CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life

Uncovering Patient and Caregiver Goals for Goal-Concordant Care in Kidney Therapy Decisions

CONTEXT

In kidney therapy (KT) decisions, goal-concordant decision-making is recognized to be important, yet alignment with patients' goals during dialysis initiation is not always achieved.

OBJECTIVES

To explore older patients' and caregivers' hopes, goals, and fears related to KT and communication of these elements with members of their health care team.

METHODS

The study included patients aged ≥75 years with an estimated glomerular filtration rate ≤25 mL/min/1.73 m2 and their caregivers enrolled in a palliative care intervention for KT decision-making. Patients and caregivers were asked open-ended questions about their hopes, goals, and fears related to KT decisions. A survey assessed if patients shared their goals with members of their health care team. Qualitative data underwent content analysis, supplemented by demographic descriptive statistics.

RESULTS

The mean age of patients (n = 26) was 82.7 (±5.7) years, and caregivers (n = 15) had a mean age of 66.4 (±13.7) years. Among the participants, 13 patients and 11 caregivers were women, and 20 patients and 12 caregivers were White. Four themes emerged: (1) Maintaining things as good as they are by avoiding dialysis-related burdens; (2) seeking longevity while avoiding dialysis; (3) avoiding pain, symptoms, and body disfigurement; and (4) deferring decision-making. Patients rarely had shared their goals with the key members of their health care team.

CONCLUSION

Patients and caregivers prioritize maintaining quality of life, deferring decision-making regarding dialysis, and avoiding dialysis-related burdens. These goals are often unshared with their family and health care teams. Given our aging population, urgent action is needed to educate clinicians to actively explore and engage with patient goals in KT decision-making.

[Renal replacement or conservative treatment in end-stage renal disease in elder patients?]

When elder individuals develop chronic kidney failure, doctors, patients, and family members are faced with the decision: Should dialysis (still) be initiated, or should a conservative-palliative therapy strategy be chosen? A prerequisite for shared decision-making is structured education about the various options, ensuring all necessary information and consequences are communicated. This article outlines the advantages and disadvantages of haemodialysis and peritoneal dialysis, as well as conservative-palliative therapy. Additionally, it discusses the option of a trial dialysis and the choice to discontinue ongoing dialysis.

Barriers to conservative kidney management for Japanese healthcare professionals involved in the treatment of end-stage renal disease

BACKGROUND

Conservative kidney management (CKM) is a treatment alternative for patients with end-stage kidney disease (ESKD). Despite the increasing population of elderly dialysis patients in Japan, CKM is not as readily available compared with that in North America and Europe. Therefore, it is important to clarify the barriers to CKM in Japan.

METHODS

We interviewed 11 experts to explore their beliefs and issues regarding CKM. Based on the interviews, we categorized the CKM barriers into eight categories and created a 24-item questionnaire. A questionnaire survey was conducted among 112 medical professionals involved in ESKD management. To investigate the types of barriers, we conducted an exploratory factor analysis using the questionnaire results.

RESULTS

Responses were obtained from 53 (47.3%) of 112 subjects (18 doctors, 29 nurses, 6 clinical engineers), with 94.3% considering CKM as a treatment option for ESKD. Factor analysis categorized the questions into the following: (1) Lack of palliative care experience, (2) Ethics and responsibility, (3) Patient's problem, (4) Dialog with patients and families, and (5) Lack of support system. Regarding barriers to CKM, "lack of experience in palliative care" and "lack of support system" scored the highest, and "ethics and responsibility" scored the lowest.

CONCLUSIONS

Barriers to CKM may be classified into five factors, with "lack of experience in palliative care" and "lack of support system" being the important barriers to overcome. Additionally, most healthcare professionals consider CKM as the fourth option for renal replacement therapy.

Perspectives of Chronic Kidney Disease Patients on Readiness for Advance Care Planning at Komfo Anokye Teaching Hospital, Ghana

This study examined the impact of advance care planning (ACP) on the quality of life for patients with chronic kidney disease (CKD) at Komfo Anokye Teaching Hospital in Ghana. It specifically investigated patients' perspectives on their readiness for ACP. Utilizing a qualitative descriptive design, one-on-one interviews were conducted with CKD patients at the renal clinic, employing a semi-structured interview guide for thematic analysis of audio data. The findings revealed a gap in understanding among CKD patients, with participants acknowledging their vulnerability to renal failure, often linked to a medical history of diabetes and hypertension. Despite recognizing potential outcomes such as dialysis dependency or death, some patients retained hope for a cure, relying on faith. The initial kidney failure diagnosis induced shock and distress, leading many patients to prefer the comfort and familiarity of home-based care, including dialysis. Meanwhile, a minority favored hospital care to protect their children from psychological trauma. Most patients deemed legal preparations unnecessary, citing limited assets or a lack of concern for posthumous estate execution. These insights emphasize the necessity for targeted education and support in ACP to enhance patient outcomes in chronic kidney disease care and end-of-life planning.

