A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy.

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.

Incidence and Outcomes of Patients Receiving Chronic Kidney Replacement Therapy Admitted to Scottish ICUs Between 2009 and 2019-A National Observational Cohort Study.

OBJECTIVES: To determine the incidence and characteristics of ICU admissions in the Scottish population of patients treated with chronic kidney replacement therapy (KRT) over an 11-year period and determine factors associated with post-ICU admission mortality. DESIGN: Retrospective observational cohort study. SETTING: We analyzed admissions to Scottish intensive care environments between January 1, 2009, and December 31, 2019. PATIENTS: All patients receiving chronic KRT-including maintenance dialysis and kidney transplant-in Scotland. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Descriptive statistics and factors associated with mortality using logistic regression and Cox proportional hazard models. From 10,657 unique individuals registered in the Scottish Renal Registry over the 11-year study period and alive as of January 1, 2009, 1,402 adult patients were identified as being admitted to a Scottish critical care setting. Between 2009 and 2019, admissions to ICU increased in a nonlinear manner driven by increases in admissions for renal causes and elective cardiac surgery. The ICU admission rate was higher among patients on chronic dialysis than in kidney transplant recipients (59.1 vs 19.9 per 1,000 person-years), but post-ICU mortality was similar (about 24% at 30 d and 40% at 1 year). Admissions for renal reasons were most common (20.9%) in patients undergoing chronic dialysis, whereas kidney transplant recipients were most frequently admitted for pneumonia (19.3%) or sepsis (12.8%). Adjusted Cox PH models showed that receiving invasive ventilation and vasoactive drugs was associated with an increased risk of death at 30 days post-ICU admission (HR, 1.75; 95% CI, 1.28-2.39 and 1.72; 95% CI, 1.28-2.31, respectively). CONCLUSIONS: With a growing population of kidney transplant recipients and the improved survival of patients on chronic dialysis, the number of ICU admissions is rising in the chronic KRT population. Mortality post-ICU admission is high for these patients.

Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare.

BACKGROUND: No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease. METHODS: This population study of Grampian (UK) followed incident presentations of acute kidney injury (AKI) and incident estimated glomerular filtration rate (eGFR) thresholds of <60, <45 and <30 mL/min/1.73 m2 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care), long-term mortality and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression and cause-specific Cox models with and without adjustment of comorbidities. RESULTS: There were 41 313, 51 190, 32 171 and 17 781 new presentations of AKI and eGFR thresholds <60, <45 and <30  mL/min/1.73 m2. A total of 6.1-7.8% of the population was from deprived areas and (versus all others) presented on average 5 years younger, with more diabetes and pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had the greatest association with long-term kidney failure at the eGFR <60 mL/min/1.73 m2 threshold {adjusted hazard ratio [HR] 1.48 [95% confidence interval (CI) 1.17-1.87]} and this association decreased with advancing disease severity [HR 1.09 (95% CI 0.93-1.28) at eGFR <30 mL/min/1.73 m2), with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were an eGFR threshold <60 mL/min/1.73 m2, AKI, males and those <65 years of age. CONCLUSIONS: Even in a high-income country with universal healthcare, serious and consistent inequities in kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.

Increasing numbers and improved overall survival of patients on kidney replacement therapy over the last decade in Europe: an ERA Registry study.

BACKGROUND: The aim of this study was to describe the trends in the incidence, prevalence and survival of patients on kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) across Europe from 2008 to 2017. METHODS: Data from renal registries in 9 countries and 16 regions that provided individual patient data to the ERA Registry from 2008 to 2017 were included. These registries cover 34% of the general population in Europe. Crude and standardized incidence and prevalence per million population (pmp) were determined. Trends over time were studied using Joinpoint regression. Survival probabilities were estimated using Kaplan-Meier analysis and hazard ratios (HRs) using Cox regression analysis. RESULTS: The standardized incidence of KRT was stable [annual percentage change (APC): -1.48 (-3.15; 0.21)] from 2008 (146.0 pmp) to 2011 (141.6 pmp), followed by a slight increase [APC: 1.01 (0.43; 1.60)] to 148.0 pmp in 2017, although trends in incidence varied across countries. This increase was primarily due to a rise in the incidence of KRT in men older than 65 years. Moreover, as a cause of kidney failure, diabetes mellitus is increasing. The standardized prevalence increased from 2008 (990.0 pmp) to 2017 (1166.8 pmp) [APC: 1.82 (1.75; 1.89)]. Patient survival on KRT improved in the time period 2011-13 compared with 2008-[adjusted HR: 0.94 (0.93; 0.95)]. CONCLUSION: This study showed an overall increase in the incidence and prevalence of KRT for ESKD as well as an increase in the KRT patient survival over the last decade in Europe.

