Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review

Predictors of survival and functioning of arteriovenous fistula in patients on hemodialysis during a one-year follow-up

INTRODUCTION

The mortality rate of hemodialysis patients is extremely high and it is significantly affected by vascular access dysfunction. Our research aimed to determine predictive parameters of arteriovenous fistula functioning and survival in a one-year follow-up period.

METHODS

The research was organized as a prospective, one-year study, which included 120 dialysis patients who were followed for one year. We recorded the demographic and gender structure, clinical parameters, and laboratory findings significant for the survival and functioning of arteriovenous fistulas. Laboratory findings are presented as the mean values of the analysis at the beginning and the end of the one-year control period.

RESULTS

Univariable regression analysis confirmed the predictive significance of anastomosis positioning, type of vascular access, length of hemodialysis treatment, hemoglobin, Kt/V index values, and creatinine concentration for one-year survival, but multivariable regression analysis confirmed predictive significance only for length of treatment. Univariable regression analysis revealed significant predictors of vascular access function for the length of hemodialysis treatment, diastolic blood pressure, leukocytes, platelets, hemoglobin, creation of an arteriovenous fistula by a nephrologist, starting hemodialysis with a fistula and not with a central venous catheter, multivariable regression analysis confirmed predictive significance for the length of dialysis treatment and creation of an arteriovenous fistula by a nephrologist.

CONCLUSION

A prognostically important parameter for the one-year survival of a patient on hemodialysis is the length of dialysis treatment. In contrast, predictive parameters for the functioning of an arteriovenous fistula are the length of dialysis and the creation of a fistula by a nephrologist.

Providers' Experiences Discussing Care for Patients with Kidney Failure Who Forgo KRT: A National Qualitative Study

Background

Many nephrology providers express difficulty in discussing care options for patients who forgo KRT, which hampers their ability to help patients make decisions about their current and future treatment of kidney disease.

Methods

We conducted a qualitative study using interviews with a national sample of nephrology providers (i.e., physicians and advanced practice providers) who participated in US professional societies between July and December 2022. We performed a thematic analysis of interviews to identify emergent themes reflecting providers' experiences discussing care for patients who forgo KRT.

Results

There were 21 providers (age 54±13 years, female 81%, White 32%) who participated in interviews, of whom 43% were physicians and most (57%) practiced in academic settings. Three dominant themes emerged from interviews reflecting challenges to discussing the option to forgo KRT: (1) Inconsistent terminology: while providers sought to use terms to describe care for patients who forgo KRT that affirmed patients' decision, clearly conveyed that KRT would not be pursued, and were already familiar to patients and other providers, they disagreed about which terms satisfied these priorities; (2) blurred distinctions between KRT and its alternative: providers' descriptions of their care practices suggested that differences in their approaches to caring for patients who forgo KRT and those who are planning to pursue KRT could be opaque; and (3) deciphering patients' decision to forgo KRT: providers did not readily accept patients' expressed preferences to forgo KRT at face value and described using a variety of methods to assess whether patients would follow through with their decision.

Conclusions

Providers used different, inconsistent terms to describe care for patients who forgo KRT. They disagreed about what this care entailed and were uncertain about what patients might mean when they express not wanting to undergo KRT.

Treatment of chronic kidney disease in older populations

As the world population ages, an expected increase in the prevalence of chronic kidney disease (CKD) among older individuals will pose a considerable challenge for health care systems in terms of resource allocation for disease management. Treatment strategies for older patients with CKD should ideally align with those applied to the general population, focusing on minimizing cardiovascular events and reducing the risk of progression to kidney failure. Emerging therapies, such as SGLT-2 inhibitors and GLP-1 receptor agonists, hold promise for the effective management of CKD in older individuals. In addition, non-pharmacological interventions such as nutritional and exercise therapies have a crucial role. These interventions enhance the effects of pharmacotherapy and, importantly, contribute to the maintenance of cognitive function and overall quality of life. Various factors beyond age and cognitive function must be taken into account when considering kidney replacement therapy for patients with kidney failure. Importantly, all treatment options, including dialysis, transplantation and conservative management approaches, should be tailored to the individual through patient-centred decision-making. The dynamic integration of digital technologies into medical practice has the potential to transform the management of CKD in the aging population.

Effect of Starting Dialysis Versus Continuing Medical Management on Survival and Home Time in Older Adults With Kidney Failure : A Target Trial Emulation Study

BACKGROUND

For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.

