Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.

Background:Multidisciplinary care is recommended for patients with advanced chronic kidney disease (CKD). A formalized, risk-based approach to CKD management is being adopted in some jurisdictions. In Ontario, Canada, the eligibility criteria for multidisciplinary CKD care funding were revised between 2016 and 2018 to a 2 year risk of kidney replacement therapy (KRT) greater than 10% calculated by the 4-variable Kidney Failure Risk Equation (KFRE). Implementation of the risk-based approach has led to the discharge of prevalent CKD patients.Objective:The primary objective of this study was to determine the frequency of occurrence of death and KRT initiation in patients discharged from CKD clinic.Design:Retrospective cohort studySetting:Single center multidisciplinary CKD clinic in Ontario, CanadaPatients:Four hundred and twenty five patients seen at least once in 2013 at the multidisciplinary CKD clinicMeasurements:Outcomes included discharge status, death, re-referral and KRT initiation. Reasons for discharge were recorded.Methods:Outcomes were extracted from available electronic medical records and the provincial death registry between the patient’s initial clinic visit in 2013 and January 1, 2020. KFRE-2 scores were calculated using the 4-variable KFRE equation. The hazard rates of death and KRT after discharge due to stable eGFR/low KFRE were compared to patients who remained in the clinic.Results:Of the 425 CKD patients, 69 (16%) and 19 (4%) were discharged to primary care and general nephrology, respectively. Of those discharged, 7 (8%) were re-referred to nephrology or CKD clinic, while only 2 (2%) discharged patients required subsequent KRT. The hazard of mortality was reduced after discharge from the clinic due to stable eGFR/low KFRE (adjusted HR = 0.45 [95% CI, 0.25-0.78, P = .005]).Limitations:Single center, observational retrospective study design and unknown kidney function over time post discharge for most patientsConclusions:Discharge of low risk patients from multidisciplinary CKD clinic appears feasible and safe, with fewer than 1 in 40 discharged patients subsequently initiated on KRT over the following 7 years.

Purpose of reviewTo summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.Sources of informationThe panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).FindingsThe objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.LimitationsThe perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.ImplicationsKnowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

BACKGROUND AND AIMS Nephrologists follow patients with chronic kidney disease (CKD) stage G3 and G4 as a homogeneous group with the assumption that everyone had similar rates of progression with scheduled visits and lab investigations based on the stage of the disease. We now recognize that not all patients progress at similar rates to kidney failure and treatment and follow-up needs vary. The Kidney Failure Risk Equation (KFRE) identifies patients at different risks of progression to kidney failure (low, medium and high risk) in each stage of the disease. Previous studies had looked at resource utilization of patients based on the stage of the CKD. The purpose of our analysis was to examine resource utilization and associated costs based on the risk of progression by KFRE in the setting of a universal healthcare system. METHOD We conducted a retrospective cohort study of adults with CKD G3 and G4 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data was collected from January 2004 through December 2012 and patients were followed for 5 years. The predicted risk of kidney failure for each patient was calculated using the 8-variable KFRE. The equation used clinical and routine laboratory data, to stratify patients into three risk categories (low, medium and high risk) of progression. We compared the number and cost of hospital admissions, physician visits and prescription drugs by risk within G3 and G4. Negative binomial regression and generalized linear model were used to compare healthcare utilization and cost between the groups respectively (α = 0.05). RESULTS A total of 1003 adults with CKD G3 and G4 were included in the study. In patients with stage G3 CKD, 311 (59%), 150 (28%) and 68 (13%) were in low, medium and high-risk categories, respectively. Amongst patients with CKD stage G4, 275 (58%), 86 (18%) and 113 (24%) were in similar categories respectively. The cost of hospital admissions, physician visits and drug dispensations in stage G4 high risk in comparison to low risk over the 5-year study period was CAD $89 265 versus $48 374 (P = .008), $23 423 versus $11 231 (P < .001) and $21 853 versus $16 757 (P = .01), respectively. In stage G3, the cost of hospital admissions was CAD $55 944 versus $36 740 (P = 0.10), physician visits $13 414 versus $10 370 (P = .08) and prescription drugs $20 394 versus $14 902 (P = .02) in high-risk patients in comparison to low-risk patients (Figure 1). CONCLUSION In patients followed in multidisciplinary clinics with CKD stages G3 and G4, the cost of hospital admissions, physician visits and prescription drugs were higher in high-risk patients compared to patients in low-risk category. In our study, the KFRE, designed to predict the risk of progression to dialysis in patients with CKD, also assisted in identifying patients with higher health resource utilization and healthcare costs compared to those with lower health resource use. We additionally suggest that patients who are in medium and high-risk categories be followed in multidisciplinary clinics rather than individual physician offices to delay the trajectory of decline to kidney failure.

