#2818 Clinical outcomes of a pre-dialysis cohort in a tertiary renal centre in the United Kingdom
Authors: O'keeffe Hannah , Donne Rosemary , Kalra Philip A , Ali Ibrahim 
Published: May 2024

Abstract

Background and Aims
Patients with advanced chronic kidney disease (CKD) require significant resources in order to manage the complications of CKD, and provide education and planning for renal replacement therapy (RRT). To better gauge the clinical trajectory of these patients, we aimed to provide a descriptive overview of patients who attended the multidisciplinary Advanced Kidney Care Service (AKCS) clinic over 8 years in a tertiary renal referral centre in the United Kingdom. Patients are typically referred to this clinic once their estimated glomerular filtration rate (eGFR) drops below 20 ml/min/1.73 m2.

Method
This was a retrospective study of consecutive patients who first attended the AKCS clinic in our centre between September 2011 and September 2018, and last follow-up was the end of September 2023. Patients with a prior renal transplant, those with acute kidney injury with subsequent recovery of renal function, and those lost to follow-up were excluded. Patient details and outcomes were extracted from the hospital Electronic Patient Record including demographics, decisions regarding active or conservative management, timing of RRT initiation, first modality of RRT, transplantation, and mortality. The primary outcomes of interest included time to RRT, first modality of RRT, and death.

Results
A total of 1 957 patients were included. Of these 1,136 (58%) were male and 821 (42%) female. Median age was 69 years at the time of first AKCS review. A large proportion (80%) identified as white British, 13% as Asian or Asian British, 2% as Black or Black British, and the remaining as other ethnicities. Median eGFR was 16 ml/min/1.73 m2 (IQR 4-25 ml/min/1.73 m2) at first AKCS clinic.
A total of 1 087 patients (56%) initiated RRT during follow-up. The first modality was haemodialysis in 622 (57%), peritoneal dialysis in 298 (27%), and a renal transplant in 167 patients (15%). Median time to RRT commencement was 12.2 months (IQR 6.4-30). A further 240 patients received a transplant after dialysis. Of the 870 patients who did not initiate RRT, 350 (40%) were documented as opting for conservative management.
756 (38.6%) patients died either before RRT initiation (434) or on the conservative care pathway (322). A further 583 (29.8%) who commenced RRT died during follow up. Median time to death from first AKCS review was 38.5 months in the active management group (21.8 months in those who died without RRT and 51.0 months in those on RRT) compared to a median of 29.7 months in the conservative group.

Conclusion
This study presents a descriptive analysis of long-term outcomes in a high-risk group of patients. Two-thirds of patients died within 5 years of their first AKCS review, demonstrating the high mortality burden in this population. Of those who died prior to RRT, 57.4% had opted for RRT or were undecided, highlighting the substantial competing risk of death prior to reaching end stage kidney disease.
We are planning further work with this dataset including risk prediction modelling. The ability to risk-stratify and profile patients, including consideration of co-morbidities and clinical frailty score, would be beneficial for patients and healthcare providers when making decisions regarding RRT and conservative care.