{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T07:55:43Z","timestamp":1791618943791,"version":"4.3.4"},"reference-count":48,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2025,11,11]],"date-time":"2025-11-11T00:00:00Z","timestamp":1762819200000},"content-version":"unspecified","delay-in-days":10,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"NHS England","award":["The UK Renal Registry is funded through a capitation."],"award-info":[{"award-number":["The UK Renal Registry is funded through a capitation."]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,9]]},"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To externally validate and subsequently repurpose\/recalibrate the easily accessible kidney failure risk equation (KFRE) for a prevalent transplant population with an estimated glomerular filtration rate (eGFR)&lt;30\u2009mL\/min\/1.73\u2009m\u00b2. It also aims to evaluate the recalibrated KFRE\u2019s potential to improve clinical practice with a clinical utility assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Retrospective cohort study using UK Renal Registry data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>68 adult UK kidney centres.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>\n                      4092 patients with grafts at least 2 years old and eGFR&lt;30\u2009mL\/min\/1.73\u2009m\n                      <jats:sup>2<\/jats:sup>\n                      from 2009 to 2018.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary outcome measure<\/jats:title>\n                    <jats:p>Death-censored allograft failure at 2 years, defined as dialysis initiation, re-transplantation or, in the absence of the former two, the recorded date of transplant failure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Prognostic model validation<\/jats:title>\n                    <jats:p>The KFRE was calculated at baseline using the 2-year, 8-variable non-North American KFRE, and performance was assessed using Harrell\u2019s C-statistic and calibration plots. The model was recalibrated using Cox Regression (2009\u20132013 cohort) and temporally validated using the 2014\u20132018 cohort. Clinical utility was assessed using decision-curve analysis, estimating per-100-patient gains in timely planning and reductions in unnecessary interventions compared with eGFR triggers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The original KFRE had excellent discrimination but was miscalibrated, underpredicting graft failure. Temporal validation demonstrated that the performance of the recalibrated KFRE could be maintained across time periods (Harrell\u2019s C-index of 0.81 (95% CI 0.80 to 0.83); O\/E (Observed\/Expected events) ratio 1.00 (95% CI 0.93 to 1.07). It identified 9\/100 more patients for timely intervention and 13\/100 more for whom intervention could be delayed compared with a late clinical trigger of an eGFR&lt;15\u2009mL\/min\/1.73 m\n                      <jats:sup>2<\/jats:sup>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>While there are other prognostic models, this is the first study to focus on the understudied and clinically important cohort of patients with an eGFR&lt;30\u2009mL\/min\/1.73\u2009m\u00b2, offering more relevant 2-year predictions. For this underserved population, we present an easily accessible model that is robust to temporal and case-mix differences, demonstrates clinical utility and has the potential to improve daily clinical practice.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-101407","type":"journal-article","created":{"date-parts":[[2025,11,11]],"date-time":"2025-11-11T11:45:50Z","timestamp":1762861550000},"page":"e101407","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Kidney failure risk equation to predict kidney transplant failure in individuals with an eGFR&lt;30 mL\/min\/1.73 m\n                    <sup>2<\/sup>\n                    : a UK Renal Registry external validation and recalibration study"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-2762-4814","authenticated-orcid":false,"given":"Sherry","family":"Masoud","sequence":"first","affiliation":[{"name":"UK Renal Registry, Bristol, UK"},{"name":"Centre for Bladder and Kidney Health, University College London, Bloomsbury Campus, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aisha","family":"Bello","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shalini","family":"Santhakumaran","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Casula","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesa","family":"Maher","sequence":"additional","affiliation":[{"name":"University of Leicester, Leicester, UK"},{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fran","family":"Benoy-Deeney","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Medcalf","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"},{"name":"University Hospitals of Leicester NHS Foundation Trust, Leicester, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rupert","family":"Major","sequence":"additional","affiliation":[{"name":"University of Leicester, Leicester, UK"},{"name":"University Hospitals of Leicester NHS Foundation Trust, Leicester, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorothea","family":"Nitsch","sequence":"additional","affiliation":[{"name":"UK Renal Registry, Bristol, UK"},{"name":"London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,11,11]]},"reference":[{"key":"2025120413264301000_15.11.e101407.1","doi-asserted-by":"publisher","DOI":"10.1093\/ckj\/sfx117"},{"key":"2025120413264301000_15.11.e101407.2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199912023412303"},{"key":"2025120413264301000_15.11.e101407.