and planned future research.

The Practiced Pattern of Vascular Access used in Hemodialysis

Background: The incidence of end-stage renal disease (ESRD) is increasing considerably worldwide; moreover, most of the patients start their therapy by hemodialysis (HD). Arteriovenous fistula (AVF) is the best type of vascular access for use in such therapy, due to its decreased rate of complications, followed by arteriovenous graft (AVG) and finally, central venous catheters, which are associated with, increased mortality and morbidity. In this study, we aim to find out the proportion of the current to initial vascular access used, the timing of creating permanent access, and any complications experienced. Patients and Methods: A cross-sectional study was conducted on two hundred eighteen patients currently on regular hemodialysis program. Their records were reviewed and the data was analyzed for vascular accesses type used at the start of hemodialysis and at the current time, the timing of the creation of permanent access, and the complications occurred. Data collected were statistically analyzed using IBM-SPSS statistics software Inc. Chicago, IL, USA. Results: Out-of-the 218 patients on hemodialysis, 193 patients (88.5%) started hemodialysis via Central venous catheters (CVC), 23 patients (10.5%) had an arterio-venous fistula (AVF), and only two patients (0.9%) used tunneled CVC, while no one has AV-graft. Currently, 82.1% of patients have AVF, 7.8% have chronic CVC, 5.9% have acute CVC and only 4.1% have AV-Graft, Many complications are noted in all types of access with different percentages of occurrence. Conclusion: We concluded that although a high percentage of patients have AVF, still pre-emptive AVF counts very low percentage, serious complications are still happening and we recommend the establishment of joined pre-dialysis clinic with surgeons and psychologists in each dialysis center.

POS-576 OUTCOMES OF GERIATRIC PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 5 : SINGLE CENTRE EXPERIENCE

Globally, the number of elderly persons with stage 5 chronic kidney disease (CKD) is rising. It's still unclear whether dialysis will benefit geriatric patients with advanced CKD. The decision to start dialysis or to follow a non-dialysis treatment plan is complex and difficult. This study aims to investigate how modality selection affects geriatric patient survival and to explore the associated risk factors. The pre-dialysis clinic database was used to identify geriatric patients (age > 65 years) with an eGFR of 15 mls/min/1.73m2 who were followed up in the nephrology clinic from January 1 to December 31 2016. Demographics, comorbidities, dialysis modality, clinical outcome, and laboratory data were obtained from hospital electronic medical reports. Patients were then followed up till 31stDecember 2018. Survival was calculated from the time when eGFR was <15 mls/min/1.73m2 until death or the end of the study. A total of 97 patients were identified during this study period. Sixty-one (62.9%) patients opted for long term dialysis (LTD) whilst the remaining 37.1% (n=36) opted for non-dialysis (ND) pathway. Patients in the ND group were older with median(IQR) age of 74.5(8) years compared to LTD patients with median age of 70.0(6) (P<0.001). One and two-year survival rates were 67.2% and 62.2% in the LTD group and 66.7% and 60.7% in the ND (p =0.815). Further analysis of patients who chose LTD found that 47.5% (n=29) started dialysis in a timely manner, with mean eGFR of 7.4ml/min/1.73m2, while 52.4% (n=32) crashed-landed with mean eGFR of 5.9ml/min/1.73m2. Patients who crash-landed had the lowest survival rate when compared to patients who started dialysis in a timely manner and those who chose the ND course, as shown in the table below. Mean time of decline in eGFR 15mls/min/ 1.73m2to death or study end was 22.5±12.7 months for those on LTD and 20.8±11.9 months for those managed conservatively (P=0.303). Comorbidities and age did not have a significant impact on survival. Tabled 1No. of patientsNo. of events1 Year Survival %2 Years Survival %P-valueLTD with timelyinitiated dialysis29589.786.10.002LTD butcrash-landed321946.940.6Non-dialysis treatment361566.760.7 Open table in a new tab In this study, geriatric patients who chose dialysis had similar survival to those who chose non-dialysis treatment. If opted for long-term dialysis treatment, it must be started in a timely manner to maximize the survival advantage as crash-lander had the lowest survival rate.

