MO530IS THERE A ROLE FOR SCALES IN RENAL REPLACEMENT THERAPY DECISION MAKING PROCESS?
Authors: De Cos Gomez Marina , Palomar Fontanet Maria Rosa , Toledo Martinez Enrique , Kislikova Maria , Mazon Ruiz Jaime , Serrano Soto Mara , Piñera Haces Vicente Celestino , Rodrigo Emilio , Salas Venero Carlos Antonio , Ruiz San Millán Juan Carlos 
Published: May 2021

Abstract

Background and Aims
Optimal care of patients with advanced CKD is key for reducing their morbidity and mortality. An accurate evaluation of these patients is necessary to improve their treatment and prepare them for renal replacement therapy (RRT) when appropriate. Beyond laboratory values, an integral evaluation of this group is essential, and it must cover a number of aspects, including physical, psychical, functional and social among others. The aim of this study is to evaluate the performance of a group status scales regarding these areas in our advanced CKD Unit and its potential utility in the eligibility decision making process.

Method
We performed a retrospective study including patients evaluated in our clinic from 1st January 2019 to December 31th 2020. According to protocol, referrals to our unit occurred when patients presented eGFR (CKD-EPI) &lt; 25 ml/min (after confirmation in two consecutive measurements). Scales and initiation of RRT election process were performed when eGFR (CKD-EPI) was below 20 ml/min. 8 scales were performed to evaluate anxiety and depression, cognitive impairment, instrumental activities decline, frailty, malnutrition, social status, comorbidity and self-report situation. Scales were conducted separately (in an interview with one of the advanced CKD nurses) and did not influence nephrologist eligibility decision. Information about patients was extracted from the prospectively maintained database at our center.

Results
During the period of study 699 patients were evaluated. Clinical characteristics and RRT eligibility results are shown in Table 1. Scales results in RRT candidates and conservative treatment candidates are shown in Table 2. 128 patients had subsequent scales after 1 year follow up; paired comparison showed higher rates of instrumental activities decline (18% vs. 25%, p 0.002), greater comorbidity (7.21 vs. 8.52, p &lt; 0.001) and worse self-report subjective assessment (63.41 vs. 67.05, p &lt; 0.0019). There were not statistically significant differences in the other scale parameters analyzed. During the period of observation, 12.1% patients died. Multivariate cox regression analysis evaluating risk of death including scales (after adjustment by age) showed a significant relation between and malnutrition (HR 7.98 CI95% (2.24-18.47), p = 0.001) and comorbidity (HR 1.29 CI95% (1.05-1.60) p = 0.017).

Conclusion
Advanced CKD is rising worldwide and represents an important burden for patients and nephrology services. Evaluation of this group remains particularly challenging, and in order to guarantee its adequate management, an integral and reproducible evaluation of these patients has to be ensured. This is especially important with regard to patients’ eligibility and RRT decision making process. According to our study, clinical scales are useful for this purpose and eligibility results (after conventional nephrologist follow-up) were associated with scale results. The parameters that particularly correlated with eligibility and specifically, renal replacement therapy contraindication, were mostly instrumental (cognitive impairment, functional activities decline, frailty and social deterioration). Additionally, repeated assessment could be helpful to highlight which aspects are deteriorating faster and find strategies to minimize them. In accordance to literature, mortality in our cohort was higher in patients with malnutrition and comorbidity, showing the importance of a systematic evaluation of these items in the management of advanced CKD. Altogether, these scales could be used to better stratify patient’s risk prior RRT decision making process and help clinicians to make more reproducible and consistent decisions. Large-scale, multicenter validation studies could be the next step to prove their utility among advanced CKD patients.