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The factors contributing to chronic kidney disease (CKD) progression are well established and include proteinuria, hypertension, diabetes, and metabolic abnormalities. However, under the conditions of ongoing military conflict, the trajectory of CKD may be shaped not only by these traditional medical determinants but also by non-medical influences.
In this context, we propose to distinguish triggers — acute or situational non-medical factors that can precipitate or accelerate CKD deterioration — from the conventional medical risk factors, which represent chronic, baseline vulnerabilities. These triggers may include disruptions in medical care, infection burden, malnutrition, and psychosocial stress — all of which can acutely destabilize kidney function and patient outcomes in wartime settings.
We conducted a retrospective analysis, which involved 303 patients with CKD stage 1-3 with the follow-up of six months. Clinical and laboratory parameters were integrated with the Charlson Comorbidity Index (CCI), the Malnutrition–Inflammation Score (MIS), the Perceived Stress Scale (PSS), and the Infectious Burden Index (IBI).
Patients were stratified into four groups according to their dominant progression trigger. We performed cluster analysis to identify common risk patterns, evaluated patient’s survival using Kaplan–Meier curves, and applied Cox proportional hazards regression to determine independent predictors of clinical outcomes. The diagnostic and prognostic performance of key parameters and indices was further assessed by ROC analysis.
Four distinct patient clusters were identified: (A) treatment interruption combined with a high IBI; (B) malnutrition and anemia; (C) elevated PSS; (D) overlapping or combined triggers. Over a 6-month follow-up, the overall mortality rate was approximately 14%, occurring predominantly in clusters A and B. Infectious burden was the strongest predictor of death (HR ≈ 2.5; 95% CI ~1.6–3.8). Malnutrition was associated with an increased risk of hospitalization (HR ≈ 1.8–1.9), while stress correlated with a higher incidence of cardiovascular events (HR ≈ 1.6). Discontinuation of follow-up or treatment monitoring was associated with a faster decline in eGFR (HR ≈ 1.9).
A triage framework prototype — CKD-WarRisk — was proposed to facilitate rapid risk assessment and prioritization in patients with chronic kidney disease (CKD) during wartime conditions.
1. Trigger screening (based on data-derived thresholds): IBI > 3 episodes/year; MIS ≥ 6; PSS > 20; “time-gap ratio” > 2.
2. Immediate actions:
– High IBI → initiate anti-infective strategies and early clinical follow-up.
– MIS ≥ 6 → provide intensive nutritional support.
– High PSS → refer for cardiologic and/or psychosocial care.
– Time-gap > 2 → restore patient monitoring using telemedicine.
3. Risk stratification:
– Low risk — no triggers above threshold.
– Moderate risk — one active trigger.
– High risk — ≥2 active triggers or an infection-dominant profile.
The proposed thresholds and weighting coefficients require external validation in independent cohorts. Subsequent work will focus on developing a digital CKD-WarRisk triage tool to support rapid, data-driven risk assessment and prioritization of CKD patients in resource-limited and conflict-affected healthcare settings.
