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Nephrol Dial Transplant. 2020 Jan 14. pii: gfz277. doi: 10.1093/ndt/gfz277. [Epub ahead of print]

Kidney function and symptom development over time in elderly patients with advanced chronic kidney disease: results of the EQUAL cohort study.

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Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
Department of Medical Informatics, Academic Medical Center, ERA-EDTA Registry, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany.
CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy.
Nephrology Dialysis and Transplant Unit Grande Ospedale Metropolitano, Reggio Calabria, Italy.
Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
Department of Clinical Sciences Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, Sweden.
UK Renal Registry, Southmead Hospital, Bristol, UK.
Population Health Sciences, University of Bristol, Bristol, UK.



Initiation of renal replacement therapy often results from a combination of kidney function deterioration and symptoms related to chronic kidney disease (CKD) progression. We investigated the association between kidney function decline and symptom development in patients with advanced CKD.


In the European Quality study on treatment in advanced CKD (EQUAL study), a European prospective cohort study, patients with advanced CKD aged ≥65 years and a kidney function that dropped <20 mL/min/1.73 m2 were followed for 1 year. Linear mixed-effects models were used to assess the association between kidney function decline and symptom development. The sum score for symptom number ranged from 0 to 33 and for overall symptom severity from 0 to 165, using the Dialysis Symptom Index.


At least one kidney function estimate with symptom number or overall symptom severity was available for 1109 and 1019 patients, respectively. The mean (95% confidence interval) annual kidney function decline was 1.70 (1.32; 2.08) mL/min/1.73 m2. The mean overall increase in symptom number and severity was 0.73 (0.28; 1.19) and 2.93 (1.34; 4.52) per year, respectively. A cross-sectional association between the level of kidney function and symptoms was lacking. Furthermore, kidney function at cohort entry was not associated with symptom development. However, each mL/min/1.73 m2 of annual kidney function decline was associated with an extra annual increase of 0.23 (0.07; 0.39) in the number of symptoms and 0.87 (0.35; 1.40) in overall symptom severity.


A faster kidney function decline was associated with a steeper increase in both symptom number and severity. Considering the modest association, our results seem to suggest that repeated thorough assessment of symptom development during outpatient clinic visits, in addition to the monitoring of kidney function decline, is important for clinical decision-making.


chronic kidney disease; clinical epidemiology; kidney function; kidney function decline; symptoms


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