The Impact of Vaccination on Incidence and Outcomes of SARS-CoV-2 Infection in Patients with Kidney Failure in Scotland.

BACKGROUND: Patients with kidney failure requiring KRT are at high risk of complications and death following SARS-CoV-2 infection, with variable antibody responses to vaccination reported. We investigated the effects of COVID-19 vaccination on the incidence of infection, hospitalization, and death from COVID-19 infection. METHODS: The study design was an observational data linkage cohort study. Multiple health care datasets were linked to ascertain all SARS-CoV-2 testing, vaccination, hospitalization, and mortality data for all patients treated with KRT in Scotland from the start of the pandemic over a period of 20 months. Descriptive statistics, survival analyses, and vaccine effectiveness were calculated. RESULTS: As of September 19, 2021, 93% (n=5281) of the established KRT population in Scotland had received two doses of an approved SARS-CoV-2 vaccine. Over the study period, there were 814 cases of SARS-CoV-2 infection (15.1% of the KRT population). Vaccine effectiveness rates against infection and hospitalization were 33% (95% CI, 0 to 52) and 38% (95% CI, 0 to 57), respectively. Within 28 days of a SARS-CoV-2-positive PCR test, 9.2% of fully vaccinated individuals died (7% patients on dialysis and 10% kidney transplant recipients). This compares to <0.1% of the vaccinated general Scottish population admitted to the hospital or dying due to COVID-19 during that period. CONCLUSIONS: These data demonstrate that a primary vaccine course of two doses has limited effect on COVID-19 infection and its complications in patients with KRT. Adjunctive strategies to reduce risk of both COVID-19 infection and its complications in this population are urgently required.

COVID-19 in patients undergoing chronic kidney replacement therapy and kidney transplant recipients in Scotland: findings and experience from the Scottish renal registry.

BACKGROUND: Infection with the severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic with coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, overwhelming healthcare systems globally. Preliminary reports suggest a high incidence of infection and mortality with SARS-CoV-2 in patients receiving kidney replacement therapy (KRT). The aims of this study are to report characteristics, rates and outcomes of all patients affected by infection with SARS-CoV-2 undergoing KRT in Scotland. METHODS: Study design was an observational cohort study. Data were linked between the Scottish Renal Registry, Health Protection Scotland and the Scottish Intensive Care Society Audit Group national data sets using a unique patient identifier (Community Health Index (CHI)) for each individual by the Public Health and Intelligence unit of Public Health, Scotland. Descriptive statistics and survival analyses were performed. RESULTS: During the period 1st March 2020 to 31st May 2020, 110 patients receiving KRT tested positive for SARS-CoV-2 amounting to 2% of the prevalent KRT population. Of those affected, 86 were receiving haemodialysis or peritoneal dialysis and 24 had a renal transplant. Patients who tested positive were older and more likely to reside in more deprived postcodes. Mortality was high at 26.7% in the dialysis patients and 29.2% in the transplant patients. CONCLUSION: The rate of detected SARS-CoV-2 in people receiving KRT in Scotland was relatively low but with a high mortality for those demonstrating infection. Although impossible to confirm, it appears that the measures taken within dialysis units coupled with the national shielding policy, have been effective in protecting this population from infection.

Routinely measured iohexol glomerular filtration rate versus creatinine-based estimated glomerular filtration rate as predictors of mortality in patients with advanced chronic kidney disease: a Swedish Chronic Kidney Disease Registry cohort study.