Effect of simplified dietary advice on nutritional status and uremic toxins in chronic kidney disease participants

Background: Traditional chronic kidney disease (CKD) dietary advice is challenging with many restrictions, consequently adherence to the CKD diet is low. Recent literature has proposed less restrictive dietary guidelines in CKD to improve dietary adherence and outcomes; however, limited evidence of its implementation exists. Objectives: This study (trial number: PACTR202002892187265) investigated the effect of simplified dietary advice on nutritional outcomes and adherence after four weeks of dietary advice. Design: A before-and-after study was conducted. Outcome measures: Sociodemographic, clinical and biochemical information was collected and anthropometric measurements performed on Stage 3–5 CKD participants attending a pre-dialysis clinic. Uremic toxins were quantified by UPLC/fluorescence detection. Dietary intake was assessed using a quantified food frequency questionnaire (QFFQ). Participants were educated by the study dietitian on simplified dietary advice using an infographic. A diet-adherence score sheet monitored adherence. All outcomes were measured at baseline and four weeks after the diet was advised. IBM SPSS® version 27 was used for statistical analysis. Results: Fifty-nine participants, mean age 41.0 ± 11.6 years, completed the study. After four weeks, significant improvements were found in body mass index (p < 0.006), waist circumference (p < 0.001), mid-upper arm circumference (P < 0.001), serum total cholesterol (p < 0.045), serum triglycerides (p < 0.017), energy (p < 0.001), protein (p< 0.001) and most dietary intake variables. Overweight and obesity prevalence was high at 68%. Uremic toxin concentrations remained stable. Dietary adherence was 88.6%. Conclusion: The simplified dietary advice suggests improved nutritional outcomes in CKD patients who were predominantly overweight and obese, without compromising kidney function. This study highlights the importance and feasibility of simplified nutrition education in CKD.

Health literacy level in a various nephrology population from Qu\xe9bec: predialysis clinic, in-centre hemodialysis and home dialysis; a transversal monocentric observational study

BackgroundHealth literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. It is especially important in nephrology due to the complexity of chronic kidney disease (CKD). The present study sought to define health literacy levels in patients followed in predialysis clinic, in-center dialysis (ICHD), peritoneal dialysis (PD) and home hemodialysis (HHD).MethodsThis transversal monocentric observational study analysed 363 patients between October 2016 and April 2017. The Brief Health Literacy Screen (BHLS) and the Health Literacy Questionnaire (HLQ) were used to measure health literacy. Multivariate linear regressions were used to compare the mean scores on the BHLS and HLQ, across the four groups.ResultsPatients on PD had a significantly higher BHLS’score than patients on ICHD (p = 0.04). HLQ’s scores differed across the groups: patients on HHD (p = 0.01) and PD (p = 0.002) were more likely to feel understood by their healthcare providers. Compared to ICHD, patients on HHD were more likely to have sufficient information to manage their health (p = 0.02), and patients in the predialysis clinic were more likely to report high abilities for health information appraisal (p < 0.001).ConclusionIn a monocentric study, there is a significant proportion of CKD patients, especially in predialysis clinic and in-centre hemodialysis, with limited health literacy. Patients on home dialysis (HHD and PD) had a higher level of health literacy compared to the other groups.

MO858BIOCHEMICAL CHARACTERIZATION AND SURVIVAL OF PATIENTS URGENT-START HEMODIALYSIS DURING COVID-19 PANDEMIC: EXPERIENCE IN A GUATEMALAN CENTER

