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Berkhout-Byrne NC, Voorend CGN, Meuleman Y, Mooijaart SP, Brunsveld-Reinders AH, Bos WJW, Van Buren M. Nephrology-tailored geriatric assessment as decision-making tool in kidney failure. J Ren Care 2024; 50:112-127. [PMID: 37031361 DOI: 10.1111/jorc.12466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 01/26/2023] [Accepted: 03/16/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Dialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients. OBJECTIVE We aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure. DESIGN In an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis. PARTICIPANTS AND MEASUREMENTS Patients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis. RESULTS Three main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics. CONCLUSIONS nephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy.
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Affiliation(s)
- Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
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Wang Y, Qiu Y, Ren L, Jiang H, Chen M, Dong C. Social support, family resilience and psychological resilience among maintenance hemodialysis patients: a longitudinal study. BMC Psychiatry 2024; 24:76. [PMID: 38279114 PMCID: PMC10811847 DOI: 10.1186/s12888-024-05526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Psychological distress is common in maintenance hemodialysis patients, and high psychological resilience can promote psychological well-being. The current research focuses on psychological resilience protective factors such as family resilience and social support. However, the trajectories of psychological resilience, family resilience, and social support over time and their longitudinal relationships in maintenance hemodialysis patients have not been fully explored yet. Therefore, this study aims to explore the longitudinal relationship between these factors. METHODS Patients who received regular hemodialysis treatment for more than three months at dialysis centers of three tertiary hospitals in Zhejiang, China, were recruited from September to December 2020. A total of 252 patients who met the inclusion and exclusion criteria completed three follow-up surveys, including social support, family resilience, and psychological resilience assessments. A repeated measures ANOVA was used to explore differences in their respective scores at different time points. The cross-lagged analysis was performed in AMOS using the maximum likelihood method to examine the the reciprocal predictive relationships between these factors. RESULTS Social support and psychological resilience remained relatively stable over time, whereas family resilience indicated a little increasing trend. According to the cross-lagged analysis, higher T1 social support predicted higher family resilience at T2 [β = 0.123, 95% CI (0.026-0.244)]. Further, the effects of T2 social support to T3 family resilience [β = 0.194, 95%CI (0.039-0.335)] and psychological resilience [β = 0.205, 95%CI (0.049-0.354)] were significant. Finally, the effects of T2 family resilience to T3 social support [β = 0.122, 95%CI (0.010-0.225)] and psychological resilience [β = 0.244, 95%CI (0.119-0.359)] were also significant. CONCLUSIONS The study showed that the directionality of the relationship appears to be from social support or family resilience to patients' psychological resilience but not vice versa. This finding reminds healthcare professionals to emphasize the vital role of social and family resources in providing appropriate support and interventions for maintenance hemodialysis patients to promote psychological resilience and mental health development.
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Affiliation(s)
- Yuxin Wang
- School of Nursing, Wenzhou Medical University, University Town, Chashan, Wenzhou, Zhejiang, 325035, China
| | - Yuan Qiu
- Zhejiang Tourism and Health College, Zhoushan, China
| | - Liya Ren
- School of Nursing, Wenzhou Medical University, University Town, Chashan, Wenzhou, Zhejiang, 325035, China
| | - Hao Jiang
- School of Nursing, Wenzhou Medical University, University Town, Chashan, Wenzhou, Zhejiang, 325035, China
| | - Meijia Chen
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chaoqun Dong
- School of Nursing, Wenzhou Medical University, University Town, Chashan, Wenzhou, Zhejiang, 325035, China.
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3
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Rosenberg KL, Burns A, Caplin B. Effect of ethnicity and socioeconomic deprivation on uptake of renal supportive care and dialysis decision-making in older adults. Clin Kidney J 2023; 16:2164-2173. [PMID: 37915922 PMCID: PMC10616494 DOI: 10.1093/ckj/sfad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Indexed: 11/03/2023] Open
Abstract
Background Renal supportive care has become an increasingly relevant treatment option as the renal patient population ages. Despite the prevalence of kidney disease amongst ethnic minority and socioeconomically deprived patients, evidence focused on supportive care and dialysis decision-making in these groups is limited. Methods This retrospective study selected older patients referred to a low clearance or supportive care service between 1 January 2015 and 31 December 2019. A descriptive analysis of clinical and socioeconomic characteristics according to treatment choice was produced and multivariate logistic regression models used to identify predictive factors for choosing supportive care. Surrogate markers for the success of decision-making processes were evaluated, including time taken to reach a supportive care decision and risk of death without making a treatment decision or within 3 months of starting kidney replacement therapy (KRT). Finally, the association between ethnicity and socioeconomic status and hospital admission rates was compared between treatment groups. Results Amongst 1768 patients, 515 chose supportive care and 309 chose KRT. Predictive factors for choosing supportive care included age, frailty and a diagnosis of cognitive impairment. However, there was no association with ethnicity or deprivation. Similarly, these factors were not associated with time taken to make a supportive care decision or the mortality outcome. Amongst those on KRT, more socially advantaged patients had decreased rates of hospital admissions compared with those less advantaged (incident rate ratio 0.96, 95% confidence interval 0.92-0.99). Conclusion Predictive factors for choosing supportive care were clinical, rather than socioeconomic. Lower socioeconomic status was associated with increased rates of hospitalization in the KRT group. This is a possible signal that these groups experienced greater morbidity on KRT versus supportive care, an association not demonstrated amongst higher socioeconomic groups.
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Affiliation(s)
| | - Aine Burns
- Department of Renal Medicine, University College London, London, UK
| | - Ben Caplin
- Department of Renal Medicine, University College London, London, UK
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Li X, Luo JK. Perceptions and attitudes of kidney supportive care among elderly patients with advanced chronic kidney disease and dialysis healthcare professionals in China: a qualitative study. BMC Nephrol 2023; 24:316. [PMID: 37884858 PMCID: PMC10604377 DOI: 10.1186/s12882-023-03372-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE Kidney supportive care (KSC) represents a novel approach wherein a multidisciplinary team of nephrology experts offers active symptom management, advance care planning, shared decision-making, conservative treatment, and end-of-life care. This study is aimed at providing comprehensive insights and evaluations regarding the understanding and perspectives of Chinese healthcare professionals, including nephrologists and dialysis nurses, as well as elderly individuals aged 60 and above who are afflicted with chronic kidney disease. The primary goal is to furnish substantial information support for a better comprehension of KSC within the Chinese context, with the ultimate aim of facilitating its effective implementation in this region. METHODS Employing a phenomenological framework, this qualitative research generated data using semi-structured interviews with 18 elderly patients diagnosed with advanced chronic kidney disease and 10 healthcare professionals across two Class III Grade A medical institutions. The Colaizzi's analytical method was utilized for coding and analyzing the interview data. RESULTS Distinct interviews were executed with patients and healthcare professionals to delineate specific themes for each group. For elderly dialysis patients, the following themes were formed: (1) Lack of understanding of KSC; (2) Concerns of how KSC is perceived; and (3) Perceived benefits of KSC. Within the healthcare professionals cohort, two salient themes emerged: (1) Prospective clinical merits of KSC ; and (2) Mltiple difficulties encountered. CONCLUSIONS This study goes some way in furnishing a holistic understanding of perceptions surrounding KSC among elderly patients undergoing dialysis and healthcare professionals in China. The overarching Chinese cultural ethos poses substantial challenges to the widespread assimilation of KSC. While healthcare professionals advocate for KSC, there remains a limit in the patients' comprehension of this therapeutic paradigm. There is a compelling imperative to cultivate this strategy, grounded in the prevailing medical landscape.
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Affiliation(s)
- Xue Li
- Beijing Friendship Hospital, Nursing Department, Beijing Friendship Hospital, Capital Medical University, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Jin Kai Luo
- Beijing Friendship Hospital, Nursing Department, Beijing Friendship Hospital, Capital Medical University, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, PR China.
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Weir MA, Walsh M, Cuerden MS, Sontrop JM, Urquhart BL, Lim YJ, Chambers LC, Garg AX. The effect of micro-particle curcumin on chronic kidney disease progression: the MPAC-CKD randomized clinical trial. Nephrol Dial Transplant 2023; 38:2192-2200. [PMID: 36849161 PMCID: PMC10539205 DOI: 10.1093/ndt/gfad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Curcumin is a commonly used herbal supplement with anti-inflammatory and anti-fibrotic properties. Animal studies and small human trials suggest that curcumin reduces albuminuria in patients with chronic kidney disease (CKD). Micro-particle curcumin is a new, more bioavailable formulation of curcumin. METHODS To determine whether micro-particle curcumin versus placebo slows the progression of albuminuric CKD we conducted a randomized, double-blind, placebo-controlled trial with 6-month follow-up. We included adults with albuminuria [a random urine albumin-to-creatinine ratio >30 mg/mmol (265 mg/g) or a 24-h urine collection with more than 300 mg of protein] and an estimated glomerular filtration rate (eGFR) between 15 and 60 mL/min/1.73 m2 within the 3 months before randomization. We randomly allocated participants 1:1 to receive micro-particle curcumin capsules (90 mg/day) or matching placebo for 6 months. After randomization, the co-primary outcomes were the changes in albuminuria and the eGFR. RESULTS We enrolled 533 participants, but 4/265 participants in the curcumin group and 15/268 in the placebo group withdrew consent or became ineligible. The 6-month change in albuminuria did not differ significantly between the curcumin and placebo groups [geometric mean ratio 0.94, 97.5% confidence interval (CI) 0.82 to 1.08, P = .32]. Similarly, the 6-month change in eGFR did not differ between groups (mean between-group difference -0.22 mL/min/1.73 m2, 97.5% CI -1.38 to 0.95, P = .68). CONCLUSIONS Ninety milligrams of micro-particle curcumin daily did not slow the progression of albuminuric CKD over 6 months. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02369549.
