Role of Patient Capacity in CKD Trajectories

Background: The Advancing American Kidney Health initiative set a 2025 goal that ≥80 % of patients start home dialysis or receive a pre-emptive transplant, yet only 14 % achieved this in 2018. These modalities demand substantial “treatment work.” According to the Theory of Patient Capacity (TPC), success depends on adequate biopsychosocial resources; when workload exceeds capacity, burden and adverse outcomes rise. Although workload-related burden is documented in ESKD, whether baseline capacity forecasts CKD progression or influences renal replacement modality is unknown. We tested whether single timepoint capacity predicts 6-month CKD stage progression or associates with dialysis modality in adults with CKD stages 3 through 5. Methods: In this prospective cohort, adults with CKD stages 3a–5 completed baseline TPC-aligned surveys across five domains: Biography, Resources, Environment, Work, and Social Support. Demographics, labs, vascular access, transplant status, and RRT modality (if applicable) were abstracted. Outcomes were CKD stage progression and RRT modality (in-center vs. independent: home dialysis or transplant). Logistic regression assessed associations between capacity scores and CKD progression; equal variance two sample t-test compared capacity by modality. Results: Among 330 participants (mean age 69.9, 56% male, median eGFR 22), 253 (76%) returned complete surveys. At six months, 12 (5.8%) progressed in CKD stage and 8 (2.4%) initiated RRT. Of 85 on RRT, 55 were in-center and 30 independent. Independent RRT was associated with better scores in four domains: Biography [SF-36 Emotional Well-being 4.4 (0.69) vs. 4.0 (0.55), p = .035], Resources [PROMIS Pain Interference 50.0 (9.08) vs. 56.6 (8.92), p = .006], Environment [PACIC 3.8 (0.82) vs. 3.4 (0.86), p = .012], and Work [Chronic Disease Self-Efficacy 7.9 (1.55) vs. 6.5 (2.26), p = .012]. No capacity domain was significantly associated with CKD progression. Conclusion: While baseline capacity did not predict 6-month CKD progression, patients on independent RRT modalities had greater capacity in 4 of 5 domains. These constructs are modifiable and may represent targets for intervention. Follow-up will continue through 2 years to assess longer-term associations. Funding: NIDDK Support