OBJECTIVE

To compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m2 and those who continued medical management.

DESIGN

Observational cohort study using target trial emulation.

SETTING

U.S. Department of Veterans Affairs, 2010 to 2018.

PARTICIPANTS

Adults aged 65 years or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2 who were not referred for transplant.

INTERVENTION

Starting dialysis within 30 days versus continuing medical management.

MEASUREMENTS

Mean survival and number of days at home.

RESULTS

Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, -17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).

LIMITATION

Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalizability to women and nonveterans.

CONCLUSION

Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs and National Institutes of Health.

The Impact of Frailty and Severe Cognitive Impairment on Survival Time and Time to Initiate Dialysis in Older Adults With Advanced Chronic Kidney Disease: A Prospective Observational Cohort Study

Background and objectives Frailty and cognitive impairment significantly impact survival time and time to initiate dialysis in older adults with advanced chronic kidney disease (CKD). This study aims to evaluate the effects of frailty and cognitive impairment on these outcomes and determine the most effective assessment tool for predicting early dialysis initiation and short survival time. Materials and methods This prospective observational cohort study involved 240 patients aged ≥65 years with stage 4 or 5 CKD, recruited from a nephrology outpatient department (ambulatory care) between March 2020 and March 2021. Frailty was assessed using the Physical Frailty Phenotype (PFP), PRISMA-7, Clinical Frailty Scale (CFS), and FRAIL scale. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA). The primary outcomes were time to initiate dialysis and survival time, with secondary outcomes including hospitalization rates, length of stay, and mortality after dialysis initiation. Results Frail patients only showed significantly shorter time to dialysis initiation when identified by the PFP and FRAIL scale (28.3 months for frail vs. 31.2 months for non-frail, p = 0.028; 26.9 months for frail vs. 30.9 months for non-frail, p = 0.038). The PFP, FRAIL, and CFS tools indicated significantly shorter survival times for frail patients compared to non-frail patients (26.8 months for frail vs. 30.6 months for non-frail, p = 0.003). Frailty is strongly correlated with severe cognitive impairment, as 45.5% of frail patients (according to the FRAIL scale) have dementia compared to 15.1% of non-frail patients (p<0.001). However, cognitive impairment did not significantly affect the time to dialysis initiation or survival time. Hospitalization rates and length of stay in the hospital were significantly higher only for frail patients identified by PRISMA-7, with a median hospital length of stay of 9.15 days for frail patients vs 6.37 days for non-frail patients (p = 0.044). Overall, 37.5% of the patients did not survive during the study follow-up, with frail patients having a higher mortality rate. Conclusion Frailty, mainly when assessed by PFP and FRAIL, is a significant predictor of early dialysis initiation and reduced survival time in older adults with advanced CKD. Cognitive impairment, while prevalent, did not independently predict these outcomes. Regular frailty screening should be incorporated into CKD management to tailor interventions and improve patient outcomes.

The Lack of a Standardized Definition of Chronic Dialysis Treatment in German Statutory Health Insurance Claims Data—Effects on Estimated Incidence and Mortality

BACKGROUND

Chronic kidney failure (CKF) is often treated with dialysis, which is invasive and costly and carries major medical risks. The existing studies of patients with CKF requiring dialysis that are based on claims data from German statutory health insurance (SHI) carriers employ varying definitions of this entity, with unclear consequences for the resulting statistical estimates.

METHODS

We carried out a cohort study on four random samples, each consisting of 62 200 persons aged 70 or above, from among the insurees of the SHI AOK Nordost, with one sample for each of the years 2012, 2014, 2016, and 2018. The prevalence, incidence, mortality, and direct health care costs of CKF requiring dialysis were estimated and compared on the basis of four different definitions from literature and a new definition developed by the authors in reference to billing data.

RESULTS

The different definitions led to variation in 12-month prevalences (range: 0.33-0.61%) and 6-month incidences (0.058-0.100%). The percentage of patients with prior acute kidney injury (AKI) ranged from 27.6% to 61.8%. Among incident patients, three-month survival ranged from 70.2% to 88.1%, and six-month survival from 60.5% to 81.3%. In CKF patients without prior AKI, the survival curves differed less across definitions (80.2-91.8% at three months, 70.7-84.4% at six months). The monthly health care costs ranged from €6010 to €9606, with marked variability across definitions in the costs of inpatient and outpatient care.