Chronic kidney disease is recognized as being highly prevalent in the population, and associated with morbidity and mortality relative to the general population. The complexity of patients and the multiplicity of interventions required to maintain health has forced clinicians to develop different models of healthcare delivery. This publication reviews the current literature on specific interventions to reduce progression of chronic kidney disease and cardiovascular disease, and studies the examination of outcomes of patients exposed to different healthcare delivery models. Specifically we examine the rationale and outcomes of those seen in multidisciplinary clinics. Current evidence supports the use of rennin-angiotensin system blockers, reduction of blood pressure and proteinuria and phosphate control. Additional less robust studies support the need for attention to anemia, hyperparathryoidism, and other more "kidney specific" risk factors. The attendance of identified chronic kidney disease patients at multidisciplinary clinics appears to improve survival once dialysis is started. Despite aggressive management, not all patients are able to meet clinical targets associated with improved outcomes. The recognition of the complexity of chronic kidney disease care and the need to develop and test models of care in addition to the single interventions is a challenge for both researchers and clinicians. Current data support the use of multidisciplinary clinics in improving outcomes of referred patients. Future research will help to refine and define appropriate care models for this growing chronic kidney disease population.

Risk-Based Triage for Nephrology Referrals: The Time is Now

Accuracy of Kidney Failure Risk Equation in Transplant Recipients

Background: Adequate pre-dialysis education was found to help patients select the best modality at the time dialysis is needed. Objectives: To identify the barriers to pre-dialysis education in the nephrology clinics among end-stage renal disease (ESRD) in the Kingdom of Saudi Arabia (KSA). Methods: We did a multi-center, cross-sectional study on 221 patients. A questionnaire was used to collect data about patients’ demographics, the primary cause of renal failure, and barriers to pre-dialysis education in the nephrology clinic. We selected the healthcare providers randomly from the same centers. Results: The leading cause of renal failure was diabetes mellitus (DM) in 24.9% of the Patient participants. About 64.7% were with hemodialysis, and 35.3% had peritoneal dialysis. The distance to the nephrology clinic is more than 50 km, about 63.7%. About 65.2% have followed up in the CKD clinic, and dietitians have seen 64.3% in the clinic. Dialysis educators.s have previously seen 59.7%. About 68.8% of the participants had the chance to understand dialysis modality before the commencement of treatment. The barriers from healthcare participants point out are 43.5 % of participants have no CKD clinic, 74% are without a multidisciplinary team, 61% evaluate more than 15 patients every clinic, and 43.5% assess patients with advanced chronic kidney disease every three months or more. 47.8% found many services in their hospital required to refer patients to another hospital because lack of nephrologists per 74% of participants, and 39% of them indicated no peritoneal dialysis unit. And 47.8% found no sociopsychology services play a role as a barrier. Conclusion: The barriers to pre-dialysis education studied in this paper from patients and healthcare providers points. That included the deficiency of a formal structured multidisciplinary chronic kidney disease clinic, lack of psychosocial support for CKD patients, and patients required to travel between hospitals more than 50 kilometers to get renal services. Key words: barriers, pre-dialysis, education, hemodialysis, ESRD, Saudi Arabia.