Background and AimsThe Coronavirus Disease 2019 (COVID-19) pandemic has greatly impacted the world health system, affecting almost 20 million people with a high fatality rate, mainly patients with comorbidities including patients with chronic kidney disease (CKD) in all its stages and renal replacement therapy. The aim of the present study was to evaluate the biochemical characteristics of the patients who urgent-start hemodialysis during the pandemic and additionally to evaluate their survival.MethodPatients urgent-start hemodialysis were taken during the months of August to November 2020, the admission laboratory data was recorded, including the test to determine SarsCov-2, and Kaplan-Meier survival analysis was applied taking in it counts variables such as sex, professional who placed the vascular access, COVID-19 test result and evaluation by nephrology in the pre-dialysis clinic.Results92 patients were including in the analysis, 65% male, the nephrologist placed the vascular access in 54% of the patients, 71% had a negative result in the COVID-19 test and 55% had no evaluation in the pre-dialysis clinic. Among the biochemical results was found BUN 95.3mg/dl (SD 38.1), sCr 10.3mg/dl (SD 6.3), Na 130.6mg/dl (SD 7.5), K 5mmol/L (SD 1.1), Ca 7.8mg/dl (SD 1), P 6.5mg/dl (SD 3.3), uric acid 8.3mg/dl (SD 10) and PTH 279pg/ml (SD 267). As prognostic markers of infection by COVID-19, the following results were found WC 12.3k/UL (SD 9.3), hemoglobin 9.35g/dl (SD 2.5), hematocrit 28.7% (SD 9.4), platelets 291mcL (SD 137), sedimentation 75mm/hr. (SD 37), CRP 81.8mg/L (SD 113.8), interleukin-6 232-6pg/ml (SD 838.8), ferritin 1074.3mg/ml (SD 825.3), D dimer 4.3mcg/dl (SD 11.2), lactate dehydrogenase 322U/L (SD 255) and procalcitonin 6.5ng/ml (SD 16.8). When evaluating survival with the Kaplan-Meier analysis, no statistically significant difference was found when analyzing the variable presence of COVID-19 infection (Figure 2 - p: 0.89), sex (Figure 3 - p: 0.54), professional who placed vascular access (Figure 4 - p: 0.1), and the pre-dialysis evaluation (Figure 5 - p: 0.33), having a survival in general of 77% at 3 months (Figure 1).ConclusionThe present study found a 77% survival rate in patients with urgent-start hemodialysis. There are no other documented data in Guatemala, which is why it provides guidelines for future studies in the country. Among the variables taken, no one was found that would determine a better survival, including SarsCov-2 infection. It will be necessary to carry out more studies with greater follow-up, more patients and more centers to carry out a better analysis.MO858 Figure 1: Overall SurvivalMO858 Figure 2: Survival by COVID-19 testMO858 Figure 3: Survival by SexMO858 Figure 4: Survival by vascular accesMO858 Figure 5: Survival by Follow-up Dialysis Clinic

Obesity and Other Nutrition Related Abnormalities in Pre-Dialysis Chronic Kidney Disease (CKD) Participants.

Chronic kidney disease (CKD) is increasing in sub-Saharan Africa. Undernutrition has been prevalent amongst end stage CKD patients, with limited data on the prevalence of obesity. The aim of this study was to assess the nutritional status of CKD patients using various methods sensitive to over and under-nutrition. Stage 3 to 5 CKD patients (glomerular filtration rate (GFR) < 60 mL/min/1.73 m2) attending a pre-dialysis clinic in Cape Town, were enrolled. Exclusion criteria included infectious and autoimmune conditions. Sociodemographic, clinical and biochemical data were collected, and anthropometric measurements were performed. Dietary intake was measured with a quantified food frequency questionnaire (FFQ). Statistical Package for the Social Sciences (SPSS) version 26 was used for statistical analysis. Seventy participants, with mean age of 41.8 ± 11.8 years, 52.9% females and 47.1% males were enrolled. Participants enrolled mainly had stage 5 kidney failure. Thirty percent were overweight (21) and 25 (36%) were obese, 22 (60%) of females were overweight and obese, while 13 (39.4%) of males were predominantly normal weight. Abdominal obesity was found in 42 (60%) of participants, mainly in females. Undernutrition prevalence was low at 3%. Dietary assessment showed a high sugar and protein intake. There was a high prevalence of overweight, obesity and abdominal obesity in CKD stage 35 patients, with unhealthy dietary intake and other nutritional abnormalities.

Exploring the choices and outcomes of older patients with advanced kidney disease.

A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004–2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.