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Affiliation(s)
- Matthew A Weir
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Michael Walsh
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Jessica M Sontrop
- London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Bradley L Urquhart
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Yong Jin Lim
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Chou A, Li C, Farshid S, Hoffman A, Brown M. Survival, symptoms and hospitalization of older patients with advanced chronic kidney disease managed without dialysis. Nephrol Dial Transplant 2023; 38:405-413. [PMID: 35438786 DOI: 10.1093/ndt/gfac154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Shared decision-making (SDM) is important when considering whether an older patient with advanced chronic kidney disease (CKD) should be managed with dialysis or conservative kidney management (CKM). Physicians may find these conversations difficult because of the relative paucity of data on patients managed without dialysis. METHODS This prospective observational study was conducted in a unit supported by a multidisciplinary Kidney Supportive Care (KSC) programme, in a cohort of 510 patients (280 CKM and 230 dialysis) ≥65 years of age with CKD stages 4 and 5. Survival was evaluated using logistic regression and Cox proportional hazards models. Linear mixed models were utilized to assess symptoms over time. RESULTS CKM patients were older (mean 84 versus 74 years; P < .001) and almost 2-fold more likely to have three or more comorbidities (P < .001). The median survival of CKM patients was lower compared with dialysis from all time points: 14 months [interquartile range (IQR) 6-32] versus 53 (IQR 28-103) from decision of treatment modality or dialysis start date (P < .001); 15 months (IQR 7-34) versus 64 (IQR 30-103) from the time the estimated glomerular filtration rate (eGFR) was ≤15 mL/min/1.73 m2 (P < .001); and 8 months (IQR 3-18) versus 49 (19-101) from eGFR ≤10 mL/min/1.73 m2. A total of 59% of CKM patients reported an improvement in symptoms by their third KSC clinic visit (P < .001). The rate of unplanned hospitalization was 2-fold higher in the dialysis cohort. CONCLUSIONS CKM patients survive a median of 14 months from the time of modality choice and have a lower rate of hospitalization than dialysis patients. Although the symptom burden in advanced CKD is high, most elderly CKM patients managed through an integrated KSC programme and can achieve improvement in their symptoms over time. These data might help with SDM.
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Affiliation(s)
- Angela Chou
- St George Hospital, Department of Renal Medicine, and University of New South Wales, Sydney, NSW, Australia
| | - Chenlei Li
- St George Hospital, Department of Renal Medicine, and University of New South Wales, Sydney, NSW, Australia
| | - Sanjay Farshid
- St George Hospital, Department of Renal Medicine, and University of New South Wales, Sydney, NSW, Australia
| | - Anna Hoffman
- St George Hospital, Department of Renal Medicine, and University of New South Wales, Sydney, NSW, Australia
| | - Mark Brown
- St George Hospital, Department of Renal Medicine, and University of New South Wales, Sydney, NSW, Australia
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Yeung EK, Brown L, Kairaitis L, Krishnasamy R, Light C, See E, Semple D, Polkinghorne KR, Toussaint ND, MacGinley R, Roberts MA. Impact of haemodialysis hours on outcomes in older patients. Nephrology (Carlton) 2023; 28:109-118. [PMID: 36401820 DOI: 10.1111/nep.14133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/02/2022] [Accepted: 11/10/2022] [Indexed: 11/20/2022]
Abstract
AIM Previous studies report an association between longer haemodialysis treatment sessions and improved survival. Worldwide, there is a trend to increasing age among prevalent patients receiving haemodialysis. This analysis aimed to determine whether the mortality benefit of longer haemodialysis treatment sessions diminishes with increasing age. METHODS This was a retrospective cohort study of people who first commenced thrice-weekly haemodialysis aged ≥65 years, reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry from 2005 to 2015, included from 90 days after dialysis start. The primary outcome was all-cause mortality. Cox regression analysis was performed with haemodialysis session duration the exposure of interest. RESULTS Of 8224 people who commenced haemodialysis as their first treatment for kidney failure aged ≥65 years during this period, 4727 patients died. Longer dialysis hours per session was associated with a decreased risk of death in unadjusted analyses [hazard ratio, HR, for ≥5 h versus 4 to <4.5 h: 0.81 (0.75-0.88, p < .001)]. Patients having longer dialysis sessions were younger but had greater co-morbidity. In an adjusted model including age and other variables, the survival benefit of longer hours was only partially attenuated [HR for previous comparison: 0.75 (0.69-0.82, p < .001)], and no interaction between age and hours was demonstrated (p = .89). CONCLUSION The apparent survival benefit associated with longer haemodialysis session length appears to be preserved in patients 65 years or older. In practice, the benefit of longer dialysis hours should be carefully weighed against other factors in this patient group.
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Affiliation(s)
- Emily K Yeung
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Leanne Brown
- School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lukas Kairaitis
- Department of Renal Medicine, Blacktown Hospital, Blacktown, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Casey Light
- Renal Service, Armadale Kalamunda Group, Mount Nasura, Western Australia, Australia
| | - Emily See
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - David Semple
- Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Kevan R Polkinghorne
- School of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.,Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Robert MacGinley
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Matthew A Roberts
- Eastern Health Clinical School, Monash University, Victoria, Australia
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Brunker LB, Boncyk CS, Rengel KF, Hughes CG. Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges. Clin Interv Aging 2023; 18:93-112. [PMID: 36714685 PMCID: PMC9879046 DOI: 10.2147/cia.s365968] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 01/23/2023] Open
Abstract
There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.
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Affiliation(s)
- Lucille B Brunker
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly F Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Brown EA, Ryan L, Corbett RW. A novel programme of supportive two-exchange assisted continuous ambulatory peritoneal dialysis for frail patients with end-stage kidney disease. ARCH ESP UROL 2023; 43:100-103. [PMID: 35818633 DOI: 10.1177/08968608221111276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We have developed a supportive two-exchange assisted continuous ambulatory peritoneal dialysis (asCAPD) programme for the older frail person who cannot do autonomous PD and do not want or are considered to be too high risk for haemodialysis (HD). Evaluation of the programme was determined by data collected retrospectively from patient records. Primary outcome was comparison of symptoms at start of dialysis and 3 months following dialysis start. Secondary outcomes were survival and peritonitis rate. Over a 4-year period (2016-2020), 49 patients with mean age 79.6 years (range 47-90) enrolled in the programme with eGFR 7.7 ± 2.6 ml/min (mean ± SD) at dialysis start. Forty-one patients had been on asCAPD for >3 months. There was an improvement in all symptoms at 3 months compared to baseline: anorexia (46% to 15%), fatigue (46% to 15%), shortness of breath (27% to 2%) and oedema (51% to 32%). One-year survival was 55%. Peritonitis rate was 0.52 episodes per patient year. The novel supportive two-exchange asCAPD programme shows potential improvement of symptoms after 3 months and may provide an acceptable dialysis modality for the frail co-morbid person with established kidney failure. More detailed study and evaluation are needed.
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Affiliation(s)
- Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Louise Ryan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Richard W Corbett
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
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Siriwardana A, Gray NA, Makris A, Li CK, Yong K, Mehta Y, Ramos J, Di Tanna GL, Gianacas C, Addo IY, Roxburgh S, Naganathan V, Foote C, Gallagher M. Treatment decision-making and care among older adults with kidney failure: protocol for a multicentre, prospective observational cohort study with nested substudies and linked qualitative research (the Elderly Advanced CKD Programme). BMJ Open 2022; 12:e066156. [PMID: 36581411 PMCID: PMC9806093 DOI: 10.1136/bmjopen-2022-066156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Shared treatment decision-making and planning of care are fundamental in advanced chronic kidney disease (CKD) management. There are limited data on several key outcomes for the elderly population including survival, quality of life, symptom burden, changes in physical functioning and experienced burden of healthcare. Patients, caregivers and clinicians consequently face significant uncertainty when making life-impacting treatment decisions. The Elderly Advanced CKD Programme includes quantitative and qualitative studies to better address challenges in treatment decision-making and planning of care among this increasingly prevalent elderly cohort. METHODS AND ANALYSIS The primary component is OUTcomes of Older patients with Kidney failure (OUTLOOK), a multicentre prospective observational cohort study that will enrol 800 patients ≥75 years with kidney failure (estimated glomerular filtration rate ≤15 mL/min/1.73 m2) across a minimum of six sites in Australia. Patients entered are in the decision-making phase or have recently made a decision on preferred treatment (dialysis, conservative kidney management or undecided). Patients will be prospectively followed until death or a maximum of 4 years, with the primary outcome being survival. Secondary outcomes are receipt of short-term acute dialysis, receipt of long-term maintenance dialysis, changes in biochemistry and end-of-life care characteristics. Data will be used to formulate a risk prediction tool applicable for use in the decision-making phase. The nested substudies Treatment modalities for the InfirM ElderLY with end stage kidney disease (TIMELY) and Caregivers of The InfirM ElderLY with end stage kidney disease (Co-TIMELY) will longitudinally assess quality of life, symptom burden and caregiver burden among 150 patients and 100 caregivers, respectively. CONsumer views of Treatment options for Elderly patieNts with kiDney failure (CONTEND) is an additional qualitative study that will enrol a minimum of 20 patients and 20 caregivers to explore experiences of treatment decision-making and care. ETHICS AND DISSEMINATION Ethics approval was obtained through Sydney Local Health District Human Research Ethics Committee (2019/ETH07718, 2020/ETH02226, 2021/ETH01020, 2019/ETH07783). OUTLOOK is approved to have waiver of individual patient consent. TIMELY, Co-TIMELY and CONTEND participants will provide written informed consent. Final results will be disseminated through peer-reviewed journals and presented at scientific meetings.