Background: Patients with chronic kidney disease are at an increased risk of cardiovascular disease and the associated morbidity and mortality. This patient population is also associated with a substantial cost to the healthcare system with traditional hospital-based care management. The objective of this study is to investigate the cost effectiveness of providing community-based multidisciplinary clinic (MDC) care to this patient population. The goal was to evaluate whether the new model of care is associated with improved patient compliance with medical appointments, and can be delivered effectively within the community in a patient-centred fashion. Design: In this retrospective analysis, participants in this study included patients started within the local regional program who needed dialysis chronically or until death and were followed for at least 3 months prior to dialysis. Comparison was made between those patients attending a hospital based clinic vs. a community based clinic with respect to optimal and suboptimal start rates, use of internet based educational resources was tracked, potassium, haemoglobin, calcium, phosphorus, PTH levels pre dialysis and patient attendance rates were measured as well. Results: The results attained from performing this 15-month retrospective analysis showed that this community based model of care yielded similar results with respect to optimal vs. suboptimal start rates, laboratory parameters at initiation of dialysis, and may have been associated with increased rates of attendance to visits. Conclusions: Our findings show that multidisciplinary care for advanced chronic kidney disease patients can be effectively delivered in a community-based model. This is likely to have significant cost benefits as well as increasing access to care for patients in rural communities or those who prefer to receive their care in a community setting.

Risk-based thresholds for arteriovenous (AV) access creation has been proposed to aid vascular access planning. We aimed to assess the clinical impact of implementing the Kidney Failure Risk Equation (KFRE) for vascular access referral. A total of 16102 nephrology-referred chronic kidney disease (CKD) patients from the Swedish Renal Registry 2008-18 were included. The KFRE was calculated repeatedly, and the timing was identified for when the KFRE risk exceeded several pre-defined thresholds and/or the estimated glomerular filtration rate was <15mL/min/1.73 m2 (eGFR15). To assess the utility of the KFRE/eGFR thresholds, cumulative incidence curves of kidney replacement therapy (KRT) or death, and decision-curve analyses were computed at 6 and 12months, and 2years. The potential impact of using the different thresholds was illustrated by an example from the Swedish access registry. The 12-month specificity for KRT initiation was highest for KFRE >50% {94.5 [95% confidence interval (CI) 94.3-94.7]} followed by KFRE >40% [90.0 (95% CI 89.7-90.3)], while sensitivity was highest for KFRE >30% [79.3 (95% CI 78.2-80.3)] and eGFR <15mL/min/1.73 m2 [81.2 (95% CI 80.2-82.2)]. The 2-year positive predictive value was 71.5 (95% CI 70.2-72.8), 61.7 (95% CI 60.4-63.0) and 47.2 (95% CI 46.1-48.3) for KFRE >50%, KFRE >40% and eGFR <15, respectively. Decision curve analyses suggested the largest net benefit for KFRE >40% over 2years and KFRE >50% over 12months when it is important to avoid the harm of possibly unnecessary surgery. In Sweden, 54% of nephrology-referred patients started hemodialysis in a central venous catheter (CVC), of whom only 5% had AV access surgery >6months before initiation. Sixty percent of the CVC patients exceeded KFRE >40% a median of 0.8years (interquartile range 0.4-1.5) before KRT initiation. The utility of using KFRE >40% and KFRE >50% is higher compared with the more traditionally used eGFR threshold <15mL/min/1.73 m2 for vascular access planning.

Background/Aim: Renal transplant recipients (RTR) and patients with native chronic kidney disease (CKD) have similar complications. It is not known how the management of CKD in RTR differs from that of patients with native CKD. This study compares the management of complications related to CKD between RTR and patients with native CKD. Methods: Cross-sectional study of all RTR with stage 4 or 5 CKD (n = 72). The control group consisted of 72 native CKD patients matched by glomerular filtration rate (within 2 ml/min/1.73 m²). Multivariate logistic regression analysis was performed to account for potential confounding variables. Results: Multivariate analysis revealed RTR to more likely have uncontrolled hypertension (adjusted odds ratio AOR 3.8; 95% confidence interval CI 1.3–10.7), less likely to be on angiotensin-converting enzyme inhibitors (AOR 0.11; 95% CI 0.04–0.32), more likely to be anemic and not be on erythropoietin (AOR 6.4; 95% CI 0.99–41.9), and more likely to have dyslipidemia and not be on statin (AOR 4.3; 95% CI 1.4–13.4). Conclusions: This study suggests that the management of non-RTR in a multidisciplinary CKD clinic differs significantly from the CKD management in a traditional transplant clinic. A disease management approach like a multidisciplinary clinic may be an appropriate model for the future.

