#5815 INTERNATIONAL VARIATIONS IN TRANSITION OF CARE PRACTICES AND TWO-YEAR OUTCOMES IN ADVANCED CHRONIC KIDNEY DISEASE
Authors: Guedes Murilo , de Pinho Natalia Alencar , Bieber Brian , Boucquemont Julie , Perlman Rachel , Sesso Ricardo , Reichel Helmut , Combe Christian , Stengel Benedicte , Pecoits-Filho Roberto 
Published: June 2023

Abstract

Background and Aims
The transition to kidney failure is the period of the highest risk for adverse outcomes in chronic kidney disease (CKD). A smooth and timely transition of care, assuring informed and patient-centric decision-making, is paramount to fostering better kidney care. We described the two-year incidence of clinical outcomes and nephrology practices among advanced CKD patients in CKDopps.

Method
CKDopps is a prospective cohort study designed to describe and evaluate variations in CKD practices and outcomes in nephrologist-led CKD clinics. For this analysis, we included CKDopps participants who reached a three-month average estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73 m2 in the US, France, and Brazil. Time at risk for outcomes started at the end of the first three-month window in which the average eGFR was lower than 20 mL/min/1.73 m2 during study follow-up. Education was defined as participation in at least one educational session about KRT modalities. They were considered to have been referred to vascular access (VA) creation if reported in medical records. Education or VA referral happening before the start of follow-up were classified as occurring at baseline. Patients were considered waitlisted if they had been registered on a pre-emptive kidney transplant waiting list. Cumulative incidence functions adjusting for the competing risk of mortality or KRT were used to estimate the 2-year probability of clinical outcomes and planning events.

Results
2,645 patients were included – 51% from France, 36% from the US, and 14% from Brazil. Overall, 56% of patients were male, the mean age was 66 ± 14 years, approximately 50% had diabetes, 27% had coronary artery disease, and 16% had heart failure. Patients in Brazil tended to be younger (63 years) than those in France (67) and the US (67); patients in the US had the greatest burden of cardiovascular comorbidities. The mean eGFR at the study baseline was 16.6 mL/min/1.73m² (15.4 in Brazil, 15.9 in the US, and 17.3 in France). Over a median follow-up of 15.7 [7.2–24] months, 1140 patients (43.1%) started KRT, whereas 377 (14.3%) died before KRT. The 2-year cumulative incidence of KRT was 32% in Brazil, 33% in France, and 44% in the US (Figure 1). The median eGFR at KRT initiation was 11.7 in Brazil, 9.0 in France, and 10.3 in the US. Pre-KRT death risk in two years was 7.3% in Brazil, 10.9% in France, and 16.4% in the US. In two years, approximately one-third of patients had a VA created across countries (Table 1). The probability of transplant waitlisting was higher in France and the US, while patient-reported KRT education was more common in Brazil (Table 1).

Conclusion
In this international analysis of advanced CKD patients, we found important variations in nephrology practice and outcomes across countries. Patients in the US have a higher risk of both pre-KRT death and KRT. Patient-reported education was far more common in Brazil than in the US and France. Although patients in Brazil are referred for VA creation earlier in the course of advanced CKD, 2-year cumulative incidences for such are similar across countries. The 2-year probability of pre-emptive kidney transplant listing was higher in France and the US. Further international studies evaluating risk factors for adverse outcomes and barriers to KRT planning among advanced CKD patients are warranted.