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Affiliation(s)
- Amanda Siriwardana
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Gray
- Department of Renal Medicine, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
- School of Health and Behavioural Science, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Chenlei Kelly Li
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Kenneth Yong
- Department of Renal Medicine, Prince of Wales Hospital and Community Health Services, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Yachna Mehta
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jannel Ramos
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Gian Luca Di Tanna
- Statistics Division, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Chris Gianacas
- Statistics Division, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Isaac Yeboah Addo
- Faculty of Arts and Social Sciences, University of New South Wales Centre for Social Research in Health, Sydney, New South Wales, Australia
| | - Sarah Roxburgh
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Geriatric Medicine, Concord Repatriation General Hospital, The University of Sydney Centre for Education and Research on Ageing, Sydney, New South Wales, Australia
| | - Celine Foote
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Martin Gallagher
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Renal Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
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An epidemiological survey of maintenance hemodialysis patients in Baoshan, Yunnan. Asian J Surg 2022; 46:2081-2082. [PMID: 36450621 DOI: 10.1016/j.asjsur.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/11/2022] [Indexed: 11/29/2022] Open
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12
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Frazier R, Levine S, Porteny T, Tighiouart H, Wong JB, Isakova T, Koch-Weser S, Gordon EJ, Weiner DE, Ladin K. Shared Decision Making Among Older Adults With Advanced CKD. Am J Kidney Dis 2022; 80:599-609. [PMID: 35351579 DOI: 10.1053/j.ajkd.2022.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown. STUDY DESIGN A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM. SETTING & PARTICIPANTS Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD. PREDICTORS Decisional readiness factors, treatment options education, and care partner support. OUTCOMES Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSIONS Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
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Affiliation(s)
- Rebecca Frazier
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois; Jesse Brown Veterans Administration Medical Center, Chicago, Illinois.
| | - Sarah Levine
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Thalia Porteny
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Tufts University School of Medicine, Boston, Massachusetts
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Elisa J Gordon
- Department of Surgery-Division of Transplantation, Center for Health Services and Outcomes Research, Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel E Weiner
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
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13
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Cho JH, Lim JH, Park Y, Jeon Y, Kim YS, Kang SW, Yang CW, Kim NH, Jung HY, Choi JY, Park SH, Kim CD, Kim YL. Factors Affecting Selection of a Dialysis Modality in Elderly Patients With Chronic Kidney Disease: A Prospective Cohort Study in Korea. Front Med (Lausanne) 2022; 9:919028. [PMID: 36237542 PMCID: PMC9550884 DOI: 10.3389/fmed.2022.919028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background We investigated factors associated with the selection of a dialysis modality for elderly patients compared to younger patients. Methods This study included 2,514 incident dialysis patients from a Korean multicenter prospective cohort. Multivariate logistic regression analyses were performed with demographic, socioeconomic, and clinical data to analyze factors associated with the chosen dialysis modality. Differences in these factors were compared between the elderly (≥65 years) and younger (<65 years) patients. Results Of the enrolled patients, 1,746 (69.5%) and 768 (30.6%) selected hemodialysis (HD) and peritoneal dialysis (PD), respectively. The percentage of PD was higher in younger patients than in elderly patients (37.1 vs. 16.9%, p < 0.001). Multivariate analysis showed that planned dialysis (p < 0.001), employment status (p < 0.001), and independent economic status (p = 0.048) were independent factors for selecting PD, whereas peripheral vascular disease (p = 0.038) and tumor (p = 0.010) were factors for selecting HD in the younger group. In the elderly group, planned dialysis (p < 0.001) and congestive heart failure (CHF; p = 0.002) were associated with choosing PD; however, tumor (p = 0.006) was associated with choosing HD. A two-way ANOVA showed that planned dialysis and CHF showed a significant interaction effect with age on modality selection. Conclusions As the age of patients with chronic kidney disease increased, HD was more frequently selected compared to PD. Dialysis planning and CHF interacted with age in selecting dialysis modalities in elderly patients. Elderly patients were less affected by socioeconomic status than younger patients.
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Affiliation(s)
- Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Jeong-Hoon Lim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yeongwoo Park
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Yena Jeon
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Yon Su Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Shin-Wook Kang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul Woo Yang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Nam-Ho Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- *Correspondence: Yong-Lim Kim
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14
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment. Korean J Intern Med 2022; 37:701-718. [PMID: 35811360 PMCID: PMC9271711 DOI: 10.3904/kjim.2021.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 12/05/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan,
Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul,
Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul,
Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul,
Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul,
Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | | | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu,
Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
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15
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Porteny T, Gonzales KM, Aufort KE, Levine S, Wong JB, Isakova T, Rifkin DE, Gordon EJ, Rossi A, Di Perna G, Koch-Weser S, Weiner DE, Ladin K. Treatment Decision Making for Older Kidney Patients during COVID-19. Clin J Am Soc Nephrol 2022; 17:957-965. [PMID: 35672037 PMCID: PMC9269620 DOI: 10.2215/cjn.13241021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/22/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. RESULTS We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty. CONCLUSIONS Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Decision Aid for Renal Therapy (DART), NCT03522740.
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Affiliation(s)
- Thalia Porteny
- Lab for Research on Ethics, Aging and Community Health, Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Kristina M. Gonzales
- Lab for Research on Ethics, Aging and Community Health, Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Kate E. Aufort
- Lab for Research on Ethics, Aging and Community Health, Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Sarah Levine
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - John B. Wong
- Division of Clinical Medicine, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dena E. Rifkin
- Division of Nephrology, Veterans’ Affairs Healthcare System, San Diego, California,Department of Medicine, Division of Nephrology and Hypertension, University of California, San Diego, San Diego, California
| | - Elisa J. Gordon
- Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | | | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel E. Weiner
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Lab for Research on Ethics, Aging and Community Health, Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
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16
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Davison S, Steinke V, Wasylynuk BA, Holroyd-Leduc J. Identification of core components and implementation strategies for a Conservative Kidney Management Pathway across a complex, multisector healthcare system in Canada using World Cafés and the Theoretical Domains Framework. BMJ Open 2022; 12:e054422. [PMID: 35636800 PMCID: PMC9152937 DOI: 10.1136/bmjopen-2021-054422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Develop a Conservative Kidney Management (CKM) Pathway for patients unlikely to benefit from dialysis. We sought to determine (1) core components of care and (2) implementation strategies across a multisector healthcare system. DESIGN We used the Knowledge to Action Cycle and the Theoretical Domains Framework to identify barriers and facilitators to CKM. Activities included a current state assessment, World Cafés, interviews, focus groups and readiness for change assessments. SETTING A provincial initiative in Alberta, Canada. PARTICIPANTS 282 participants were purposively selected to reflect those involved in the care of patients receiving CKM. This included policy-makers, multidisciplinary healthcare professionals, patients and their family. MAIN OUTCOME MEASURES Theoretical domains linked to pathway content and implementation strategies. RESULTS Environmental context and resources, social/professional role and identity, knowledge and social influences were the most influential behaviour change domains identified. The most effective strategies for facilitating behaviour change were identified to be education, training, environmental restructuring and modelling. Core components of care were determined to be guidelines for treating symptoms and disease complications consistent with the philosophy of CKM, timely communication of the choice for CKM, coordination with community services, crisis planning, advance care planning and tools to enhance patients' capacity for self-management and shared decision-making. This resulted in development of Alberta's CKM Pathway, an interactive, digital, decision-support tool consisting of: (1) a patient decision aid; (2) a patient/family portal; and (3) a healthcare professional portal, where all resources can be freely accessed. CONCLUSIONS The pathway was codesigned by patients and healthcare professionals and involves tailor-made combinations of tools to address unique patient needs and system-community circumstances. Most of the strategies are adaptable to local context and are likely translatable to the implementation of sustainable CKM in other national and international jurisdictions.