Background:A risk-based model of care for managing patients with chronic kidney disease (CKD) using the Kidney Failure Risk Equation (KFRE) has been successfully integrated into nephrology care pathways in several jurisdictions. However, as most patients with CKD can be managed in primary care, the next pertinent steps would be to integrate the KFRE into primary care pathways.Objective:Using a risk-based approach for guiding CKD care in the primary care setting, the objective of the study is to develop, implement, and evaluate tools that can be used by patients and providers.Design:This study is a multicenter cluster randomized control trial.Setting:Thirty-two primary care clinics belonging to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) across Manitoba and Alberta.Patients:All patients at least 18 years old or older with CKD categories G3-G5 attending the participating clinics; we estimate each clinic will have an average of 185 patients with CKD.Methods:Thirty-two primary care clinics will be randomized to receive either an active knowledge translation intervention or no intervention. The intervention involves the addition of the KFRE and decision aids to clinics’ Data Presentation Tool (DPT), as well as patient-facing visual aids, a medical detailing visit, and sentinel feedback reports. Control clinics will only be exposed to current guidelines for CKD management, without active dissemination.Measurements:Data from the CPCSSN repository will be used to assess whether a risk-based care approach affected management of CKD. Primary outcomes are as follows: the proportion of patients with measured urine albumin-to-creatinine ratio, and the proportion of patients being appropriately treated with angiotensin-converting enzyme inhibitor or angiotensin receptor blockers. Secondary outcomes are as follows: the optimal management of diabetes (hemoglobin A1C <8.5%, and the use of sodium-glucose cotransporter-2 inhibitors in CKD G3 patients), hypertension (office blood pressure <130/80 for patients with diabetes, 140/90 for those without), and cardiovascular risk (statin prescription); prescriptions of nonsteroidal anti-inflammatory drugs; and decline in estimated glomerular filtration rate (eGFR). In addition, in a substudy, we will measure CKD-specific health literacy and trust in physician care via surveys administered in the clinic post-visit. At the provider level, we will measure satisfaction with the risk prediction tools. Lastly, at the health system level, outcomes include cost of CKD care, and appropriate referrals for patients at high risk of kidney failure based on provincial guidelines. Primary and secondary outcomes will be measured at the patient level and enumerated at the clinic level 1 year after the intervention implementation, except for decline in eGFR, which will be measured 2 years postintervention.Limitations:Limitations include scalability of the proposal in other health care systems.Conclusions:If successful, this intervention has the potential to improve the management of patients with CKD within Canadian primary care settings, leading to health and economic benefits, and influencing practice guidelines.Trial Registration:ClinicalTrials.gov identifier: NCT03365063