Usefulness of assessment of the Clinical Frailty Scale and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items at the time of initiation of maintenance hemodialysis in older patients with chronic kidney disease

INTRODUCTION

We examined whether the Clinical Frailty Scale (CFS), a widely adopted tool for stratifying the degree of frailty, and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items (DASC-21), a simple tool for simultaneous assessment of impaired cognition and impaired ADL, at the time of initiation of hemodialysis is useful tool of older patients for the outcome and prognosis.

METHODS

Data for 101 patients aged 75 years or older (mean age, 84.3 years) with ESRD who were initiated on hemodialysis and could be followed up for a period of 6 months were reviewed.

RESULTS

The 6-month survival curves showed a significantly higher number of deaths in the frailty (CFS≥5) group than in the normal to vulnerable (CFS<5) group (p<0.01). The CFS level was also significantly higher (6.5±1.5) in patients who died within 6 months of dialysis initiation as compared with that (4.6±1.7) in patients who survived (p<0.01). On the other hand, the total score of DASC-21 was related to need for inpatient maintenance dialysis (p<0.01). The total score on the DASC-21 were found as showing significant correlations with the CFS level. The IADL outside the home was identified in the DASC-21 sub-analyses as being correlated with CFS.

CONCLUSIONS

The CFS and the DASC-21 appeared to be a useful predictive tool of outcome and prognosis for older patients being initiated on hemodialysis. Assessment by the CFS or the DASC-21 might be useful for selecting the renal replacement therapy by shared decision-making and for advance care planning.

Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.

Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care

Key Points

A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices. Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance. Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers.

Background

Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers.

Methods

The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC.

Results

The seven key lessons are (1 ) systematically assess KSC needs; (2 ) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3 ) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4 ) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5 ) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6 ) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7 ) implement systematic approaches to support patients who choose active medical management without dialysis.

Conclusions

Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals.

Clinical Trial registry name and registration number

Pathways Project: KSC, NCT04125537 .

The trajectory of a range of commonly captured symptoms with standard care in people with kidney failure receiving haemodialysis: consideration for clinical trial design

BACKGROUND

Despite the recognized high symptom prevalence in haemodialysis population, how these symptoms change over time and its implications for clinical practice and research is poorly understood.

METHODS

Prevalent haemodialysis patients in the SHAREHD trial reported 17 POS-S Renal symptoms (none, mild, moderate, severe and overwhelming) at baseline, 6, 12 and 18 months. To assess the prevalence change at population level in people reporting moderate or worse symptoms at baseline, the absolute change in prevalence was estimated using multi-level mixed effects probit regression adjusting for age, sex, time on haemodialysis and Charlson Comorbidity Score. To assess changes at individual level, the proportion of people changing their symptom score every 6 months was estimated.

RESULTS

Five hundred fifty-two participants completed 1725 questionnaires at four timepoints. Across all 17 symptoms with moderate or worse symptom severity at baseline, the majority of the change in symptom prevalence at population level occurred in the 'severe' category. The absolute improvement in prevalence of the 'severe' category was ≤ 20% over 18 months in eleven of the seventeen symptoms despite a large degree of relatively balanced movement of individuals in and out of severe category every six months. Examples include depression, skin changes and drowsiness, which had larger proportion (75-80%) moving in and out of severe category each 6 months period but < 5% difference between movement in and out of severe category resulting in relatively static prevalence over time. Meanwhile, larger changes in prevalence of > 20% were observed in six symptoms, driven by a 9 to 18% difference between movement in and movement out of severe category. All symptoms had > 50% of people in severe group changing severity within 6 months.

CONCLUSIONS

Changes in the severity of existing symptoms under standard care were frequent, often occurring within six months. Certain symptoms exhibited clinically meaningful shifts at both the population and individual levels. This highlighted the need to consider improvements in symptom severity when determining sample size and statistical power for trials. By accounting for potential symptom improvements with routine care, researchers can design trials capable of robustly detecting genuine treatment effects, distinguishing them from spontaneous changes associated with standard haemodialysis.