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Affiliation(s)
- Sara Davison
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vanessa Steinke
- Clinical Project Support Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Betty Ann Wasylynuk
- Alberta Kidney Care-North, Alberta Health Services, Edmonton, Alberta, Canada
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17
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Wong SP, Oestreich T, Chandler B, Curtis JR. Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease. KIDNEY360 2022; 3:1242-1252. [PMID: 35919540 PMCID: PMC9337892 DOI: 10.34067/kid.0000392022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/04/2022] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Susan P.Y. Wong
- VA Puget Sound Health Care System, Division of Nephrology, University of Washington, Seattle, Washington,University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - Taryn Oestreich
- University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - Bridgett Chandler
- University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - J. Randall Curtis
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington
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18
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Thorsteinsdottir B, Espinoza Suarez NR, Curtis S, Beck AT, Hargraves I, Shaw K, Wong SPY, Hickson LJ, Boehmer KR, Amberg B, Dahlen E, Wirtz C, Albright RC, Kumbamu A, Tilburt JC, Sutton EJ. Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study. J Gen Intern Med 2022; 37:1031-1037. [PMID: 35083651 PMCID: PMC8971255 DOI: 10.1007/s11606-021-07176-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). OBJECTIVE To understand the prognostic information preferences expressed by older patients with CKD. DESIGN AND PARTICIPANTS Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. APPROACH Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. KEY RESULTS We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. CONCLUSION Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.
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Affiliation(s)
- Bjorg Thorsteinsdottir
- Division of Community Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA. .,Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA. .,Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA. .,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Susan Curtis
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
| | - Annika T Beck
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
| | - Ian Hargraves
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Kevin Shaw
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Susan P Y Wong
- University of Washington and VA Puget Sound Health Care System, Seattle, WA, USA
| | - LaTonya J Hickson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Brigid Amberg
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Erin Dahlen
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Cristina Wirtz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Ashok Kumbamu
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jon C Tilburt
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Divisions of General Internal Medicine All at Mayo Clinic, Rochester, MN, USA
| | - Erica J Sutton
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
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19
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Allen RJ, Saeed F. Dialysis Organization Online Information on Kidney Failure Treatments: A Content Analysis Using Corpus Linguistics. Kidney Med 2022; 4:100462. [PMID: 35620083 PMCID: PMC9127690 DOI: 10.1016/j.xkme.2022.100462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale & Objective Dialysis organizations’ websites may influence patient decision making, but the websites have received almost no consideration. We investigated how/whether these websites present all kidney replacement therapy options and how the quality of life of these options is portrayed. Study Design Content analysis using corpus linguistics (computer-assisted language analysis). Setting Website content aimed at patients from the 2 major dialysis organizations’ websites, totaling 226,968 words. The analysis took place from November 12, 2020, to March 30, 2021. Analytical Approach We used linguistic software (AntConc) to document the frequencies of words needed to present treatment options and quality of life information. Results Over both sites, dialysis mentions outstripped transplantation mentions. Organization A did not appear to reference conservative kidney management. Organization B mentioned dialysis more often than conservative management, at a ratio of 34:1. Organization A did not attribute symptoms to dialysis, whereas organization B had 12 mentions of dialysis-induced symptoms out of 87 total symptom references. Both organizations framed life on dialysis optimistically, suggesting that patients can continue to engage in “work,” “sex,” or “travel”; organization A referenced sex, work, and/or travel 123 times and organization B referenced these 262 times. Limitations We used quantitative analysis and linked ideas with certain keywords. We did not conduct a detailed qualitative inquiry. Conclusions The websites emphasized dialysis as a treatment for kidney failure, and the quality of life on dialysis was framed very optimistically. Qualitative studies of treatment modalities and the quality of life on dialysis in the patient-targeted material of dialysis organizations are needed.
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20
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Kennard A, Glasgow N, Rainsford S, Talaulikar G. Frailty in chronic kidney disease: challenges in nephrology practice. A review of the current literature. Intern Med J 2022; 53:465-472. [PMID: 35353436 DOI: 10.1111/imj.15759] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/08/2022] [Accepted: 03/24/2022] [Indexed: 12/01/2022]
Abstract
Frailty is a multidimensional clinical syndrome characterised by low physical activity, reduced strength, accumulation of multi-organ deficits, decreased physiological reserve and vulnerability to stressors. Frailty pathogenesis and "inflammaging" is augmented by uraemia, leading to a high prevalence of frailty potentially contributing to adverse outcomes in patients with advanced chronic kidney (CKD) disease including end stage kidney disease (ESKD). The presence of frailty is a stronger predictor of CKD outcomes than estimated Glomerular Filtration Rate (eGFR) and more aligned with dialysis outcomes than age. Frailty assessment should form part of routine assessment of patients with CKD and inform key medical transitions. Frailty screening and interventions in CKD/ESKD should be a research priority. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alice Kennard
- Department of Renal Medicine, Canberra Health Services, ACT, Australia.,Australian National University, Canberra, ACT, Australia
| | - Nicholas Glasgow
- Australian National University, Canberra, ACT, Australia.,Calvary Health Care Bruce - Clare Holland House Palliative Care Service, Calvary Health Services, ACT, Australia
| | | | - Girish Talaulikar
- Department of Renal Medicine, Canberra Health Services, ACT, Australia.,Australian National University, Canberra, ACT, Australia
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21
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Chou A, Li KC, Brown MA. Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review. Kidney Med 2022; 4:100447. [PMID: 35498159 PMCID: PMC9046625 DOI: 10.1016/j.xkme.2022.100447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Shared decision making is important when deciding the appropriateness of dialysis for any individual, particularly for older patients with advanced chronic kidney disease who have high mortality. Emerging evidence suggests that patients with advanced age, high comorbidity burden, and poor functional status may not have any survival advantage on dialysis compared with those on a conservative kidney management pathway. The purpose of this narrative review is to summarize the existing studies on the survival of older patients with stage 4 or 5 chronic kidney disease managed with or without dialysis and to evaluate the factors that may influence mortality in an effort to assist clinicians with shared decision making. Median survival estimates of conservative kidney management patients are widely varied, ranging from 1-45 months with 1-year survival rates of 29%-82%, making it challenging to provide consistent advice to patients. In existing cohort studies, the selected group of patients on dialysis generally survives longer than the conservative kidney management cohort. However, in patients with advanced age (aged ≥80 years), high comorbidity burden, and poor functional status, the survival benefit conferred by dialysis is no longer present. There is an overall paucity of data, and the variability in outcomes reflect the heterogeneity of the existing studies; further prospective studies are urgently needed.
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Affiliation(s)
- Angela Chou
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Kelly Chenlei Li
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Mark Ashley Brown
- University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
- Address for Correspondence: Mark Ashley Brown, MBBS, FRACP, MD, Department of Renal Medicine, St George Hospital, Kogarah, Sydney, New South Wales 2217, Australia.
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22
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Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton) 2022; 27:551-565. [PMID: 35201646 PMCID: PMC9315017 DOI: 10.1111/nep.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.
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Affiliation(s)
- Jenny H C Chen
- Faculty of Medicine, University of Wollongong, Wollongong, Australia.,Wollongong Hospital, Wollongong, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Medicine, University of Western Australia, Perth, Australia
| | - Prue Howson
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
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23
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Polkinghorne KR, Kerr PG. Taking a broader view of the health care needs of people with chronic kidney disease. Med J Aust 2022; 216:137-138. [DOI: 10.5694/mja2.51387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/07/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
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24
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Penninger LP, Collins SG. Saying Goodbye. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Voorend CGN, van Oevelen M, Verberne WR, van den Wittenboer ID, Dekkers OM, Dekker F, Abrahams AC, van Buren M, Mooijaart SP, Bos WJW. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1529-1544. [PMID: 35195249 PMCID: PMC9317173 DOI: 10.1093/ndt/gfac010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice. Methods Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions. Results A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m2 ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted. Conclusions Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.
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Affiliation(s)
| | | | - Wouter R Verberne
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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26
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:578-595. [PMID: 34922430 PMCID: PMC8685366 DOI: 10.23876/j.krcp.21.700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/17/2022] Open
Abstract
The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).
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Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Lu E, Chai E. Kidney Supportive Care in Peritoneal Dialysis: Developing a Person-Centered Kidney Disease Care Plan. Kidney Med 2021; 4:100392. [PMID: 35243304 PMCID: PMC8861952 DOI: 10.1016/j.xkme.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Individuals receiving peritoneal dialysis (PD)—similar to those receiving hemodialysis —may experience high mortality coupled with a high symptom burden and reduced health-related quality of life. In this context, a discussion of the risks, benefits, and tradeoffs of PD and/or other kidney treatment modalities should be explored based on individual goals and preferences. Through these principles, kidney supportive care provides a person-centered approach to kidney disease care throughout the spectrum of kidney failure and earlier stages of chronic kidney disease. Kidney supportive care is offered in conjunction with life-prolonging therapies, including dialysis and kidney transplants, and is increasingly recognized as an integral part of advancing the care of PD patients. Using “My Kidney Care Roadmap” for shared decision making, kidney supportive care guides patients undergoing PD and their clinicians to (1) elicit patient goals, values, and priorities; (2) convey medical prognosis and suitable treatment options; and (3) ask “Which of these kidney treatment options will best help me achieve my goals and priorities?” to inform both current and future decisions, including choice of dialysis modalities, time-limited trials, and/or nondialysis management. Recognizing that patient priorities and choices may evolve, this framework ultimately allows patients to continually reassess their PD care to better achieve goal-directed dialysis.