CONCLUSION

The lack of a standardized definition of CKF requiring dialysis in German SHI claims data leads to variability in the estimated case numbers, mortality, and health care costs. These differences are most probably in part due to the variable inclusion of inpatients who received short-term dialysis after AKI.

A National Survey of Conservative Kidney Management Practices for Patients Who Forgo RRT

Key Points

In the largest survey of US nephrology providers on conservative kidney management (CKM), most reported limited experience with CKM and varied approaches and local resources to provide CKM. There is need to enhance provider training and surveillance of CKM practices and to develop models of CKM that optimize care delivery and outcomes for these patients.

Background

Clinical practice guidelines advocate for conservative kidney management (CKM), a planned, holistic, patient-centered approach to caring for patients who forgo initiation of RRT. Little is known about the extent to which current care practices meet these expectations.

Methods

We conducted a cross-sectional survey of a national sample of nephrology providers recruited through US professional societies between March and July 2022 and inquired about their experiences with caring for patients who forgo RRT and their capacity to provide CKM.

Results

Overall, 203 nephrology providers (age 47±12 years, 53.2% White, 66.0% female), of which 49.8% were nephrologists and 50.2% advanced practice providers, completed the survey. Most (70.3%) reported that <10% of their practice comprised patients who had forgone RRT. Most indicated that they always or often provided symptom management (81.8%), multidisciplinary care (68.0%), tools to support shared decision making about treatment of advanced kidney disease (66.3%), and psychological support (52.2%) to patients who forgo RRT, while less than half reported that they always or often provided staff training on the care of these patients (47.8%) and spiritual support (41.4%). Most providers reported always or often working with primary care (72.9%), palliative medicine (68.8%), hospice (62.6%), social work (58.1%), and dietitian (50.7%) services to support these patients, while only a minority indicated that they always or often offered chaplaincy (23.2%), physical and/or occupational therapy (22.8%), psychology or psychiatry (31.5%), and geriatric medicine (28.1%).

Conclusions

Many nephrology providers have limited experience with caring for patients who forgo RRT. Our findings highlight opportunities to optimize comprehensive CKM care for these patients.

Using Relative Survival to Estimate the Burden of Kidney Failure

RATIONALE & OBJECTIVE

Estimates of mortality from kidney failure are misleading because the mortality from kidney failure is inseparable from the mortality attributed to comorbid conditions. We sought to develop an alternative method to reduce the bias in estimating mortality due to kidney failure using life table methods.

STUDY DESIGN

Longitudinal cohort study.

SETTING & PARTICIPANTS

Using data from the US Renal Data System and the Medicare 5% sample, we identified an incident cohort of patients, age 66+, who first had kidney failure in 2009 and a similar general population cohort without kidney failure.

EXPOSURE

Kidney failure.

OUTCOME

Death.

ANALYTICAL APPROACH

We created comorbidity, age, sex, race, and year-specific life tables to estimate relative survival of patients with incident kidney failure and to attain an estimate of excess kidney failure-related deaths. Estimates were compared with those based on standard life tables (not adjusted for comorbidity).

RESULTS

The analysis included 31,944 adults with kidney failure with a mean age of 77±7 years. The 5-year relative survival was 31% using standard life tables (adjusted for age, sex, race, and year) versus 36% using life tables also adjusted for comorbidities. Compared with other chronic diseases, patients with kidney failure have among the lowest relative survival. Patients with incident kidney failure ages 66-70 and 76-80 have a survival comparable to adults without kidney failure roughly 86-90 and 91-95 years old, respectively.

LIMITATIONS

Relative survival estimates can be improved by narrowing the specificity of the covariates collected (eg, disease severity and ethnicity).

CONCLUSIONS

Estimates of survival relative to a matched general population partition the mortality due to kidney failure from other causes of death. Results highlight the immense burden of kidney failure on mortality and the importance of disease prevention efforts among older adults.

PLAIN-LANGUAGE SUMMARY

Estimates of death due to kidney failure can be misleading because death information from kidney failure is intertwined with death due to aging and other chronic diseases. Life tables are an old method, commonly used by actuaries and demographers to describe the life expectancy of a population. We developed life tables specific to a patient's age, sex, year, race, and comorbidity. Survival is derived from the life tables as the percentage of patients who are still alive in a specified period. By comparing survival of patients with kidney failure to the survival of people from the general population, we estimate that patients with kidney failure have one-third the chance of survival in 5 years compared with people with similar demographics and comorbidity but without kidney failure. The importance of this measure is that it provides a quantifiable estimate of the immense mortality burden of kidney failure.

Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease

Key Points

There are three distinct classes of symptoms, functional impairment, and medication burden among older adults with advanced kidney disease. One class with Complex Needs with pain and psychological symptoms, functional difficulties, and polypharmacy may benefit from tailored multidisciplinary care.

Background

Older adults with advanced CKD (stages 4 and 5) have significant symptoms, polypharmacy, and functional difficulties, and previous studies evaluated these burdens separately. Identifying subgroups with similar patterns of burdens could help clinicians optimize care for these individuals.

Methods

We conducted a secondary analysis of 377 older participants (70 years and older) with stage 4 and 5 CKD at high risk of hospitalization enrolled in a national Veterans Affairs prospective cohort study. Adults on dialysis or with prior kidney transplant were excluded. We used latent class analysis to identify participants with similar patterns across symptoms, medication burden, and function. Sixteen variables were included: symptoms (anxiety, depression, appetite, pain, shortness of breath, fatigue, dizziness, leg weakness, constipation, and stiffness using the Symptom Burden Score), polypharmacy (≥10 medications and potentially inappropriate medications), and function (activities of daily living [ADLs], physical and cognitive instrumental ADLs [IADLs], and falls in the past year). We also compared 12-month hospitalization and mortality rates between the three classes.

Results

Three classes of participants with similar functional impairment, medication burden, and symptom phenotypes were identified. The largest participant class (N =208) primarily had difficulties with physical IADLs and polypharmacy. The second participant class (N =99) had shortness of breath, constipation, and dizziness. The third participant class (N =70) had complex needs with daily pain, psychological symptoms (anxiety and depression), functional limitations (ADLs and physical and cognitive IADLs), and polypharmacy. The three classes had significantly different levels of comorbidities, financial stress, and social support. There were no significant differences in mortality and hospitalization among the three classes.

Conclusion

There are distinct classes of older adults with advanced CKD who have physical and psychological symptoms, functional impairment, and medication burden. Tailoring care for this population should include a multidisciplinary team to address these overlapping symptoms, medication, and functional needs.

Kidney Clinicians' Perceptions of Challenges and Aspirations to Improve End-Of-Life Care Provision

Introduction

End-of-life care is an essential part of integrated kidney care. However, renal clinicians' experiences of care provision and perceptions of end-of-life care needs are limited. This study explored renal clinicians' experiences of providing end-of-life care and developed recommendations to improve experiences.

Methods

An exploratory qualitative study using semistructured focus groups and 1 interview was undertaken at 5 kidney services in Victoria, Australia. The transcripts were analyzed thematically.

Results

Between February and December 2017, 54 renal clinicians (21 doctors and 33 nurses) participated in the study. Clinicians reported multiple challenges of end-of-life care experiences resulting in compromised treatment planning and decision making and highlighted priorities to guide better care experiences. Challenges of providing end-of-life care were underpinned by mismatches in illness and treatment expectations, limited engagement in advance care planning, medical complexity, and differences between clinicians and patients in what constituted quality of life. These challenges were associated with compromised end-of-life care planning, which resulted in care experiences that were rushed with a prolonged treatment focus, risking limited preparation for death and moral distress. Clinicians aspired for positive end-of-life care experiences, including patient control and consensus in decision making, and a coordinated and collaborative approach across healthcare providers.

Conclusions

Renal clinicians highlighted multiple factors and circumstances which resulted in experiences of compromised end-of-life care for patients with kidney disease. To improve care experiences, clinician-directed priorities included more training and support to facilitate systematic and earlier discussions about illness expectations and end-of-life care planning and greater communication and collaboration across healthcare providers is required.