P1083A TRANSITIONAL REGIME OF INCREMENTAL HAEMODIALYSIS IN PATIENTS WITH END-STAGE RENAL DISEASE (ENDURE): A FEASIBILITY TRIAL

Abstract Background and Aims Mortality rates are high in patients starting long-term haemodialysis (HD) therapy, particularly in the first 6-months. Incremental HD has been proposed as a means of making patients’ transition into long-term HD treatment less physiologically demanding with reduced burden of treatment at the start. A feasibility study is being conducted with the primary aim of evaluating the acceptability, tolerance and safety of a novel incremental HD regime. The secondary aims are to study the effect of incremental HD on residual renal function (RRF), fluid load, quality of life, functional status, blood pressure and blood markers of renal anaemia, secondary hyperparathyroidism and cardiac load. Method The regime being tested aims to start patients on twice-weekly HD with progressive increases in the duration and frequency of sessions over approximately 15 weeks (figure 1). 40 patients from pre-dialysis clinics, who have been referred for start of long-term HD therapy, will receive the study regime (incremental HD group). They will be followed-up for 12 months. Acceptability and tolerance will be gauged by documenting rates of participation and retention in the study. Completion rate of each study test will be recorded to evaluate the feasibility of their inclusion in a future trial; these tests include: 24-hour urine collection to measure RRF, bio-impedance analysis for estimation of overhydration, six-minute walk test to monitor performance status and a quality-of-life questionnaire. Rates of pre-defined safety events will be recorded and compared to a cohort of 40 matched patients who previously started conventional HD (historical controls, conventional HD group). Blood tests for estimation of RRF and markers of renal anaemia, bone disease and cardiac load will be performed at regular intervals and compared to the conventional HD group. Results Eight months in to the 18-month recruitment period, 106 patients have been screened for participation in the trial. Of these, 47 (43%) met eligibility criteria. Reasons for exclusions were: patient choosing other dialysis modalities over HD, 34; clinically unsuitable for incremental HD, 7; dialysis modality undetermined, 6; already started HD, 5; for conservative (non-dialysis) management, 4; non-compliant with treatment, 3. Of the 47 eligible patients, 35 have been approached by the study team. Of these, 16 (46%) have been consented, 10 (28%) declined and 9 (26%) remain undecided. Patients who consented were relatively older compared to those who declined (68 vs. 58 years) and to all eligible patients (68 vs. 63 years). Men were more likely to decline than women (M:F ratio 1.3 vs 4.0 among participants and decliners respectively). Not all study participants have started treatment yet. Baseline characteristics of the first 6 patients starting incremental HD and their matched controls are shown in table 1. Conclusion The ENDURE study tests the feasibility of starting patients on a novel incremental HD regime. This regime is relatively short and has fixed increments in treatment times. It aims to make patient transition smoother in to dialysis dependency. Early data point towards an encouraging levels of patient interest in the study. The outcome of this trial will be used to design a future RCT of incremental HD vs. conventional treatment.

P1542DIALYSIS MODALITY AND OUTCOMES IN GERIATRIC END STAGE RENAL DISEASE (ESRD) PATIENTS. AN ASIAN SINGLE CENTER EXPERIENCE

Abstract Background and Aims The prevalence of CKD increases with age and more elderly patients are on maintenance dialysis as advanced age is no longer an impediment. The selection of dialysis modality can be difficult for the simultaneous benefit and burden of individual modality on top of the complexity of co-morbidity and quality of life. To study the survival outcomes based on dialysis modality in geriatric ESRD patients Method The cohort of geriatric patients (aged &amp;gt; 65 years) with ESRD who were referred to our pre-dialysis clinic from 1st January 2016 to 31st December 2018 and started on maintenance dialysis were identified via the hospital information system. Demographics, co-morbidities, dialysis modalities and clinical outcome in terms of survival were obtained from the hospital electronic medical record. Glomerular filtration rates (eGFR) were calculated using the CKD-EPI formula in mls/min/1.73m2. The statistical analysis was done using SPSS version 23. Results A total of 145 geriatric ESRD patients were initiated on chronic dialysis. The cohort was predominated by male with 77 patients (53.1%). The mean age was 72.5±5.2 years. Majority had multiple comorbidities with 95% having hypertension, 82.8% with diabetes, 65.5% and 32.8% having dyslipidemia and ischemic heart disease, respectively. The mean eGFR at point of referral and dialysis initiation were 12.5±4.9 mls/min/1.73m2 and 6.57±2.33 mls/min/1.73m2 respectively. Mean duration to initiate dialysis from first review was 6.7±5.8 months. Majority opted for hemodialysis (HD) with 106 patients (73.1%). 74% patients in the HD cohort initiated dialysis via a catheter and remainder with an arteriovenous fistula (AVF). 39 patients (27.1%) opted for peritoneal dialysis (PD) and all were initiated via tenckhoff catheter. Mean eGFR at dialysis initiation were 6.44±2.47 (HD) and 6.9±1.9(PD) respectively. At 6 months, all PD patients survived and 18.2% of HD patients died with statistically significance difference at p=0.003. No survival predictors were identified. Conclusion PD modality has advantage in survival outcome in geriatric ESRD patients.