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Affiliation(s)
- Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Address for Correspondence: Emily Lu, MD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1243, New York, NY 10029.
| | - Emily Chai
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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28
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Jung JY, Yoo KD, Kang E, Kang HG, Kim SH, Kim H, Kim HJ, Park TJ, Suh SH, Jeong JC, Choi JY, Hwang YH, Choi M, Kim YL, Oh KH. Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment. Kidney Res Clin Pract 2021; 40:S1-S37. [PMID: 34923803 PMCID: PMC8694695 DOI: 10.23876/j.krcp.21.600] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Su Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Jin Park
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jong Cheol Jeong
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - for the Korean Society of Nephrology Clinical Practice Guideline Work Group
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans College of Medicine, Seoul, Republic of Korea
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
- Asan Jin Internal Medicine Clinic, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
- Truewords Dialysis Clinic, Incheon, Republic of Korea
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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29
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van Oevelen M, Abrahams AC, Bos WJW, Hoekstra T, Hemmelder MH, ten Dam M, van Buren M. Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation. Nephrol Dial Transplant 2021; 36:2112-2119. [PMID: 34390576 PMCID: PMC8577625 DOI: 10.1093/ndt/gfab244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dialysis withdrawal is a common cause of death in dialysis-dependent patients. This study aims to describe dialysis withdrawal practice in The Netherlands, focussing on time trends, risk factors and centre variation. METHODS Data were retrieved from the Dutch registry of kidney replacement therapy patients. All patients who started maintenance dialysis and died in the period 2000-2019 were included. The main outcome was death after dialysis withdrawal; all other causes of death were used for comparison. Time trends were analysed as unadjusted data (proportion per year) and the year of death was included in a multivariable logistic model. Univariable and multivariable analyses were performed to identify factors associated with withdrawal. Centre variation was compared using funnel plots. RESULTS A total of 34 692 patients started dialysis and 18 412 patients died while on dialysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 18.3% in 2000-2004 to 26.8% in 2015-2019. Of all patients withdrawing, 26.1% discontinued treatment within their first year. In multivariable analysis, increasing age, female sex, haemodialysis as a treatment modality and year of death were independent factors associated with death after dialysis withdrawal. Centre variation was large (80.7 and 57.4% within 95% control limits of the funnel plots for 2000-2009 and 2010-2019, respectively), even after adjustment for confounding factors. CONCLUSIONS Treatment withdrawal has become the main cause of death among dialysis-dependent patients in The Netherlands, with large variations between centres. These findings emphasize the need for timely advance care planning and improving the shared decision-making process on choosing dialysis or conservative care.
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Affiliation(s)
- Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Tiny Hoekstra
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands
- Department of Nephrology, Amsterdam University Medical Center–Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc ten Dam
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
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30
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Maenosono R, Matsunaga T, Yoshikawa Y, Nishimura K, Onaka H, Komura K, Uehara H, Azuma H. Hemodialysis Initiation in Oldest-Old Patients: A Case Series. Case Rep Nephrol Dial 2021; 11:286-291. [PMID: 34722647 PMCID: PMC8543281 DOI: 10.1159/000518706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
With an increase in the number of older adults worldwide, the oldest-old population, defined as individuals over the age of 90, is also growing. Japan is now facing the problem of a “super-aged society” in which over 21% of the population is aged over 65. The oldest-old constituted 1.8% (2.31 million) of the Japanese population in 2019. Such individuals have special health-care needs. In cases of acute or chronic (or both) renal failure in the oldest-old, it becomes difficult to decide whether dialysis should be initiated. The issue is controversial, and there is some debate on whether dialysis should be avoided in elderly people because of their frailty or if it should be initiated to enable them to spend their remaining years with their families by improving their quality of life. Herein, we describe our experience in 4 cases of hemodialysis initiated in patients over the age of 90. In our experience, dialysis enabled them to spend the rest of their lives with their families, which could not have been possible without it. Although further studies are needed, we concluded that oldest-old individuals in good general health could be eligible for and benefit from hemodialysis.
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Affiliation(s)
- Ryoichi Maenosono
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Tomohisa Matsunaga
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yuki Yoshikawa
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kazuki Nishimura
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Haruhiko Onaka
- Department of Cardiology, Takatsuki Red Cross Hospital, Osaka, Japan
| | - Kazumasa Komura
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hirofumi Uehara
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Haruhito Azuma
- Department of Urology, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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Palliative Care in Patients with End-Stage Renal Disease: A Meta Synthesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010651. [PMID: 34682395 PMCID: PMC8535479 DOI: 10.3390/ijerph182010651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 01/20/2023]
Abstract
End-stage renal disease is the last stage of chronic kidney disease and is associated with a decreased quality of life and life expectancy. This study aimed to explore palliative care with end-stage renal disease. Qualitative meta-synthesis was used as the study design. The search was performed for qualitative studies published until June 2021 and uses reciprocal translation and synthesis of in vivo and imported concepts. Five themes were included: Struggling to face the disease, experiencing deterioration, overcoming the challenges of dialysis, leading to a positive outlook, and preparing for the end of life. In facing chronic disease with life-limiting potential, patients experienced some negative feelings and deterioration in their quality of life. Adaptation to the disease then leads patients to a better outlook through increased spirituality and social status. Furthermore, by accepting the present condition, they started to prepare for the future. Increasing awareness of mortality leads them to discuss advance care (ACP) planning with healthcare professionals and families.
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32
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Engelbrecht BL, Kristian MJ, Inge E, Elizabeth K, Guldager LT, Helbo TL, Jeanette F. Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review. BMC Nephrol 2021; 22:307. [PMID: 34507554 PMCID: PMC8434727 DOI: 10.1186/s12882-021-02516-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Patients with stage 5 chronic kidney disease (CKD5) collaborate with their clinicians when choosing their future treatment modality. Most elderly patients with CKD5 may only have two treatment options: dialysis or conservative kidney management (CKM). The objective of this systematic review was to investigate whether CKM offers a quantity or quality of life benefit compared to dialysis for some patients with CKD5. Methods The databases MEDLINE, EMBASE, the Cochrane Library, and CINAHL were systematically searched for studies comparing patients with CKD5 who had chosen or were treated with either CKM or dialysis. The primary outcomes were mortality and quality of life (QoL). Hospitalization, symptom burden, and place of death were secondary outcomes. For studies reporting hazard ratios, pooled values were calculated, and forest plots conducted. Results Twenty-five primary studies, all observational, were identified. All studies reported an increased mortality in patients treated with CKM (pooled hazard ratio 0.47, 95 % confidence interval 0.34–0.65). For patients aged ≥ 80 years and for elderly individuals with comorbidities, results were ambiguous. In most studies, CKM seemed advantageous for QoL and secondary outcomes. Findings were limited by the heterogeneity of studies and biased outcomes favouring dialysis. Conclusions In general, patients with CKD5 who have chosen or are on CKM live for a shorter time than patients who have chosen or are on dialysis. In patients aged ≥ 80 years old, and in elderly individuals with comorbidities, the survival benefits of dialysis seem to be lost. Regarding QoL, symptom burden, hospitalization, and place of death, CKM may have advantages. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02516-6.
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Affiliation(s)
- Buur Louise Engelbrecht
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Madsen Jens Kristian
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Eidemak Inge
- Department of Palliative Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Krarup Elizabeth
- Department of Renal Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | | | - Finderup Jeanette
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Nierenersatzverfahren bei Hochbetagten. DER NEPHROLOGE 2021; 16:261-268. [PMID: 34405030 PMCID: PMC8361401 DOI: 10.1007/s11560-021-00518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/03/2022]
Abstract
Hochbetagte haben an der Hämodialyse eine 1‑Jahres-Mortalität, die im Zusammenhang mit Komorbiditäten und einem Katheter als Dialysezugang 30 % übersteigt. Metaanalysen zeigen aber, dass frühzeitige Vorbereitung und individuelle Verfahrensauswahl die Morbidität und Mortalität auch im hohen Lebensalter entscheidend bessern. Mit zunehmendem Alter und Gebrechlichkeit verschieben sich dabei die Behandlungsziele weg von der Verlängerung der Lebensdauer auf die Verbesserung der Lebensqualität. Damit kann die Präferenz von Heimdialyseverfahren, auch als assistierte Peritonealdialyse, ebenso Bedeutung erringen wie die fachnephrologische Behandlung ohne Nierenersatzverfahren mit palliativem Therapieziel. Im höheren Lebensalter bestimmen zunehmend Komorbiditäten, kognitive Einschränkungen, Gebrechlichkeit und die Gesamtprognose das sinnvolle Vorgehen. Bereits bei der Anlage von Gefäßzugängen ergeben sich hinsichtlich Anastomosenort und Anlagezeitpunkt bei Hochbetagten andere Entscheidungskriterien. Empfehlungen zu Dialysedauer und -frequenz folgen der Lebensqualität mit inkrementellen und am Ende des Lebens auch dekrementellen Therapieregimen. Die demographische Entwicklung stellt die Nephrologie mit einer Zunahme älterer Patienten vor besondere Herausforderungen. Frühzeitige Aufklärung über alle Nierenersatzverfahren und die Festlegung individueller Therapieziele können bei sorgfältiger Auswahl von Dialysemodalität und -intensität auch bei Hochbetagten entscheidend zur Verbesserung der Prognose und insbesondere der Lebensqualität beitragen.