BackgroundPatients with chronic kidney disease (CKD) are at high risk of end-stage kidney disease (ESKD). The Kidney Failure Risk Equation (KFRE), which predicts ESKD risk among patients with CKD, has not been validated in primary care clinics in Southeast Asia (SEA). Therefore, we aimed to (1) evaluate the performance of existing KFRE equations, (2) recalibrate KFRE for better predictive precision, and (3) identify optimally feasible KFRE thresholds for nephrologist referral and dialysis planning in SEA.MethodsAll patients with CKD visiting nine primary care clinics from 2010 to 2013 in Singapore were included and applied 4-variable KFRE equations incorporating age, sex, estimated glomerular filtration rate (eGFR), and albumin-to-creatinine ratio (ACR). ESKD onset within two and five years were acquired via linkage to the Singapore Renal Registry. A weighted Brier score (the squared difference between observed vs predicted ESKD risks), bias (the median difference between observed vs predicted ESKD risks) and precision (the interquartile range of the bias) were used to select the best-calibrated KFRE equation.ResultsThe recalibrated KFRE (named Recalibrated Pooled KFRE SEA) performed better than existing and other recalibrated KFRE equations in terms of having a smaller Brier score (square root: 2.8% vs. 4.0–9.3% at 5 years; 2.0% vs. 6.1–9.1% at 2 years), less bias (2.5% vs. 3.3–5.2% at 5 years; 1.8% vs. 3.2–3.6% at 2 years), and improved precision (0.5% vs. 1.7–5.2% at 5 years; 0.5% vs. 3.8–4.2% at 2 years). Area under ROC curve for the Recalibrated Pooled KFRE SEA equations were 0.94 (95% confidence interval [CI]: 0.93 to 0.95) at 5 years and 0.96 (95% CI: 0.95 to 0.97) at 2 years. The optimally feasible KFRE thresholds were > 10–16% for 5-year nephrologist referral and > 45% for 2-year dialysis planning. Using the Recalibrated Pooled KFRE SEA, an estimated 82 and 89% ESKD events were included among 10% of subjects at highest estimated risk of ESKD at 5-year and 2-year, respectively.ConclusionsThe Recalibrated Pooled KFRE SEA performs better than existing KFREs and warrants implementation in primary care settings in SEA.

Background: The chronic kidney disease (CKD) clinic plays a vital role in providing comprehensive ambulatory care for patients with CKD. Pharmacists contribute to ensuring proper drug use and identifying potential drug-related problems (DRPs). However, the evaluation of DRPs in the early phase of CKD clinic, particularly in resource-limited countries, remains limited. Objective: This study aimed to assess the prevalence of DRPs in CKD patients attending a CKD clinic, investigate the associated drug categories, and identify factors contributing to DRPs in CKD patients. Methods: A cross-sectional study was conducted from January 2020 to June 2021 among CKD patients attending a CKD clinic. Patient information records were used to collect demographic and relevant CKD data. A checklist for DRPs related to CKD progression and complications was utilized. Eight categories of unmet DRPs were examined. Multiple linear regression was used to investigate the relationship between pre-defined factors and the number of DRPs per patients. Results: The study included 80 patients with a total of 1,073 prescribed medications. The mean age was 73.1 ± 10.0 years, and the mean estimated glomerular filtration rate (eGFR) was 43.4± 12.9 mL/min/1.73 m². A total of 269 DRPs (25.1% of prescriptions) were identified, primarily involving the need for additional drug therapy (14.9%), dosage too high (6.3%), and inappropriate drug therapy (1.5%). Notably, renin-angiotensin-aldosterone system (RAAS) blockers were frequently omitted when indicated. NSAID use, non-compliance, and drug interactions were notable issues. The significant predictor of DRPs was the number of medications more than 7 items (ß = 0.258, P = 0.02). Conclusions: Implementing medication optimization in CKD care involving multidisciplinary teams and pharmacists is essential. Our study highlights the importance of ACEIs/ARBs, dosage adjustments, avoiding nephrotoxic agents, addressing non-compliance, and managing drug interactions for improved CKD care. The study identifies polypharmacy as a significant predictor of DRPs among CKD patients, facilitating targeted interventions for at-risk patients.

