Abstract Background The Kidney Failure Risk Equation (KFRE) is widely used to estimate the risk of kidney replacement therapy (KRT), but evidence in real-world multicentre advanced CKD (ACKD) cohorts—particularly among older patients with substantial competing mortality—remains limited. Methods We conducted a multicentre retrospective cohort study including adults with ACKD (baseline eGFR 20 mL/min/1.73 m²) followed at specialised multidisciplinary clinics in Barcelona and Seville (2017–2022). The 2-year 4-variable KFRE (age, sex, eGFR, UACR) was externally validated for predicting KRT initiation, treating death as a competing event. Discrimination was assessed using time-dependent AUC; calibration was evaluated using decile-based plots and quantitative metrics (calibration-in-the-large, Brier score) using Fine–Gray competing risk methods. Clinical utility was explored using decision curve analysis (DCA) and a 20% KFRE threshold in patients aged ≥65 years. Results A total of 503 patients were included. During follow-up, 248 patients initiated KRT and 94 died before KRT. The 2-year 4-variable KFRE showed good discrimination (time-dependent AUC 0.82, 95% CI 0.73–0.91), preserved across age strata. Calibration demonstrated appropriate risk ordering across deciles with mild underestimation (CITL −0.21 by Fine–Gray; Brier score 0.23). In patients aged ≥65 years, a KFRE ≥20% was strongly associated with KRT initiation in competing risk models (SHR 5.92, 95% CI 4.08–8.60). DCA showed positive net benefit across clinically relevant thresholds. Conclusions In a multicentre Spanish ACKD cohort, the 2-year KFRE demonstrated robust discrimination and acceptable calibration. These findings highlight theclinical utility of the KFRE for risk stratification and KRT planning in older patients with advanced CKD.
Collado et al. (2026) studied this question.