Optimizing Kidney Replacement Therapy Preparation Using Kidney Failure Risk Equation (KFRE) and eGFR Fall Rate: A Single-Centre, Risk-Based Approach for Effective Care Planning

Background: The Kidney Failure Risk Equation (KFRE) is a validated prognostic tool that estimates the 2- and 5-year risk of progression to kidney failure in patients with chronic kidney disease (CKD). Although it has strong predictive performance, the use of KFRE in clinical practice for guiding dialysis preparation, such as determining the timing of access placement, remains limited. A deficiency, in this setting, is the absence of eGFR fall rate in the preceding year. Methods: We conducted a single-centre retrospective observational study of patients with advanced CKD in all patients having 2 consecutive eGFR of <20 ml/min/1.73m2 between Jan 2007 and April 2023. Those with AKI with clear reversibility were excluded. KFRE 2-year risk scores were calculated using the 4-variable model, recalibrated for the UK population. Patients were stratified into three risk categories: KFRE; eGFR fall rate in preceding year; and primary renal diagnosis. Results: Of the 1913 eligible patients 1586 (82.9%) were in the pre-RRT group and 327 (17.1%) were in the conservative management (CM) group. Of the pre-RRT group, 1000 (63.1%) started RRT. Of the CM group 102 (31.2%) reached the endpoint of eGFR 8, and 179 (54.7%) died before reaching the endpoint. Using binary logistic regression, KFRE, rate of eGFR fall and age were strong predictors of ESRF in 2 years. uACR was a predictor if KFRE is not used. Interstitial nephritis and obstructive uropathy were predictors of slow decline in a univariate but not multivariate models. Conclusion: KFRE is an effective tool for stratifying risk and informing dialysis preparation, but can be improved by the addition of rate of eGFR fall. Whilst CM is an important treatment choice, at least some patients were disadvantaged by having these discussions when there was low likelihood of progression to ESRF.