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The capacity to provide optimal care for patients with kidney failure in kidney replacement therapy (KRT) differs importantly across countries. International variations in care over the transition period from advanced chronic kidney disease (CKD) to kidney failure with KRT are lesser known.
The international CKDopps (CKD Outcomes and Practice Pattern Study) was designed to prospectively describe and evaluate variations in CKD practices and outcomes in nephrologist-led CKD clinics. In this analysis, we describe characteristics and transition care (education about KRT modalities, arteriovenous access creation or peritoneal catheter placement, and kidney transplant wait-listing) in patients who were enrolled with or had reached over the follow-up a three-month average estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73 m2 in the US, France, and Brazil. Probabilities of having received transition care were estimated with cumulative incidence functions accounting for competing risks of KRT initiation and death. We used Fine and Gray models, with and without adjustment for age, sex, eGFR, and history of cardiovascular disease, to compare these probabilities across countries.
: 2,505 patients were included – 1,273 from France, 898 from the US, and 334 from Brazil. Mean eGFR at the study baseline was 17.3, 15.9, and 15.6 mL/min/1.73m², respectively. Patients in Brazil tended to be younger (mean age 63 years) than those in France and the US (67 years in both countries), they also had a lower frequency of history of cardiovascular disease (36%, 46%, and 48%, respectively). Over a median follow-up of 15.7 [7.2–24] months, 1,140 patients (43.1%) started KRT, whereas 377 (14.3%) died before KRT. The 2-year cumulative incidence of KRT education (one-on-one or a class), before initiating KRT, was 75.7% in Brazil, 55.8% in France, and 54.0% in the US, that of pre-emptive dialysis access creation, 27.8% in Brazil, x33.1% in France, and 32.9% in the US, and that of being pre-emptively waitlisted for kidney transplantation, 16.4% in Brazil, 24.9% in France, and 21.6% in the US. Adjusting for patient characteristics and comorbidities across countries did not attenuate these associations (Figure).
In patients with advanced CKD under nephrology care, there are remarkable differences in the probability of receiving care related to the transition from advanced CKD to KRT. These differences are hardly explained by patient characteristics and may be related to health policies (e.g., rules for pre-emptive kidney transplant waitlisting), to health care organization and resources allocated to kidney care.