Background: Estimated glomerular filtration rate (eGFR) becomes less reliable in patients with advanced chronic kidney disease (CKD). Methods: Using the Swedish CKD Registry (2005-11), linked to the national inpatient, dialysis and death registers, we compared the performance of plasma-iohexol measured GFR (mGFR) and urinary clearance measures versus eGFR to predict death in adults with CKD stages 4/5. Performance was assessed using survival and prognostic models. Results: Of the 2705 patients, 1517 had mGFR performed, with the remainder providing 24-h urine clearances. Median eGFR (CKD-EPI creatinine ) was 20 mL/min/1.73 m 2 [interquartile range (IQR) 14-26], mGFR 18 mL/min/1.73 m 2 (IQR 13-23) and creatinine clearance 23 mL/min (IQR 15-31). Median follow-up was 45 months (IQR 26-59), registering 968 deaths (36%). In fully adjusted Cox models, a rise in mGFR of 1 mL/min/1.73 m 2 was associated with a 5.3% fall in all-cause mortality compared with a 1.7% corresponding fall for eGFR [adjusted hazard ratio (aHR) 0.947 (95% CI, 0.930-0.964) versus aHR 0.983 (95% CI, 0.970-0.996)]. mGFR was also statistically superior in prognostic models (discrimination using logistic regression and integrated discrimination improvement). Urinary clearance measures showed a stronger aetiological relationship with death than eGFR, but were not statistically superior in the prognostic models. Conclusions: The performance of mGFR was superior to eGFR, in both aetiological and prognostic models, in predicting mortality in adults with CKD stage 4/5, demonstrating the importance of GFR per se versus non-GFR determinants of outcome. However, the relatively modest enhancement suggests that eGFR may be sufficient to use in everyday clinical practice while mGFR adds important prognostic information for those where eGFR is believed to be biased.

A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy.

BACKGROUND: Patients who start renal replacement therapy (RRT) for End-Stage Kidney Disease (ESKD) without having had timely access to specialist renal services have poor outcomes. At one NHS Trust in England, a community-wide CKD management system has led to a decline in the incident rate of RRT and the lowest percentage of patients presenting within 90 days of starting RRT in the UK. We describe the protocol for a quality improvement project to scale up and evaluate this innovation. METHODS: The intervention is based upon an off-line database that integrates laboratory results from blood samples taken in all settings stored under different identifying labels relating to the same patient. Graphs of estimated glomerular filtration rate (eGFR) over time are generated for patients <65 years with an incoming eGFR <50 ml/min/1.73 m2 and patients >65 years with an incoming eGFR <40 ml/min/1.73 m2. Graphs where kidney function is deteriorating are flagged by a laboratory scientist and details sent to the primary care doctor (GP) with a prompt that further action may be needed. We will evaluate the impact of implementing this intervention across a large population served by a number of UK renal centres using a mixed methods approach. We are following a stepped-wedge design. The order of implementation among participating centres will be randomly allocated. Implementation will proceed with unidirectional steps from control group to intervention group until all centres are generating graphs of eGFR over time. The primary outcome for the quantitative evaluation is the proportion of patients referred to specialist renal services within 90 days of commencing RRT, using data collected routinely by the UK Renal Registry. The qualitative evaluation will investigate facilitators and barriers to adoption and spread of the intervention. It will include: semi-structured interviews with laboratory staff, renal centre staff and service commissioners; an online survey of GPs receiving the intervention; and focus groups of primary care staff. DISCUSSION: Late presentation to nephrology for patients with ESKD is a source of potentially avoidable harm. This protocol describes a robust quantitative and qualitative evaluation of a quality improvement intervention to reduce late presentation and improve the outcomes for patients with ESKD.

International Network of Chronic Kidney Disease cohort studies (iNET-CKD): a global network of chronic kidney disease cohorts.