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Rao IR, Vallath N, Anupama YJ, Gupta KL, Rao KS. Decision-making around Commencing Dialysis. Indian J Palliat Care 2021; 27:S6-S10. [PMID: 34188372 PMCID: PMC8191747 DOI: 10.4103/ijpc.ijpc_61_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/05/2021] [Indexed: 11/08/2022] Open
Abstract
The decision regarding dialysis initiation is complex. Awareness that renal replacement therapy should not be regarded as default therapy for every patient with advanced renal failure is necessary. Decision to initiate dialysis and modality should be individualized in a shared decision-making process involving the treating nephrologist and the patient. Patients should receive predialysis education early in the course of chronic kidney disease so as to help prepare them well in advance for this eventuality. Withholding dialysis may be a reasonable option in a certain subset of patients, especially elderly patient with multiple co-morbid illnesses. Comprehensive conservation care should be offered in all patients where the decision to not dialyze is taken.
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Affiliation(s)
- Indu Ramachandra Rao
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nandini Vallath
- Division of Palliative Care, National Cancer Grid, India.,Department of Palliative Care, BARC Hospital, Mumbai, Maharashtra, India.,Department of Palliative Care and Division of Medical Humanities, KEM Hospital, Mumbai, Maharashtra, India
| | - Y J Anupama
- Department of Nephrology, Nanjappa Hospital, Shivamogga, Karnataka, India
| | - Krishan Lal Gupta
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Krithika S Rao
- Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
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Murphy E, Burns A, Murtagh FEM, Rooshenas L, Caskey FJ. The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease. Nephrol Dial Transplant 2021; 36:975-982. [PMID: 32940683 PMCID: PMC8160947 DOI: 10.1093/ndt/gfaa209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 11/12/2022] Open
Abstract
Shared decision making in advanced chronic kidney disease (CKD) requires unbiased information on survival and person-centred outcomes known to matter to patients: quality of life, symptom burden and support from family and healthcare professionals. To date, when deciding between dialysis and conservative care, patients have had to rely on evidence from small observational studies. Clinicians recognize that like is not being compared with like in these studies, and interpret the results differently. Furthermore, support differs considerably between renal units. What patients choose therefore depends on which renal unit they attend. To address this, a programme of work has been underway in the UK. After reports on survival and symptoms from a small number of renal units, a national, mixed-methods study-the Conservative Kidney Management Assessment of Practice Patterns Study-mapped out conservative care practices and attitudes in the UK. This led to the Prepare for Kidney Care study, a randomized controlled trial comparing preparation for dialysis versus preparation for conservative care. Although powered to detect a positivist 0.345 difference in quality-adjusted life years between the two treatments, this trial also takes a realist approach with a range of person-centred secondary outcomes and embedded qualitative research. To understand generalizability, it is nested in an observational cohort study, which is nested in a CKD registry. Challenges to recruitment and retention have been rapidly identified and addressed using an established embedded mixed methods approach-the QuinteT recruitment intervention. This review considers the background to and progress with recruitment to the trial.
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Affiliation(s)
- Emma Murphy
- Health Sciences, University of Southampton, Southampton, UK
| | - Aine Burns
- The Royal Free Hospital, Renal Center for Nephrology Royal Free Hospital NHS Trust, London, UK
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, UK
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Blum MF, Sozio SM. Conservative Kidney Management Versus Dialysis Initiation: Can New Statistical Tools Help Understand the Bias in This Choice? Kidney Med 2021; 3:18-19. [PMID: 33605944 PMCID: PMC7873830 DOI: 10.1016/j.xkme.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Matthew F. Blum
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
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Jassal SV, Larkina M, Jager KJ, Murtagh FEM, O'Hare AM, Hanafusa N, Morgenstern H, Port FK, McCullough K, Pisoni R, Tentori F, Perlman R, Swartz RD. International variation in dialysis discontinuation in patients with advanced kidney disease. CMAJ 2020; 192:E995-E1002. [PMID: 32868271 DOI: 10.1503/cmaj.191631] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. METHODS We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. RESULTS A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. INTERPRETATION We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.
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Affiliation(s)
- Sarbjit V Jassal
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich.
| | - Maria Larkina
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Kitty J Jager
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Fliss E M Murtagh
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Ann M O'Hare
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Norio Hanafusa
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Hal Morgenstern
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Friedrich K Port
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Keith McCullough
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Ronald Pisoni
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Francesca Tentori
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Rachel Perlman
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Richard D Swartz
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
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Harris DCH, Davies SJ, Finkelstein FO, Jha V, Donner JA, Abraham G, Bello AK, Caskey FJ, Garcia GG, Harden P, Hemmelgarn B, Johnson DW, Levin NW, Luyckx VA, Martin DE, McCulloch MI, Moosa MR, O'Connell PJ, Okpechi IG, Pecoits Filho R, Shah KD, Sola L, Swanepoel C, Tonelli M, Twahir A, van Biesen W, Varghese C, Yang CW, Zuniga C. Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int 2020; 95:S1-S33. [PMID: 30904051 DOI: 10.1016/j.kint.2018.12.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/28/2018] [Indexed: 12/17/2022]
Abstract
The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.
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Affiliation(s)
- David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia.
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India; University of Oxford, Oxford, UK
| | - Jo-Ann Donner
- International Society of Nephrology, Brussels, Belgium
| | - Georgi Abraham
- Nephrology Division, Madras Medical Mission Hospital, Pondicherry Institute of Medical Sciences, Chennai, India
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fergus J Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK; Population Health Sciences, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Guillermo Garcia Garcia
- Servicio de Nefrologia, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital 278, Guadalajara, JAL, Mexico
| | - Paul Harden
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Brenda Hemmelgarn
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David W Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia; Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Nathan W Levin
- Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Valerie A Luyckx
- Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland; Lecturer, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mignon I McCulloch
- Paediatric Intensive and Critical Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mohammed Rafique Moosa
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa; Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Roberto Pecoits Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil; Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | | | - Laura Sola
- Dialysis Unit, CASMU-IAMPP, Montevideo, Uruguay
| | - Charles Swanepoel
- Division of Nephrology and Hypertension, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Twahir
- Parklands Kidney Centre, Nairobi, Kenya; Department of Medicine, The Aga Khan University Hospital, Nairobi, Kenya
| | - Wim van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | | | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Carlos Zuniga
- School of Medicine, Catholic University of Santisima Concepción, Concepcion, Chile
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Verberne WR, van den Wittenboer ID, Voorend CGN, Abrahams AC, van Buren M, Dekker FW, van Jaarsveld BC, van Loon IN, Mooijaart SP, Ocak G, van Delden JJM, Bos WJW. Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review. Nephrol Dial Transplant 2020; 36:1418-1433. [DOI: 10.1093/ndt/gfaa078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/18/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.
Methods
We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.
Results
Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.
Conclusions
The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.
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Affiliation(s)
- Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carlijn G N Voorend
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, Haga Hospital, The Hague, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands
| | - Ismay N van Loon
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gurbey Ocak
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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40
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Carswell C, Noble H, Reid J, McKeaveney C. Conservative management of patients with end-stage kidney disease. Nurs Stand 2020; 35:43-50. [PMID: 31867916 DOI: 10.7748/ns.2019.e11416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2019] [Indexed: 06/10/2023]
Abstract
The prevalence of end-stage kidney disease is increasing, particularly among older people and those with multiple comorbidities. Typically, patients who develop end-stage kidney disease receive renal replacement therapies such as dialysis; however, this treatment can significantly affect quality of life and may not prolong life in older patients. Therefore, some patients may choose not to undergo dialysis and instead choose conservative management, which involves a palliative approach that focuses on maintaining quality of life and advance care planning. This article details the steps involved in a conservative kidney management pathway for end-stage kidney disease, including symptom management and advance care planning. It also discusses the importance of a palliative approach for patients receiving dialysis.
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Affiliation(s)
- Claire Carswell
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, Northern Ireland
| | - Helen Noble
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, Northern Ireland
| | - Joanne Reid
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, Northern Ireland
| | - Clare McKeaveney
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, Northern Ireland
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41
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Li HL, Tai PH, Hwang YT, Lin SW. A five-year longitudinal study of the relation between end-stage kidney disease as the outcomes. BMC Nephrol 2020; 21:132. [PMID: 32295526 PMCID: PMC7161172 DOI: 10.1186/s12882-020-01795-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patients with end-stage kidney disease (ESKD) are required to undergo consecutive time-based blood and biochemical tests to determine the progression of the disease according to changes in their blood and biochemical data. This study employed a random intercept model to investigate whether time-based blood and biochemical data present any notable clinical meaning that can be used to track disease progression. Methods This study conducted a retrospective analysis on the dialytic data of 148 patients with ESKD, who received hemodialysis between January 2005 and December 2015. The patients were all at least 20 years old, and the data used included patient demographic information and results for at least 60 blood and biochemical tests. A random intercept model was used to analyze the relationships among blood and biochemical test results, explanatory variables of patient comorbidities, and time. Results The age range of patients was between 33 and 98 years, with an average of 66.1 years and those over 65 years old comprising 51.3% (n = 76) of the total. Furthermore, hypertension was found to be the most common comorbidity among patients (87.2%, n = 129), followed by anemia (48.6%, n = 72), diabetes (47.3%, n = 70), dyslipidemia (19.6%, n = 29), and peptic ulcer (19.6%, n = 29). Coronary atherosclerotic heart disease is a comorbidity that can serve as a strong and independent marker for prognosis in patients with ESKD. Serum creatinine level can serve as an alternative indicator because patients with ESKD and comorbid diabetes may exhibit increased creatinine levels. Conclusions The results of a parameter estimation for longitudinal data analysis suggested that comorbidity and time were critical variables influencing blood and biochemical test results. Furthermore, WBC and HBC, HCT, albumin, protein, and creatinine levels were recognized as variables of critical significance. The results obtained in this study indicate that multimorbidity increases the treatment burden on patients, leading to polypharmacy. For this reason, comprehensive care and treatment of ESKD cannot rely solely on data from one single time point; instead, longitudinal analysis and other data that can affect patient prognosis must also be considered.