Introduction: Chronic kidney disease (CKD) and ischemic stroke are both associated with significant global disease burdens and share common risk factors. Understanding the impact of CKD on stroke incidence is essential for improving patient outcomes. Traditionally, CKD severity has been graded using the estimated glomerular filtration rate (eGFR). However, the Kidney Failure Risk Equation (KFRE), which incorporates age, sex, eGFR, and the urine albumin/creatinine ratio, has emerged as a more robust tool for predicting progression to end-stage kidney disease. This study aimed to investigate if CKD severity, as assessed by these parameters is associated with incident acute ischemic stroke. Methods: Consecutive CKD patients receiving care within the National University Health System from March 2022 to September 2023 were included for analyses. Patients with a previous history of ischemic stroke or transient ischemic attack were excluded. CKD severity was defined by eGFR calculated with the CKD-EPI equation and as per KDIGO guidelines. The 2-year and 5-year risk of kidney failure was estimated by the 4-variable KFRE. Cox proportional hazards model was used to study the relationship between CKD stage and KFRE scores with acute ischemic stroke. Results: A total of 14,794 consecutive CKD patients were included, of which 155 (1.05%) experienced an acute ischemic stroke. The median age was 73 years old (IQR = 14), with 6,251 females (42.3%) and the majority being Chinese (n = 10,759; 73.5%). The median days-to-stroke was 265 days (IQR 242 days). Older age (p&lt;0.001), ischemic heart disease (p&lt;0.001), advanced CKD Stage 4-5 (p=0.013) and KFRE strata (p=0.0018) were associated with ischemic stroke. The risk of ischemic stroke was higher with advanced CKD stage; CKD Stage 4-5 patients were more likely to develop an acute ischemic stroke event as compared to CKD Stage 1-3b patients (HR 1.70, 95%CI: 1.14-2.53). Moreover, a 10% increase in 2-year and 5-year kidney failure risks corresponded to significantly higher risks of ischemic stroke, with hazard ratios of 1.38 (95% CI: 1.17-1.63) and 1.20 (95% CI: 1.10-1.31), respectively. These associations remained significant after adjusting for age, gender, ethnicity, comorbidities, HbA1c and lipid parameters. Conclusion: CKD patients at elevated risk of kidney failure also face an increased risk of suffering an acute ischemic stroke. Implementing the KFRE in CKD management could prove valuable in assessing ischemic stroke risk.

BackgroundThe Kidney Failure Risk Equation (KFRE) uses the 4 variables of age, sex, urine albumin-to-creatinine ratio (ACR), and estimated glomerular filtration rate (eGFR) in individuals with chronic kidney disease (CKD) to predict the risk of end stage renal disease (ESRD), i.e., the need for dialysis or a kidney transplant, within 2 and 5 years. Currently, national guideline writers in the UK and other countries are evaluating the role of the KFRE in renal referrals from primary care to secondary care, but the KFRE has had limited external validation in primary care. The study’s objectives were therefore to externally validate the KFRE’s prediction of ESRD events in primary care, perform model recalibration if necessary, and assess its projected impact on referral rates to secondary care renal services.Methods and findingsIndividuals with 2 or more Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR values < 60 ml/min/1.73 m2 more than 90 days apart and a urine ACR or protein-to-creatinine ratio measurement between 1 December 2004 and 1 November 2016 were included in the cohort. The cohort included 35,539 (5.6%) individuals (57.5% female, mean age 75.9 years, median CKD-EPI eGFR 51 ml/min/1.73 m2, median ACR 3.2 mg/mmol) from a total adult practice population of 630,504. Overall, 176 (0.50%) and 429 (1.21%) ESRD events occurred within 2 and 5 years, respectively. Median length of follow-up was 4.7 years (IQR 2.8 to 6.6). Model discrimination was excellent for both 2-year (C-statistic 0.932, 95% CI 0.909 to 0.954) and 5-year (C-statistic 0.924, 95% 0.909 to 0.938) ESRD prediction. The KFRE overpredicted risk in lower (<20%) risk groups. Reducing the model’s baseline risk improved calibration for both 2- and 5-year risk for lower risk groups, but led to some underprediction of risk in higher risk groups. Compared to current criteria, using referral criteria based on a KFRE-calculated 5-year ESRD risk of ≥5% and/or an ACR of ≥70 mg/mmol reduced the number of individuals eligible for referral who did not develop ESRD, increased the likelihood of referral eligibility in those who did develop ESRD, and referred the latter at a younger age and with a higher eGFR. The main limitation of the current study is that the cohort is from one region of the UK and therefore may not be representative of primary care CKD care in other countries.ConclusionsIn this cohort, the recalibrated KFRE accurately predicted the risk of ESRD at 2 and 5 years in primary care. Its introduction into primary care for referrals to secondary care renal services may lead to a reduction in unnecessary referrals, and earlier referrals in those who go on to develop ESRD. However, further validation studies in more diverse cohorts of the clinical impact projections and suggested referral criteria are required before the latter can be clinically implemented.