BACKGROUND: Chronic kidney disease (CKD) is a global health burden, yet it is still underrepresented within public health agendas in many countries. Studies focusing on the natural history of CKD are challenging to design and conduct, because of the long time-course of disease progression, a wide variation in etiologies, and a large amount of clinical variability among individuals with CKD. With the difference in health-related behaviors, healthcare delivery, genetics, and environmental exposures, this variability is greater across countries than within one locale and may not be captured effectively in a single study. METHODS: Studies were invited to join the network. Prerequisites for membership included: 1) observational designs with a priori hypotheses and defined study objectives, patient-level information, prospective data acquisition and collection of bio-samples, all focused on predialysis CKD patients; 2) target sample sizes of 1,000 patients for adult cohorts and 300 for pediatric cohorts; and 3) minimum follow-up of three years. Participating studies were surveyed regarding design, data, and biosample resources. RESULTS: Twelve prospective cohort studies and two registries covering 21 countries were included. Participants age ranges from >2 to >70 years at inclusion, CKD severity ranges from stage 2 to stage 5. Patient data and biosamples (not available in the registry studies) are measured yearly or biennially. Many studies included multiple ethnicities; cohort size ranges from 400 to more than 13,000 participants. Studies' areas of emphasis all include but are not limited to renal outcomes, such as progression to ESRD and death. CONCLUSIONS: iNET-CKD (International Network of CKD cohort studies) was established, to promote collaborative research, foster exchange of expertise, and create opportunities for research training. Participating studies have many commonalities that will facilitate comparative research; however, we also observed substantial differences. The diversity we observed across studies within this network will be able to be leveraged to identify genetic, behavioral, and health services factors associated with the course of CKD. With an emerging infrastructure to facilitate interactions among the investigators of iNET-CKD and a broadly defined research agenda, we are confident that there will be great opportunity for productive collaborative investigations involving cohorts of individuals with CKD.

Socio-economic status influences chronic kidney disease prevalence in primary care: a community-based cross-sectional analysis.

BACKGROUND: Primary care chronic kidney disease (CKD) registers report widely varying prevalence within the UK. We examined the effects of laboratory ascertainment and adjusting for practice-level variables on the variation in CKD prevalence. We carried out an Ayrshire-wide laboratory database analysis of primary care practices (PCPs). METHODS: We analysed 54 PCPs with 313 639 registered patients aged ≥ 18. All patients with a low estimated glomerular filtration rate (<60 mL/min/1.73 m(2)) had their serum creatinine values extracted from 1st January 2009 to 31st March 2012. Individuals with CKD stage 3-5 were identified with an algorithm that confirmed chronicity. These data were linked to PCP attributes from Information Services Division, Scotland. Using laboratory-ascertained CKD prevalence, we examined whether adjusting for practice-level factors [socio-economic status (SES), rurality and patients to general practitioner ratio (PGR)] and patient-level factors (age, gender) explained some of the observed variation among PCPs. Individual and combined hierarchical multilinear regression models were used. RESULTS: Eighteen thousand two hundred and eighty-five (5.8%) had CKD stage 3-5 on 31 March 2011. SES, rurality and PGR predicted 39% (F(3,50) = 12.37, P < 0.001) of the variation in prevalence with SES exerting the most influence (25%). With the stepwise addition of explanatory variables, variation between practices fell from 3.9-fold using PCP register prevalence to laboratory ascertained (3.1-fold variation), with age and gender adjustment (further fall to 2.1-fold), and lastly to 1.8-fold variation with adjustment for SES. Funnel plots using these adjustments reduced the number of outliers outside of 3 SD from 15 to 7 to 6, and outliers between 2 and 3 SD by 16 to 13 to 5. CONCLUSIONS: Laboratory ascertainment is practicable, reduces variation and facilitates benchmarking. PCP attributes other than age and gender impact on prevalence. Over a third of variation in CKD prevalence among PCPs can be explained by rurality, PGR and especially SES even after age and gender stratification.

Comparison of urinary albumin and urinary total protein as predictors of patient outcomes in CKD.