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Affiliation(s)
- Hsiu-Lan Li
- Graduate Institute of Business and Management, Chang Gung University, Taoyuan City, Taiwan
| | - Pei-Hui Tai
- Department of Nursing, En Cku Kong Hospital, New Taipei City, Taiwan
| | - Yi-Ting Hwang
- Department of Statistics, National Taipei University, New Taipei City, Taiwan
| | - Shih-Wei Lin
- Department of Information Management, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, 333, Taiwan. .,Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan. .,Department of Industrial Engineering and Management, Ming Chi University of Technology, New Taipei City, Taiwan.
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42
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Ramspek CL, Verberne WR, van Buren M, Dekker FW, Bos WJW, van Diepen M. Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease. Clin Kidney J 2020; 14:189-196. [PMID: 33564418 PMCID: PMC7857791 DOI: 10.1093/ckj/sfaa021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background Conservative care (CC) may be a valid alternative to dialysis for certain older patients with advanced chronic kidney disease (CKD). A model that predicts patient prognosis on both treatment pathways could be of value in shared decision-making. Therefore, the aim is to develop a prediction tool that predicts the mortality risk for the same patient for both dialysis and CC from the time of treatment decision. Methods CKD Stage 4/5 patients aged ≥70 years, treated at a single centre in the Netherlands, were included between 2004 and 2016. Predictors were collected at treatment decision and selected based on literature and an expert panel. Outcome was 2-year mortality. Basic and extended logistic regression models were developed for both the dialysis and CC groups. These models were internally validated with bootstrapping. Model performance was assessed with discrimination and calibration. Results In total, 366 patients were included, of which 126 chose CC. Pre-selected predictors for the basic model were age, estimated glomerular filtration rate, malignancy and cardiovascular disease. Discrimination was moderate, with optimism-corrected C-statistics ranging from 0.675 to 0.750. Calibration plots showed good calibration. Conclusions A prediction tool that predicts 2-year mortality was developed to provide older advanced CKD patients with individualized prognosis estimates for both dialysis and CC. Future studies are needed to test whether our findings hold in other CKD populations. Following external validation, this prediction tool could be used to compare a patient’s prognosis on both dialysis and CC, and help to inform treatment decision-making.
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Affiliation(s)
- Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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43
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Engels N, de Graav G, van der Nat P, van den Dorpel M, Bos WJ, Stiggelbout AM. Shared decision-making in advanced kidney disease: a scoping review protocol. BMJ Open 2020; 10:e034142. [PMID: 32111615 PMCID: PMC7050317 DOI: 10.1136/bmjopen-2019-034142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Patients with advanced kidney disease (AKD) have to make difficult treatment modality decisions as their disease progresses towards end-stage kidney disease. International guidelines in nephrology suggest shared decision-making (SDM) to help patients make timely treatment modality decisions that align with their values and preferences. However, systematic reviews or scoping reviews on these SDM interventions and on their reported use or outcomes are lacking. This limits the adoption of SDM in clinical practice and hampers further research and development on the subject. Our aim is to provide a comprehensive and up-to-date overview of these SDM interventions by means of a scoping review of the literature. Scoping reviews can provide a broad overview of a topic, identify gaps in the research knowledge base and report on the types of evidence that address and inform practices. This paper presents our study protocol. METHODS AND ANALYSIS The proposed scoping review will be performed in accordance with the Joanna Briggs Institute's (JBI) methodology for scoping reviews. It will cover both qualitative and quantitative scientific literature, as well as the grey literature on SDM interventions for treatment modality decisions in AKD. Only literature written in English will be considered for inclusion. Two independent reviewers will participate in an iterative process of screening the literature, paper selection and data extraction. Disagreements between the reviewers will be resolved by discussion until consensus is reached or after consultation with the research team when needed. Results will be reported with descriptive statistics and diagrammatic or tabular displayed information, accompanied by narrative summaries as explained in the JBI guidelines. ETHICS AND DISSEMINATION Ethical approval for the conduct of this study is not required. We will analyse previously collected data for the proposed scoping review. Our results will be published in a peer-reviewed journal and disseminated through conferences and/or seminars.
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Affiliation(s)
- Noel Engels
- Shared decision making, Santeon, Utrecht, Utrecht, The Netherlands
| | - Gretchen de Graav
- Internal Medicine, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | | | | | - Willem Jan Bos
- Internal Medicine, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Leiden University Medical Center, Leiden, Zuid Holland, The Netherlands
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44
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Hole B, Hemmelgarn B, Brown E, Brown M, McCulloch MI, Zuniga C, Andreoli SP, Blake PG, Couchoud C, Cueto-Manzano AM, Dreyer G, Garcia Garcia G, Jager KJ, McKnight M, Morton RL, Murtagh FEM, Naicker S, Obrador GT, Perl J, Rahman M, Shah KD, Van Biesen W, Walker RC, Yeates K, Zemchenkov A, Zhao MH, Davies SJ, Caskey FJ. Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world. Kidney Int Suppl (2011) 2020; 10:e86-e94. [PMID: 32149013 DOI: 10.1016/j.kisu.2019.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022] Open
Abstract
A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.
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Affiliation(s)
- Barnaby Hole
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Brenda Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Edwina Brown
- Imperial College Healthcare National Health Service Trust, London, UK
| | - Mark Brown
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Mignon I McCulloch
- Paediatric Intensive and Critical Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Carlos Zuniga
- School of Medicine, Catholic University of Santisima Concepción, Advanced Renal Care Unit - Las Higueras Hospital, Talcahuano, Chile
| | - Sharon P Andreoli
- Department of Pediatrics, Pediatric Nephrology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Peter G Blake
- Ontario Renal Network, Toronto, Ontario, Canada.,Division of Nephrology, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Cécile Couchoud
- French Renal Epidemiology and Information Network (REIN) Registry, Biomedicine Agency, Paris, France
| | - Alfonso M Cueto-Manzano
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Gavin Dreyer
- Department of Nephrology, Barts Health National Health Service Trust, London, UK
| | - Guillermo Garcia Garcia
- Servicio de Nefrologia, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital 278, Guadalajara, Jalisco, Mexico
| | - Kitty J Jager
- The European Renal Association - European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Marla McKnight
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Saraladevi Naicker
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gregorio T Obrador
- Universidad Panamericana Faculty of Health Sciences and School of Medicine, Mexico City, Mexico
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Muhibur Rahman
- Department of Nephrology, Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
| | | | - Wim Van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Rachael C Walker
- School of Nursing, Eastern Institute of Technology, Napier, New Zealand.,Renal Department, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Karen Yeates
- Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia.,Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Key Lab of Renal Disease, Ministry of Health of China, Beijing, China.,Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Fergus J Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK.,The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
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Tam-Tham H, Ravani P, Zhang J, Weaver RG, Quinn RR, James MT, Liu P, Manns BJ, Tonelli M, Ronksley PE, Harrison TG, Thomas C, Davison S, Hemmelgarn BR. Association of Initiation of Dialysis With Hospital Length of Stay and Intensity of Care in Older Adults With Kidney Failure. JAMA Netw Open 2020; 3:e200222. [PMID: 32108896 PMCID: PMC7049084 DOI: 10.1001/jamanetworkopen.2020.0222] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Comparative outcome data examining the association of dialysis initiation with hospital length of stay and intensity of care in older adults with kidney failure are scarce, and prior studies are limited to patients treated by nephrology teams. OBJECTIVE To compare in-hospital days and intensity of care among older adults with kidney failure who were treated vs not treated with maintenance dialysis. DESIGN, SETTING, AND PARTICIPANTS This population-based, retrospective cohort study included adults in Alberta, Canada, 65 years or older with kidney failure, defined by at least 2 consecutive outpatient estimated glomerular filtration rate values of less than 10 mL/min/1.73 m2 spanning a period of at least 90 days from May 15, 2002, to March 31, 2014. Data were analyzed from August 1, 2017, to August 29, 2019. EXPOSURES Time-varying exposure to maintenance dialysis for treatment of kidney failure. MAIN OUTCOMES AND MEASURES The primary outcome was rate of in-hospital days. Secondary outcomes included rates of hospital admissions, intensive care unit admissions, cardiopulmonary resuscitations, inpatient palliative care, and emergency department visits; risk of in-hospital death; and time to admission to long-term care. RESULTS A total of 968 patients (median age, 78.5 [interquartile range, 72.4-84.7] years; 489 men [50.5%]; median follow-up, 2.0 [interquartile range, 0.8-3.9] years) were included in the analysis. Patients who underwent dialysis spent more adjusted in-hospital days per person-year (36.25 [95% CI, 30.72-41.77] vs 14.65 [95% CI, 12.28-17.02]; incidence rate ratio [IRR], 2.47 [95% CI, 1.99-3.08]). However, the dialysis group did not have a higher rate of hospital admissions (1.18 [95% CI 1.07-1.29] vs 1.32 [95% CI 1.17-1.48] per year; IRR, 0.89 [95% CI, 0.77-1.03]). Patients in the dialysis group had a higher rate of intensive care unit admissions per 1000 hospitalizations (98.37 [95% CI, 81.09-115.65] vs 54.51 [95% CI, 37.76-71.26]; IRR, 1.80 [95% CI, 1.28-2.54]) and lower rates of inpatient palliative care per 1000 in-hospital days (3.92 [95% CI, 3.13-4.72] vs 8.60 [95% CI, 6.3-11.0]; IRR, 0.45 [95% CI, 0.32-0.64]). CONCLUSIONS AND RELEVANCE In this cohort study, compared with nondialysis care, patients who received maintenance dialysis spent more time in the hospital and were more likely to be admitted to intensive care units. This finding suggests trade-offs between longer survival and higher intensity of use of health care services as a function of dialysis initiation. Maintenance dialysis may be a proxy for the type of philosophy of care driving increased in-hospital time and intensive care and less use of palliative care.