Influence of Nephrologist Physician Teaching about Dialysis Modalities in Pre-Dialysis Clinic on Peritoneal Dialysis Choice, Single Centre Experience

Abstract Background: The Pre-dialysis clinic can improve the length and quality of survival of patients with end-stage renal disease, delaying the progression of chronic kidney disease and the need for dialysis. Also, it has a link to make the best therapy selection at the time that dialysis is needed. Aim of Study: Nephrologist physicians teaching about dialysis modalities in the pre-dialysis clinic influence the choice of home dialysis modality especially peritoneal dialysis. Patients and Methods: Retrospective observational study that focuses on the first modality of dialysis choice and the influence of nephrologist physician teaching in these choices. Observation for follow up patients in the pre-dialysis clinic started from March 6-2018 to March 19-2019. The teaching about access was responsible by the nephrologist physician, education about access started on the second clinic visit with encouraging and discussion each visit after, till the patient started on dialysis. After applying inclusion criteria, a total number of patients follow-up for over two visits with stage III B to V were 104 patients. Results: A total of 24 out of 34 patients after teaching about access by nephrologist physician choose peritoneal dialysis. Most of them were male patients and younger than 45y old. Both of CKD stage IV and V showed more interesting in peritoneal dialysis. 15 of them were a candidate for perito-neal catheter insertion after assessment by interventional team and they have catheter insertion. Ten patients have chosen hemodialysis as a first choice modality but 19 patients end up on conventional hemodialysis in the center. Conclusion: Nephrologist physicians could influence the choice of home dialysis modality especially peritoneal dialysis. Further studies will require to assess this concept.

Impact of Arteriovenous fistula creation on estimated glomerular filtration rate decline in Predialysis patients

BackgroundArteriovenous fistula (AVF) is the vascular access of choice for patients on hemodialysis. Recent evidence suggests that AVF creation may slow estimated glomerular filtration rate (eGFR) decline. The study objective was to assess the impact of the AVF creation on eGFR decline, after controlling for key confounding factors.MethodsThis retrospective cohort study included adult patients followed in a single-center predialysis clinic between 1999 and 2016. Patients with a patent AVF were followed up to 2 years pre- and post-AVF creation. Estimated GFR trajectory was reported using linear mixed models adjusted for demographic characteristics, comorbidities and use of renin-angiotensin-aldosterone blockade.ResultsA total of 146 patients were studied with a median age 68.7 (60.5–75.4) years and a median eGFR at time of AVF creation of 12.8 (11.3–13.9) mL/min/1.73m2. The crude annual eGFR decline rates were − 3.60 ± 4.00 mL/min/1.73 m2 pre- and − 2.28 ± 3.56 mL/min/1.73 m2 post-AVF, resulting in a mean difference of 1.28 mL/min/1.73 m2 (95% CI 0.49, 2.07). In a mixed effect linear regression model, monthly eGFR decline was − 0.63 (95% CI -0.81, − 0.46; p < 0.001) mL/min/1.73m2/month. The period after AVF creation was associated with a relatively higher eGFR (β 0.94, 95% CI 0.61–1.26, p < 0.001). There was a significant association between follow-up time and the period pre/post AVF (β 0.19, 95% CI 0.16, 0.22; p < 0.001) such that eGFR decline was more attenuated each month after AVF creation.ConclusionsIn this cohort, AVF creation was associated with a significant reduction of eGFR decline. Further prospective studies are needed to confirm this association.