BACKGROUND: Proteinuria is common and is associated with adverse patient outcomes. The optimal test of proteinuria to identify those at risk is uncertain. This study assessed albuminuria and total proteinuria as predictors of 3 patient outcomes: all-cause mortality, start of renal replacement therapy (RRT), and doubling of serum creatinine level. STUDY DESIGN: Retrospective longitudinal cohort study. SETTING & PARTICIPANTS: Nephrology clinic of a city hospital in Scotland; 5,586 patients with chronic kidney disease (CKD) and proteinuria measured in random urine samples (n = 3,378) or timed urine collections (n = 1,808). PREDICTORS: Baseline measurements of albumin-creatinine ratio (ACR), total protein-creatinine ratio (PCR), 24-hour albuminuria, and total proteinuria. OUTCOMES: All-cause mortality, start of RRT, and doubling of serum creatinine level were assessed using receiver operating characteristic curves and Cox proportional hazards models. MEASUREMENTS: Blood pressure, serum creatinine level, ACR, PCR, date of death, date of starting RRT. RESULTS: Patients were followed up for a median of 3.5 (25th-75th percentile, 2.1-6.0) years. For all outcomes, adjusted HRs were similar for PCR and ACR (derived from random urine samples and timed collections): death, 1.41 (95% CI, 1.31-1.53) vs 1.38 (95% CI, 1.28-1.50); RRT, 1.96 (95% CI, 1.76-2.18) vs 2.33 (95% CI, 2.06-3.01); and doubling of serum creatinine level, 2.03 (95% CI, 1.87-2.19) vs 1.92 (95% CI, 1.78-2.08). Receiver operating characteristic curves showed almost identical performance for ACR and PCR for the 3 outcome measures. Adjusted HRs for ACR and PCR were similar when derived from random urine samples or timed collections and compared with 24-hour total protein and albumin excretion for each outcome measure. LIMITATIONS: This is a retrospective study. CONCLUSIONS: Total proteinuria and albuminuria perform equally as predictors of renal outcomes and mortality in patients with CKD. ACR and PCR were as effective as 24-hour urine samples at predicting outcomes and are more convenient for patients, clinicians, and laboratories. Both ACR and PCR stratify risk in patients with CKD.

Assessing proteinuria in chronic kidney disease: protein-creatinine ratio versus albumin-creatinine ratio.

BACKGROUND: Quantification of proteinuria is important in the assessment of chronic kidney disease (CKD). The aim of this study was to investigate the optimal test to identify significant proteinuria. METHODS: We retrospectively assessed the relationship between total protein:creatinine ratio (TPCR), albumin:creatinine ratio (ACR) and 24-h urine total protein in 6842 patients with CKD focusing on performance at thresholds of 0.5 and 1 g/day of proteinuria. RESULTS: The relationship between ACR and TPCR is non-linear. TPCR is highly correlated with 24-h urine protein (Spearman's rho = 0.91), though ACR also performs well (rho = 0.84). Using receiver-operator characteristic curve analysis, TPCR outperforms ACR at predicting 0.5 g/day [area under the curve (AUC) 0.967 vs 0.951, P < 0.001] and 1 g/day of proteinuria (AUC 0.968 vs 0.947, P = 0.004). A TPCR threshold of 100 mg/mmol had a higher sensitivity (94% vs 79%) but lower specificity (88% vs 95%) than an ACR of 70 mg/mmol to predict 1 g/day of total proteinuria. To achieve comparable sensitivity, the ACR threshold falls to 17.5 mg/mmol, with lower specificity than TPCR (69.8%). Sensitivity of TPCR rose with increasing age, and in females: to achieve 95% sensitivity in a man <49 years, requires a TPCR of 65 mg/mmol, compared to 179 mg/mmol in a woman >79 years. Non-albumin proteinuria was a lower proportion of total proteinuria in patients receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockade than in those who were not (P < 0.001). CONCLUSIONS: TPCR is a more sensitive screening test than ACR to predict clinically relevant proteinuria. The diagnostic performance of both tests varies substantially with age and gender, and should be taken into consideration when interpreting results. Total proteinuria cannot be adequately predicted from ACR, and our results suggest that caution is appropriate before utilizing ACR in patients with non-diabetic CKD.