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Affiliation(s)
- Helen Tam-Tham
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jianguo Zhang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G. Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ping Liu
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G. Harrison
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra Thomas
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sara Davison
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Worthen G, Tennankore K. Frailty Screening in Chronic Kidney Disease: Current Perspectives. Int J Nephrol Renovasc Dis 2019; 12:229-239. [PMID: 31824188 PMCID: PMC6901033 DOI: 10.2147/ijnrd.s228956] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022] Open
Abstract
Frailty has been defined as a state of increased vulnerability as a consequence of deficit accumulation. Frailty screening has not yet been widely implemented into routine nephrology care. Patients with chronic kidney disease (CKD) are at high risk of being frail, and frailty has been associated with worse outcomes in this population. Standard management of CKD, including initiation of renal replacement therapies, may have decreased benefit or potentially cause harm in the presence of frailty, and a variety of interventions for modifying frailty in the CKD population have been proposed. The optimal means of screening for frailty in patients with kidney disease remains unclear. This review highlights the value of frailty screening in CKD by summarizing the outcomes associated with frailty and exploring proposed changes to the management of frail patients with CKD. Finally, we will propose a framework for how to implement frailty screening into standard nephrology care.
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Affiliation(s)
- George Worthen
- Department of Medicine, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Karthik Tennankore
- Division of Nephrology, Nova Scotia Health Authority, Halifax, NS, Canada
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47
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End-of-life and palliative care of patients on maintenance hemodialysis treatment: a focus group study. BMC Palliat Care 2019; 18:89. [PMID: 31666038 PMCID: PMC6822338 DOI: 10.1186/s12904-019-0481-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/18/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Despite complex illness trajectories and a high symptom burden, palliative care has been sub-optimal for patients with end-stage kidney disease and hemodialysis treatment who have a high rate of hospitalization and intensive care towards end of life. There is a growing awareness that further development of palliative care is required to meet the needs of these patients and their family members. In this process, it is important to explore healthcare professionals' views on provision of care. The aim of this study was therefore to describe nurses' and physicians' perspectives on end-of-life and palliative care of patients treated with maintenance hemodialysis. METHODS Four focus group interviews were conducted with renal nurses (17) and physicians (5) in Sweden. Qualitative content analysis was used to analyze data. RESULTS Participants were committed to giving the best possible care to their patients, but there were challenges and barriers to providing quality palliative care in nephrology settings. Professionals described palliative care as end-of-life care associated with hemodialysis withdrawal or palliative dialysis, but also identified care needs and possibilities that are in line with an earlier integrated palliative approach. This was perceived as complex from an organizational point of view. Participants identified challenges related to coordination of care and different perspectives on care responsibilities that impacted symptom management and patients' quality of life. Communication issues relating to the provision of palliative care were revealed where the hemodialysis setting was regarded as an impediment, and personal and professional experiences, beliefs and knowledge were considered of major importance. CONCLUSIONS Nurses and physicians identified a need for the improvement of both late and earlier palliative care approaches. The results highlighted a requirement for and possibilities of training, counselling and support of health care professionals in the dialysis context. Further, multi-professional palliative care collaborations should be developed to improve the coordination and organization of end-of-life and palliative care of patients and their family members. A climate allowing conversations about advance care planning throughout the illness trajectory may facilitate the gradual integration of palliative care alongside life-prolonging treatment for improved support of patients and families.
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48
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Ohya M, Iwashita Y, Kunimoto S, Yamamoto S, Mima T, Negi S, Shigematsu T. An Analysis of Medication Adherence and Patient Preference in Long-term Stable Maintenance Hemodialysis Patients in Japan. Intern Med 2019; 58:2595-2603. [PMID: 31178499 PMCID: PMC6794165 DOI: 10.2169/internalmedicine.2676-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/17/2019] [Indexed: 01/27/2023] Open
Abstract
Objective This follow-up survey report describes medication adherence and patient preferences, beliefs, and expectations of maintenance hemodialysis treatment in Japan. Methods This patient-reported questionnaire-based survey was conducted in six regions in Japan from September 2016 to November 2016. Patients The questionnaire was provided to 700 patients (50-79 years old) on maintenance hemodialysis for >3 years who were members of the Japan Association of Kidney Disease Patients. Patients were randomly selected by a stratified sampling method based on patient distribution observed from the Japanese Society for Dialysis Therapy Renal Data Registry. Results A total of 524 (74.9%) complete patient questionnaires were evaluated; the mean (SD) age was 66.6 (7.2) years (men, 63.4%) with a dialysis vintage of 16.9 (9.1) years. Adherence was high for all types of medications: between 76.7% for phosphate binders and 95.7% for antidiabetic medications. The most common reason for a missed dose was forgetting to take medication [52.5% (117/223)]. Patient preference for oral medication was as low as 0.9% (1/110), 9% (31/345), and 2.9% (2/69) for patients who felt mental burden, felt no mental burden, and neither, respectively, with their current treatment regimen. In addition, 37.8% (198/524) of patients responded that the elimination of 1 medication (1 tablet) would reduce their mental burden. Conclusion The results of this survey show that overall medication adherence is high in Japanese patients on maintenance hemodialysis. While many patients perceive an absence of mental burden, they still prefer to avoid oral medication when possible.
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Affiliation(s)
- Masaki Ohya
- Department of Nephrology, Wakayama Medical University, Japan
| | - Yuko Iwashita
- Department of Nephrology, Wakayama Medical University, Japan
| | - Satoko Kunimoto
- Department of Nephrology, Wakayama Medical University, Japan
| | - Shuto Yamamoto
- Department of Nephrology, Wakayama Medical University, Japan
| | - Toru Mima
- Department of Nephrology, Wakayama Medical University, Japan
| | - Shigeo Negi
- Department of Nephrology, Wakayama Medical University, Japan
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Sowa PM, Purtell L, Hoy WE, Healy HG, Bonner A, Connelly LB. Utilization and Costs of Health Care in a Kidney Supportive Care Program. J Palliat Care 2019; 35:176-184. [PMID: 31456473 DOI: 10.1177/0825859719868174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Kidney supportive care (KSC) is a patient-centered model of multidisciplinary care designed for patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Our goal was to characterize the types, frequencies, and costs of services accessed by patients enrolled in a KSC program. We analyzed health care utilization data prospectively collected from 102 patients who enrolled in the KSC program during the first 52 weeks of its existence. The data comprised program appointments, emergency department presentations, ambulance service use, outpatient visits, inpatient episodes, and dialysis treatments made within the Brisbane area of Metro North. Costs of resource use were estimated using Queensland Health funding principles and guidelines. Analyses included descriptive statistics, correlations, and multivariate regressions. During the median program participation of 22 weeks, patients had 3975 contacts with health care, with the total value of services amounting to nearly A$3 million. Dialysis treatments accounted for 70% of visits and 49% of costs. Patients receiving dialysis had higher utilization of outpatient services and associated cost, compared to patients who were not dialyzed. The presence of diabetes and the choice of conservative pathway were both predictors of higher frequency and cost of services. Longer program participation was associated with lower weekly utilization and cost. The program attracted patients representing various characteristics, pathways, needs, and outcomes. Exploring these patterns will enable better understanding of the patient population and improved service planning, in KSC and similar programs that aim to comprehensively address the needs of patients with advanced CKD and ESKD.
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Affiliation(s)
- P Marcin Sowa
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Centre for the Business and Economics of Health, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Louise Purtell
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Herston, Queensland, Australia
| | - Wendy E Hoy
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Helen G Healy
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Ann Bonner
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Herston, Queensland, Australia
| | - Luke B Connelly
- NHMRC Chronic Kidney Disease Centre of Research Excellence, The University of Queensland, Herston, Queensland, Australia.,Centre for the Business and Economics of Health, The University of Queensland, Woolloongabba, Queensland, Australia.,Department of Sociology and Business Law, The University of Bologna, Bologna, Italy
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50
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Brown L, Gardner G, Bonner A. A randomized controlled trial testing a decision support intervention for older patients with advanced kidney disease. J Adv Nurs 2019; 75:3032-3044. [DOI: 10.1111/jan.14112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Leanne Brown
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Glenn Gardner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
| | - Ann Bonner
- School of Nursing and Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane Qld Australia
- Chronic Kidney Disease Centre for Research Excellence University of Queensland Brisbane Qld Australia
- Visiting Research Fellow, Kidney Health Service Metro North Hospital and Health Service Brisbane Qld Australia
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