The impact of multiple long-term conditions on mortality, progression to kidney failure and health-related quality of life among people with chronic kidney disease: a multicentre cohort study (NURTuRE-CKD).

Abstract

Multiple long-term conditions (MLTC) are common in people with chronic kidney disease (CKD). This study examined the impact of MLTC on mortality, CKD progression, and health-related quality of life (HRQoL) in a referred CKD population. Adults with non-kidney replacement therapy (KRT)-dependent CKD (stages G1 to G5) were recruited to the prospective NURTuRE-CKD cohort across 16 UK nephrology centres. MLTC was defined as ≥2 conditions (including CKD) and comorbidities categorised into 19 groups. Depression and anxiety were defined using the Hospital Anxiety and Depression Scale, and Cognitive impairment using the Six-item Cognitive Impairment Test. Outcomes were all-cause mortality, CKD progression (eGFR <15 mL/min/1.73m 2 or KRT), and HRQoL (EQ-5D-5L, at two time points). Participants with eGFR < 15 at baseline were excluded from progression analyses. All 2996 participants had comorbidities at baseline, and therefore MLTC. Mean age was 62.7 (SD ± 14.7) years, mean eGFR 37.3 mL/min/1.73m 2 (SD ± 17.9), and 41% were female. Median baseline comorbidity count was 3 (IQR 2 to 5; range 1 to 19). The commonest baseline comorbidities were hypertension, pain, obesity, hyperuricaemia, diabetes, sarcopenia, and cardiovascular disease. Over a median 1.42 years between baseline and first follow up, the most frequent new comorbidities were pain (285 people (14%)), anxiety and depression (226 (11%)), cognitive impairment (115 (6%)), obesity (98 (5%)), and anaemia (82 (4%)). Increasing comorbidity count was associated with higher mortality (adjusted hazard ratios (vs. 1 comorbidity): 1.37 (2), 1.45 (3), 1.54 (4), and 1.80 (≥5)), with statistical significance at ≥4 comorbidities). Comorbidity number was not associated with CKD progression. Greater number and certain specific comorbidities were associated with worse HRQoL. Greater comorbidity burden was associated with mortality and worse HRQoL but not CKD progression in this cohort. CKD management should target prevention of additional conditions, prioritise holistic care and focus on MLTC as much as kidney protection. What is already known on this topic Having multiple long-term conditions is common among people with CKD.People with CKD commonly have worse health-related quality of life (HRQoL) than similar populations without CKD.HRQoL is affected by many factors among people with CKD and often worsens over time.What this study adds Accruing new comorbidities over time is common among people with non-kidney replacement therapy (KRT)-dependent CKD, particularly pain and mental health conditions.Having a greater number of comorbidities was associated with mortality, but not progression to kidney failure among people with CKD in this particular population and period of follow up.A greater number and a wider range of specific comorbidities were associated with worse longitudinal HRQoL among people with CKDHow this study might affect research, practice, or policy This research encourages holistic care of people with CKD with a focus on multiple long-term conditions being as important as kidney protection.Greater efforts are needed to address specific comorbidities, particularly pain, mental health conditions (anxiety and depression), cognitive impairment, obesity, sarcopenia, anaemia, and cardiovascular disease.This research supports preventative interventions that reduce the risk of developing new long-term conditions among people living with CKD.