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.kint.2020.07.025"},{"key":"2025120413264301000_15.11.e101407.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.kint.2019.01.017"},{"key":"2025120413264301000_15.11.e101407.5","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1159\/000455015","article-title":"Mortality after Renal Allograft Failure and Return to Dialysis","volume":"45","author":"Brar","year":"2017","journal-title":"Am J Nephrol"},{"key":"2025120413264301000_15.11.e101407.6","doi-asserted-by":"crossref","first-page":"2606","DOI":"10.1097\/TP.0000000000001751","article-title":"Nonprogrammed Vascular Access Is Associated With Greater Mortality in Patients Who Return to Hemodialysis With a Failing Renal Graft","volume":"101","author":"Laham","year":"2017","journal-title":"Transplantation"},{"key":"2025120413264301000_15.11.e101407.7","unstructured":"Hole B , Casula A , Wong E , et al . What is the individual background of patients starting dialysis? A UKRR analysis. Oral presentation UK kidney week. UK, 2021."},{"key":"2025120413264301000_15.11.e101407.8","doi-asserted-by":"crossref","DOI":"10.1097\/TXD.0000000000000788","article-title":"Assessment of a Dedicated Transplant Low Clearance Clinic and Patient Outcomes on Dialysis After Renal Allograft Loss at 2 UK Transplant Centers","volume":"4","author":"Evans","year":"2018","journal-title":"Transplant Direct"},{"key":"2025120413264301000_15.11.e101407.9","doi-asserted-by":"crossref","DOI":"10.1177\/2054358120985376","article-title":"Outcomes of an Inpatient Dialysis Start in Patients With Kidney Graft Failure: A Population-Based Multicentre Cohort Study","volume":"8","author":"Naylor","year":"2021","journal-title":"Can J Kidney Health Dis"},{"key":"2025120413264301000_15.11.e101407.10","doi-asserted-by":"publisher","DOI":"10.1016\/j.xkme.2020.09.004"},{"key":"2025120413264301000_15.11.e101407.11","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.l4923","article-title":"Prediction system for risk of allograft loss in patients receiving kidney transplants: international derivation and validation study","volume":"366","author":"Loupy","year":"2019","journal-title":"BMJ"},{"key":"2025120413264301000_15.11.e101407.12","unstructured":"British . Transplantation society. UK guideline for the management of the patient with a failing kidney transplant. Available: https:\/\/bts.org.uk\/uk-guideline-for-the-management-of-the-patient-with-a-failing-kidney-transplant\/ [Accessed 24 Nov 2024]."},{"key":"2025120413264301000_15.11.e101407.13","doi-asserted-by":"publisher","DOI":"10.1681\/ASN.2020071077"},{"key":"2025120413264301000_15.11.e101407.14","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2011.451"},{"key":"2025120413264301000_15.11.e101407.15","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002955","article-title":"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","volume":"16","author":"Major","year":"2019","journal-title":"PLoS Med"},{"key":"2025120413264301000_15.11.e101407.16","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2015.18202"},{"key":"2025120413264301000_15.11.e101407.17","unstructured":"National Institute for Health and Care Excellence . Chronic kidney disease: assessment and management (NICE guideline NG203). 2021. Available: https:\/\/www.nice.org.uk\/guidance\/ng203"},{"key":"2025120413264301000_15.11.e101407.18","doi-asserted-by":"crossref","first-page":"1334","DOI":"10.1016\/j.ekir.2019.05.009","article-title":"Accuracy of Kidney Failure Risk Equation in Transplant Recipients","volume":"4","author":"Akbari","year":"2019","journal-title":"Kidney Int Rep"},{"key":"2025120413264301000_15.11.e101407.19","doi-asserted-by":"crossref","DOI":"10.1177\/2054358120922627","article-title":"Validation of the Kidney Failure Risk Equation in Kidney Transplant Recipients","volume":"7","author":"Tangri","year":"2020","journal-title":"Can J Kidney Health Dis"},{"key":"2025120413264301000_15.11.e101407.20","doi-asserted-by":"publisher","DOI":"10.1186\/s12882-021-02552-2"},{"key":"2025120413264301000_15.11.e101407.21","doi-asserted-by":"crossref","first-page":"2937","DOI":"10.1111\/ajt.16717","article-title":"The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients","volume":"21","author":"Lubetzky","year":"2021","journal-title":"Am J Transplant"},{"key":"2025120413264301000_15.11.e101407.22","doi-asserted-by":"crossref","first-page":"1076","DOI":"10.1016\/j.kint.2023.05.010","article-title":"Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference","volume":"104","author":"Josephson","year":"2023","journal-title":"Kidney Int"},{"key":"2025120413264301000_15.11.e101407.23","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-150-9-200905050-00006"},{"key":"2025120413264301000_15.11.e101407.24","doi-asserted-by":"publisher","DOI":"10.7326\/M20-0529"},{"key":"2025120413264301000_15.11.e101407.25","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfs386"},{"key":"2025120413264301000_15.11.e101407.26","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2007.01745.x"},{"key":"2025120413264301000_15.11.e101407.27","doi-asserted-by":"publisher","DOI":"10.1053\/j.ajkd.2013.10.059"},{"key":"2025120413264301000_15.11.e101407.28","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1111\/aor.12473","article-title":"Prognostic