The association between dietetic consultation and time to dialysis for patients attending a pre‐dialysis clinic: A retrospective cohort study

A multidisciplinary approach, including dietetics, is considered the optimal model of care for dialysis preparation. Dietetic consultation (DC) focuses on symptom management and dietary changes to delay time to dialysis. Evidence of the effectiveness of DC on time to dialysis is limited. This study aimed to investigate the impact of DC on time to dialysis for patients attending a pre-dialysis clinic. A retrospective cohort study was designed to include all patients attending outpatient pre-dialysis clinics at a large metropolitan renal service between January 2014 and March 2018. Time to dialysis (days) was compared between patients that received DC and those who did not. Cox proportional hazards analysis allowing for adjustment of differences and confounders was undertaken. A cohort of 246 patients was identified. Median estimated glomerular filtration rate was 16mL/min per 1.73 m2 (interquartile range = 13-20) at initial pre-dialysis clinic visit and 63% commenced dialysis during the study period. Only 41% of patients received dietetic consultation. Significantly fewer patients needed to commence dialysis in the DC group compared to the no-DC group (hazards ratio 0.63; 95% confidence interval (CI) 0.45-0.89; P = 0.008 Cox proportion hazard). The DC group commenced dialysis significantly later than the no-DC group; 933 days (95% CI 832-1034) versus 710 days (95% CI 630-790) respectively, after the initial pre-dialysis clinic visit; log-rank 0.005. DC provided to patients attending a pre-dialysis clinic was associated with a delayed time to dialysis. Standardised referral pathways to improve patient access to renal dietetic services are recommended to optimise care.

SUN-227 THE IMPACT OF DIETETIC INTERVENTION ON TIME TO DIALYSIS IN PATIENTS ATTENDING A PRE-DIALYSIS CLINIC: AN OBSERVATIONAL COHORT STUDY

Nutrition therapy is a key component of chronic kidney disease (CKD) treatment. A multidisciplinary approach, including dietetics, is considered as the optimal model of care for dialysis preparation. Dietetic interventions (DI) focus on symptom management and dietary changes to delay dialysis. Delaying dialysis is a significant motivator for patients to implement dietary changes. Evidence of the effectiveness of DI on delaying dialysis is limited. This study aimed to investigate the impact of DI on time to dialysis for patients attending a pre-dialysis clinic.

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature.

Background:Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD).Objective:To determine common definitions and patient risk factors for unplanned dialysis.Design:Systematic review.Setting:MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018.Patients:Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included.Measurements:Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis.Methods:Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale.Results:From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3).Limitations:Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking.Conclusions:Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.

Outcomes in dialysis versus conservative care for older patients: A prospective cohort analysis of stage 5 Chronic Kidney Disease.

BackgroundThe benefits of dialysis in older people with ESKD are not clear. We prospectively evaluated whether dialysis has survival advantage compared to conservative care (CC) in older people who were medically suitable for dialysis therapy.MethodsThis was a prospective observational study of CKD patients aged ≥75 years when eGFR first reached ≤15ml/min/1.73m2. Hazard ratios (HR) for death were compared between patients who chose dialysis versus conservative care (CC) from when first seen in pre-dialysis clinic (eGFR ≤15ml/min/1.73m2), and when initiation of dialysis was first considered (eGFR ≤10ml/min/1.73m2). Patients with co-morbidities likely to significantly reduce life expectancy such as advanced heart failure, advanced dementia, and malignancy, were excluded.ResultsThere were 204 patients (123 dialysis, 81 CC). 115 went on to record eGFR of ≤10ml/min/1.73m2 (73 dialysis, 42 CC). The median survival from eGFR first ≤15ml/min/1.73m2 for the dialysis and CC groups were 42 (33–50) months and 31 (21–41) months. The adjusted hazard ratio (HR) for death in the dialysis group compared to CC was 0.61 (0.41–0.61, p = 0.01). The median survival from eGFR first ≤10ml/min/1.73m2 for dialysis and CC group were 36 (25–47) months and 12 (0–5) months. The adjusted HR for death in the dialysis group compared to CC was 0.36 (0.21–0.62, p <0.001).ConclusionDialysis confers a survival benefit in older patients medically suitable for dialysis. This study is novel in being both prospective and in excluding patients with co-morbidities which may limit suitability for dialysis and life expectancy. A future focus on quality of life is needed to establish the true benefits of dialysis in older people.