THE KIDNEY FAILURE RISK EQUATION

Practice points for the clinical use of the KFRE

  1. KDIGO recommends that in people with CKD Stages G3-G5, the KFRE – as an externally validated risk equation – is used to estimate the absolute risk of kidney failure. (GRADE: 1A)

  2. A 5-year kidney failure risk of 3% – 5% can be used to determine need for nephrology referral in addition to criteria based on estimated glomerular filtration rate (eGFR) or urine albumin-to-creatinine ratio (ACR), and other clinical considerations.

  3. A 2-year kidney failure risk of > 10% can be used to determine the timing of multidisciplinary care, in addition to eGFR-based criteria and other clinical considerations.

  4. A 2-year kidney failure risk threshold of > 40% can be used to determine timing of modality education and timing of preparation for kidney replacement therapy (including vascular access planning or referral for kidney transplantation), in addition to eGFR-based criteria and other clinical considerations.

Current evidence supporting the use of the KFRE in different populations and settings

The KFRE was initially developed in 2011 using data from 2 independent Canadian cohorts of patients with CKD stages G3-G5 (www.doi.org/10.1001/jama.2011.451), and was subsequently validated in 2016 using data from more than 30 countries spanning 4 continents (www.doi.org/10.1001/jama.2015.18202). Since then, evidence from across the globe has been growing for the use of the KFRE in different patient populations and settings, some of which is highlighted below.

Use of the KFRE in the primary care setting to guide referrals to nephrology

  1. Duggal V, Montez-Rath ME, Thomas IC, Goldstein MK, Tamura MK. Nephrology referral based on laboratory values, kidney failure risk, or both: a study using veterans affairs health system data. American Journal of Kidney Diseases. 2022 Mar 1;79(3):347-53. www.doi.org/10.1053/j.ajkd.2021.06.028

  2. Bhachu HK, Cockwell P, Subramanian A, Adderley NJ, Gokhale K, Fenton A, Kyte D, Nirantharakumar K, Calvert M. Impact of using risk-based stratification on referral of patients with chronic kidney disease from primary care to specialist care in the United Kingdom. Kidney international reports. 2021 Aug 1;6(8):2189-99. www.doi.org/10.1016/j.ekir.2021.05.031

  3. Major RW, Shepherd D, Medcalf JF, Xu G, Gray LJ, Brunskill NJ. The kidney failure risk equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study. PLoS medicine. 2019 Nov 6;16(11):e1002955. www.doi.org/10.1371/journal.pmed.1002955

  4. Hingwala J, Wojciechowski P, Hiebert B, Bueti J, Rigatto C, Komenda P, Tangri N. Risk-based triage for nephrology referrals using the kidney failure risk equation. Canadian journal of kidney health and disease. 2017 Aug 4;4:2054358117722782. www.doi.org/10.1177/2054358117722782

Use of the KFRE in diverse CKD etiologies

  1. Ali I, Donne RL, Kalra PA. A validation study of the kidney failure risk equation in advanced chronic kidney disease according to disease aetiology with evaluation of discrimination, calibration and clinical utility. BMC nephrology. 2021 Dec;22(1):1-3. www.doi.org/10.1186/s12882-021-02402-1

  2. Hundemer GL, Tangri N, Sood MM, Ramsay T, Bugeja A, Brown PA, Clark EG, Biyani M, White CA, Akbari A. Performance of the kidney failure risk equation by disease etiology in advanced CKD. Clinical Journal of the American Society of Nephrology. 2020 Oct 7;15(10):1424-32. www.doi.org/10.2215/CJN.03940320

Use of the KFRE in transplant recipients

  1. Chu CD, Ku E, Fallahzadeh MK, McCulloch CE, Tuot DS. The kidney failure risk equation for prediction of allograft loss in kidney transplant recipients. Kidney medicine. 2020 Nov 1;2(6):753-61. www.doi.org/10.1016/j.xkme.2020.09.004