Significance of 1-Year Serum Albumin Levels Within the Normal Range After Kidney Transplantation","volume":"39","author":"Oh","year":"2015","journal-title":"Artif Organs"},{"key":"2025120413264301000_15.11.e101407.29","doi-asserted-by":"publisher","DOI":"10.1002\/sim.9275"},{"key":"2025120413264301000_15.11.e101407.30","doi-asserted-by":"publisher","DOI":"10.1002\/sim.6370"},{"key":"2025120413264301000_15.11.e101407.31","doi-asserted-by":"crossref","first-page":"2079","DOI":"10.1093\/ndt\/gfae064","article-title":"Clinical impact of the Kidney Failure Risk Equation for vascular access planning","volume":"39","author":"Hahn Lundstr\u00f6m","year":"2024","journal-title":"Nephrol Dial Transplant"},{"key":"2025120413264301000_15.11.e101407.32","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2021-069249","article-title":"Validation of prediction models in the presence of competing risks: a guide through modern methods","volume":"377","author":"van Geloven","year":"2022","journal-title":"BMJ"},{"key":"2025120413264301000_15.11.e101407.33","doi-asserted-by":"publisher","DOI":"10.1175\/1520-0493(1950)078<0001:VOFEIT>2.0.CO;2"},{"key":"2025120413264301000_15.11.e101407.34","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0b013e3181c9029d"},{"key":"2025120413264301000_15.11.e101407.35","doi-asserted-by":"publisher","DOI":"10.7326\/M14-0698"},{"key":"2025120413264301000_15.11.e101407.36","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-13-1"},{"key":"2025120413264301000_15.11.e101407.37","doi-asserted-by":"publisher","DOI":"10.1186\/s41512-019-0064-7"},{"key":"2025120413264301000_15.11.e101407.38","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.i6","article-title":"Net benefit approaches to the evaluation of prediction models, molecular markers, and diagnostic tests","volume":"352","author":"Vickers","year":"2016","journal-title":"BMJ"},{"key":"2025120413264301000_15.11.e101407.39","doi-asserted-by":"crossref","DOI":"10.1186\/s12882-021-02402-1","article-title":"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","volume":"22","author":"Ali","year":"2021","journal-title":"BMC Nephrol"},{"key":"2025120413264301000_15.11.e101407.40","doi-asserted-by":"crossref","first-page":"748","DOI":"10.1093\/ndt\/gfx067","article-title":"Pro: Risk scores for chronic kidney disease progression are robust, powerful and ready for implementation","volume":"32","author":"Tangri","year":"2017","journal-title":"Nephrol Dial Transplant"},{"key":"2025120413264301000_15.11.e101407.41","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/2047-1440-3-18","article-title":"Factors influencing survival after kidney transplant failure","volume":"3","author":"McCaughan","year":"2014","journal-title":"Transplant Res"},{"key":"2025120413264301000_15.11.e101407.42","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1093\/ndt\/gfac131","article-title":"Risk of end-stage kidney disease in kidney transplant recipients versus patients with native chronic kidney disease: multicentre unmatched and propensity-score matched analyses","volume":"38","author":"De Nicola","year":"2023","journal-title":"Nephrol Dial Transplant"},{"key":"2025120413264301000_15.11.e101407.43","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.i3140","article-title":"External validation of clinical prediction models using big datasets from e-health records or IPD meta-analysis: opportunities and challenges","volume":"353","author":"Riley","year":"2016","journal-title":"BMJ"},{"key":"2025120413264301000_15.11.e101407.44","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2014.06.018"},{"key":"2025120413264301000_15.11.e101407.45","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1186\/s12882-019-1635-0","article-title":"Relationship between early proteinuria and long term outcome of kidney transplanted patients from different decades of donor age","volume":"20","author":"Diena","year":"2019","journal-title":"BMC Nephrol"},{"key":"2025120413264301000_15.11.e101407.46","doi-asserted-by":"publisher","DOI":"10.1681\/ASN.2015010062"},{"key":"2025120413264301000_15.11.e101407.47","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1111\/tri.13787","article-title":"The relationship between proteinuria and allograft survival in patients with transplant glomerulopathy: a retrospective single-center cohort study","volume":"34","author":"Zhang","year":"2021","journal-title":"Transpl Int"},{"key":"2025120413264301000_15.11.e101407.48","doi-asserted-by":"crossref","first-page":"16094069231168485","DOI":"10.1177\/16094069231168485","article-title":"The IN-FAKT Study Protocol: Investigating the Experiences and Management of Individuals With Failing Kidney Transplants","volume":"22","author":"Bailey","year":"2023","journal-title":"Int J Qual Methods"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-101407","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T21:28:16Z","timestamp":1764883696000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-101407"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11]]},"references-count":48,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,11,11]]},"published-print":{"date-parts":[[2025,11]]}},"alternative-id":["10.1136\/bmjopen-2025-101407"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-101407","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11]]}}}