Understanding Similarities and Differences in CKD and Dialysis Care in Children and Adults

In lower-income settings there is often a dearth of resources and nephrologists, especially pediatric nephrologists, and individual physicians often find themselves caring for patients with chronic kidney diseases and end-stage kidney failure across the age spectrum. The management of such patients in high-income settings is relatively protocolized and permits high-volume services to run efficiently. The basic principles of managing chronic kidney disease and providing dialysis are similar for adults and children, however, given the differences in body size, causes of kidney failure, nutrition, and growth between children and adults with kidney diseases, nephrologists must understand the relevance of these differences, and have an approach to providing quality and safe dialysis to each group. Prevention, early diagnosis, and early intervention with simple therapeutic and lifestyle interventions are achievable goals to manage symptoms, complications, and reduce progression, or avoid kidney failure in children and adults. These strategies currently are easier to implement in higher-resource settings with robust health systems. In many low-resource settings, kidney diseases are only first diagnosed at end stage, and resources to pay out of pocket for appropriate care are lacking. Many barriers therefore exist in these settings, where specialist nephrology personnel may be least accessible. To improve management of patients at all ages, we highlight differences and similarities, and provide practical guidance on the management of children and adults with chronic kidney disease and kidney failure. It is important that children are managed with a view to optimizing growth and well-being and maximizing future options (eg, maintaining vein health and optimizing cardiovascular risk), and that adults are managed with attention paid to quality of life and optimization of physical health.

Conservative Kidney Management in Kidney Transplant Populations

Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.

How Do Kidney Disease Clinicians View Kidney Supportive Care and Palliative Care? A Qualitative Study

RATIONALE & OBJECTIVE

Kidney supportive care (KSC) is a developing area in medicine that integrates the expertise of kidney and palliative care practitioners to improve symptoms and quality of life for people with advanced kidney disease. The intersection of the practical aspects of KSC (including care activities and clinical referrals) with palliative and end-of-life care (EOLC) are largely unknown. The aim of this study was to explore kidney disease clinicians' experiences of KSC, palliative care, and EOLC.

STUDY DESIGN

An exploratory qualitative study using semistructured focus groups.

SETTING & PARTICIPANTS

Kidney disease clinicians (18 physicians, 3 trainees, and 33 kidney disease nurses) from 5 public hospitals were recruited across Victoria, Australia.

ANALYTICAL APPROACH

Thematic analysis of focus group transcripts.

RESULTS

The 2 overarching themes highlighted by clinicians were their perception that their health care systems insufficiently addressed the needs of people with advanced kidney disease, as well as their aspirations to develop KSC services to improve health care experiences. Three subthemes were identified related to limitations in health care systems: (1) variation in the clinical scope of KSC, (2) limited integration of palliative care, and (3) experiences of challenging and compromised provision of EOLC. The second theme described aspirations for future KSC services to be more inclusive, seamless, and collaborative across health care providers with capacity to respond to meet changing palliative care needs.

LIMITATIONS

Findings may not be transferable to contexts outside of Victoria, Australia; data were collected in 2017-2018 and may not reflect current or future experiences.

CONCLUSIONS

Kidney clinicians described systemic challenges and compromises in care experiences and the need for development of KSC services. They expressed that this development would require a consistent and systematic approach that integrates palliative care and embeds KSC as part of kidney health service delivery.

Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease

Background

Most patients are unaware of approaches to treating advanced chronic kidney disease (CKD) other than dialysis.

Methods

We developed a dedicated decision aid on conservative kidney management using human-centered design principles in three phases: (1) discovery: engagement of informants to understand their needs and preferences; (2) design: multiple rapid cycles of ideation, prototyping, and testing of a decision aid with a small group of informants; and (3) implementation: testing the decision aid in real-world settings with attention to how the decision aid can be further refined. Informants included a national patient advisory committee on kidney diseases, 50 patients with stage 4 or 5 CKD and 35 of their family members, and 16 clinicians recruited from the greater Seattle area between June 2019 and September 2021.

Results

Findings from the discovery phase informed an initial prototype of the decision aid, which included five sections: a description of kidney disease and its signs and symptoms, an overview of conservative kidney management and the kinds of supports provided, self-reflection exercises to elicit patients' values and goals, the pros and cons of conservative kidney management, and the option of changing one's mind about conservative kidney management. The prototype underwent several rounds of iteration during its design phase, which resulted in the addition of an introductory section describing the intended audience and more detailed information in other sections. Findings from its implementation phase led to the addition of examples of common questions that patients and family members had about conservative kidney management and a final section on other related educational resources.

Conclusions

Human-centered design principles supported a systematic and collaborative approach between researchers, patients, family members, and clinicians for developing a decision aid on conservative kidney management.