  2. Tangri N, Ferguson TW, Wiebe C, Eng F, Nash M, Astor BC, Lam NN, Ye F, Shin JI, Whitlock R, Yuen DA. Validation of the kidney failure risk equation in kidney transplant recipients. Canadian Journal of Kidney Health and Disease. 2020 May;7:2054358120922627. www.doi.org/10.1177/2054358120922627

  3. Major RW, Shepherd D, Medcalf JF, Xu G, Gray LJ, Brunskill NJ. The kidney failure risk equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study. PLoS medicine. 2019 Nov 6;16(11):e1002955. www.doi.org/10.1371/journal.pmed.1002955

  4. Akbari S, Knoll G, White CA, Kumar T, Fairhead T, Akbari A. Accuracy of kidney failure risk equation in transplant recipients. Kidney International Reports. 2019 Sep;4(9):1334. www.doi.org/10.1016/j.ekir.2019.05.009

Use of the KFRE to inform risk-based clinical care and clinical resource utilization

  1. National Institute for Health and Care Excellence. Chronic kidney disease: assessment and management (NICE guideline NG203). 2021. https://www.nice.org.uk/guidance/ng203

  2. Reaven NL, Funk SE, Mathur V, Ferguson TW, Lai J, Tangri N. Association of the Kidney Failure Risk Equation With High Health Care Costs. Kidney International Reports. 2023 Mar 20. www.doi.org/10.1016/j.ekir.2023.03.008

  3. Yuen J, Harasemiw O, Singer A, Bello A, Ronksley PE, Bohm C, Drummond N, Tangri N. Risk of CKD progression and quality-of-care indicators in the primary care setting. American Journal of Kidney Diseases. 2023 Feb 1;81(2):247-9. www.doi.org/10.1053/j.ajkd.2022.07.009

  4. Prasad B, Osman M, Jafari M, Gordon L, Tangri N, Ferguson TW, Jin S, Kappel J, Kozakewycz D. Kidney failure risk equation and cost of care in patients with chronic kidney disease. Clinical Journal of the American Society of Nephrology. 2022 Jan 1;17(1):17-26. www.doi.org/10.2215/CJN.06770521

  5. Ahmed S, Mothi SS, Sequist T, Tangri N, Khinkar RM, Mendu ML. The kidney failure risk equation score and CKD care delivery measures: A cross-sectional study. Kidney Medicine. 2022 Jan 1;4(1):100375. www.doi.org/10.1016/j.xkme.2021.08.010

  6. Grill AK, Brimble S. Approach to the detection and management of chronic kidney disease: what primary care providers need to know. Canadian Family Physician. 2018 Oct 1;64(10):728-35. www.cfp.ca/content/64/10/728

Patient and provider perspectives on risk-based care using the KFRE

  1. Sparkes D, Lee L, Rutter B, Harasemiw O, Thorsteinsdottir B, Tangri N. Patient Perspectives on Integrating Risk Prediction Into Kidney Care: Opinion Piece. Canadian Journal of Kidney Health and Disease. 2022 Mar;9:20543581221084522. www.doi.org/10.1177/20543581221084522

  2. Smekal MD, Tam-Tham H, Finlay J, Donald M, Thomas C, Weaver RG, Quinn RR, Tam K, Manns BJ, Tonelli M, Bello A. Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study. BMC nephrology. 2019 Dec;20(1):1-2. www.doi.org/10.1186/s12882-019-1269-2

  3. Smekal MD, Tam-Tham H, Finlay J, Donald M, Benterud E, Thomas C, Quinn RR, Tam K, Manns BJ, Tonelli M, Bello A. Perceived benefits and challenges of a risk-based approach to multidisciplinary chronic kidney disease care: a qualitative descriptive study. Canadian journal of kidney health and disease. 2018 Mar 22;5:2054358118763809. www.doi.org/10.1177/2054358118763809