Influence of mortality on estimating the risk of kidney failure in people with stage 4 CKD

Pietro Ravani, Marta Fiocco, Ping Liu, Robert R. Quinn, Brenda Hemmelgarn, Matthew James, Ngan Lam, Braden Manns, Matthew J. Oliver, Giovanni F.M. Strippoli, Marcello Tonelli

Research output: Contribution to journalArticlepeer-review

23 Citations (Scopus)

Abstract

Background Most kidney failure risk calculators are based on methods that censor for death. Because mortality is high in people with severe, nondialysis-dependent CKD, censoring for death may overestimate their risk of kidney failure. Methods Using 2002–2014 population-based laboratory and administrative data for adults with stage 4 CKD in Alberta, Canada, we analyzed the time to the earliest of kidney failure, death, or censoring, using methods that censor for death and methods that treat death as a competing event factoring in age, sex, diabetes, cardiovascular disease, eGFR, and albuminuria. Stage 4 CKD was defined as a sustained eGFR of 15–30 ml/min per 1.73 m2. Results Of the 30,801 participants (106,447 patient-years at risk; mean age 77 years), 18% developed kidney failure and 53% died. The observed risk of the combined end point of death or kidney failure was 64% at 5 years and 87% at 10 years. By comparison, standard risk calculators that censored for death estimated these risks to be 76% at 5 years and .100% at 7.5 years. Censoring for death increasingly overestimated the risk of kidney failure over time from 7% at 5 years to 19% at 10 years, especially in people at higher risk of death. For example, the overestimation of 5-year absolute risk ranged from 1% in a woman without diabetes, cardiovascular disease, or albuminuria and with an eGFR of 25 ml/min per 1.73 m2 (9% versus 8%), to 27% in a man with diabetes, cardiovascular disease, albuminuria .300 mg/d, and an eGFR of 20 ml/min per 1.73 m2 (78% versus 51%). Conclusions Kidney failure risk calculators should account for death as a competing risk to increase their accuracy and utility for patients and providers.

Original languageEnglish
Pages (from-to)2219-2227
Number of pages9
JournalJournal of the American Society of Nephrology
Volume30
Issue number11
DOIs
Publication statusPublished - 2019
Externally publishedYes

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