A practical guide to diagnosis and assessment of chronic kidney disease for the non-nephrologist.

Chronic kidney disease (CKD) is common. People with CKD have a wide range of comorbidities and, therefore, the majority of non-nephrologists will care for people with CKD. This paper aims to provide a brief overview of the diagnosis and management of CKD for the non-nephrologist. Identifying those with CKD and optimising treatment is essential as CKD has a direct association with adverse patient outcomes. There are modifiable factors where interventions may delay progression of CKD, including: smoking cessation, dietary advice, hypertension management, renin-angiotensin system blockade, glycaemic control and relieving urinary outflow obstruction. Complications, such as renal anaemia, metabolic acidosis, CKD-related mineral bone disease, hyperkalaemia and gout, are best managed in conjunction with nephrology input. The progression of CKD is often variable and nonlinear, but person-centred intervention can delay progression of CKD, reduce morbidity and mortality, and allow time for preparation for renal replacement therapy, ultimately providing the best possible personalised care.

Clinical management of chronic kidney disease.

CKD is common and its prevalence may be increasing. It carries with it a substantial cardiovascular risk but the vast majority of patients will never require dialysis. The minority requiring further investigation or complex management should be promptly identified and referred to a nephrologist. The remaining patients require lifelong monitoring in primary care and careful attention to their cardiovascular risk factors.

To Dialyse or not to Dialyse - Is that the Question? A Psychosocial Perspective on Dilemmas Concerning Dialysis for People with Dementia.

There is increasing recognition that the organisation of health care into specialist areas of practice can be counterproductive for older people with multiple morbidities and that dementia can raise particular challenges in health care. In the context of treatment for chronic kidney disease, these challenges concern complex decisions about the suitability and efficacy of dialysis and other treatments. This article draws on a literature review to present a psychosocial perspective on these decisions. It considers the value of the concept of 'dementia friendliness' for nephrology practice and suggests how this could provide a valuable frame of reference for the multidisciplinary nephrology team to ensure they are best equipped to work with people living with dementia and their carers and to ensure that the individual patient is truly at the centre of their treatment regime.

Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study.

OBJECTIVE: To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD). DESIGN: Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia. SETTING: A purposive sample of nine UK renal centres differing in the scale of their CKM programmes. PARTICIPANTS: Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.732 or >65 years with end-stage kidney disease). RESULTS: Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary 'best interests' decision-making for those without capacity. Attitudes to advance care planning were divided. CONCLUSIONS: In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.

Cinacalcet use and the risk of cardiovascular events, fractures and mortality in chronic kidney disease patients with secondary hyperparathyroidism.

With the aim to expand the randomized controlled trial evidence of cinacalcet treatment to the unselected, general chronic kidney disease (CKD) population we analysed a large inception cohort of CKD patients in the region of Stockholm, Sweden 2006-2012 (both non-dialysis, dialysis and transplanted) with evidence of secondary hyperparathyroidism (SHPT). We used marginal structural models to account for both confounding by indication and time-dependent confounding. Over 37 months, 435/3,526 (12%) initiated cinacalcet de novo. Before cinacalcet initiation, parathyroid hormone (PTH) had increased progressively to a median of 636ng/L. After cinacalcet initiation, PTH declined, as did serum calcium and phosphate. In total, 42% of patients experienced a fatal/non-fatal cardiovascular event, 32% died and 9% had a new fracture. The unadjusted cardiovascular odds ratio (OR) associated with cinacalcet treatment was 1.01 (95% confidence interval: 0.83, 1.22). In the fully weighted model, the cardiovascular odds was lower in cinacalcet treated patients (OR 0.67: 0.48, 0.93). The adjusted ORs for all-cause mortality and for fractures were 0.79 (0.56, 1.11) and 1.08 (0.59, 1.98) respectively. Our study suggests cinacalcet treatment improves biochemical abnormalities in the wider CKD population, and adds real-world support that treating SHPT with cinacalcet may have beneficial effects on cardiovascular outcomes.