Economic evaluation of dialysis and comprehensive conservative care for chronic kidney disease using the ICECAP-O and EQ-5D-5L; a comparison of evaluation instruments

BACKGROUND

Chronic Kidney Disease (CKD) patients often require long-term care, and while Hemodialysis (HD) is the standard treatment, Comprehensive Conservative Care (CCC) is gaining popularity as an alternative. Economic evaluations comparing their cost-effectiveness are crucial. This study aims to perform a cost-utility analysis comparing HD and CCC using the EQ-5D-5L and ICECAP-O instruments to assessing healthcare interventions in CKD patients.

METHODS

This short-term economic evaluation involved 183 participants (105 HD, 76 CCC) and collected data on demographics, comorbidities, laboratory results, treatment costs, and HRQoL measured by ICECAP-O and EQ-5D-5L. Incremental Cost-Effectiveness Ratios (ICERs) and Net Monetary Benefit (NMB) were calculated separately for each instrument, and Probabilistic Sensitivity Analysis (PSA) assessed uncertainty.

RESULTS

CCC demonstrated significantly lower costs (mean difference $8,544.52) compared to HD. Both EQ-5D-5L and ICECAP-O indicated higher Quality-Adjusted Life Years (QALYs) for both groups, but the difference was not statistically significant (p > 0.05). CCC dominated HD in terms of HRQoL measures, with ICERs of -$141,742.67 (EQ-5D-5L) and -$4,272.26 (ICECAP-O). NMB was positive for CCC and negative for HD, highlighting its economic feasibility.

CONCLUSION

CCC proves a preferable and more cost-effective treatment option than HD for CKD patients aged 65 and above, regardless of the quality-of-life measure used for QALY calculations. Both EQ-5D-5L and ICECAP-O showed similar results in cost-utility analysis.

Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review

CONTEXT

People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all.

OBJECTIVES

This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services.

METHODS

Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751).

DATA SOURCES

Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses.

RESULTS

Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.

Conservative Kidney Management Practice Patterns and Resources in the United States: A Cross-Sectional Analysis of CKDopps (Chronic Kidney Disease Outcomes and Practice Patterns Study) Data

Rationale & Objective

Conservative kidney management (CKM) is a viable treatment option for many patients with chronic kidney disease. However, CKM practices and resources in the United States are not well described. We undertook this study to gain a better understanding of factors influencing uptake of CKM by describing: (1) characteristics of patients who choose CKM, (2) provider practice patterns relevant to CKM, and (3) CKM resources available to providers.

Study Design

Cross-sectional study.

Setting & Participants

This study is a cross-sectional analysis of data from US nephrology clinics enrolled in the chronic kidney disease Outcomes and Practice Patterns Study (CKDopps) collected between 2014 and 2020. Data for this study includes chart-abstracted characteristics of patients with an estimated glomerular filtration rate ≤30mL/min/1.73m2 (n=1018) and available information on whether a decision had been made to pursue CKM at the time of kidney failure, patient (n=407) reports of discussions about forgoing dialysis, and provider (n=26) responses about CKM delivery and available resources in their health systems.

Analytical Approach

Descriptive statistics were used to report patient demographics, clinical information, provider demographics, and clinic characteristics.

Results

Among data from 1018 patients, 68 (7%) were recorded as planning for CKM. These patients were older, had more comorbidities, and were more likely to require assistance with transfers. Of the 407 patient surveys, 18% reported a conversation about forgoing dialysis with their nephrologist. A majority of providers felt comfortable discussing CKM; however, no clinics had a dedicated clinic or protocol for CKM.

Limitations

Inconsistent survey terminology and unlinked patient and provider responses.

Conclusions

Few patients reported discussion of forgoing dialysis with their providers and even fewer anticipated a choice of CKM on reaching kidney failure. Most providers were comfortable discussing CKM, but practiced in clinics that lacked dedicated resources. Further research is needed to improve the implementation of a CKM pathway.

Plain-Language Summary

For older comorbid adults with kidney failure, conservative kidney management (CKM) can be an appropriate treatment choice. CKM is a holistic approach with treatment goals of maximizing quality of life and preventing progression of chronic kidney disease (CKD) without initiation of dialysis. We investigated US CKM practices and found that among 1018 people with CKD, only 7% were planning for CKM. Of 407 surveyed patients, 18% reported a conversation with their provider about forgoing dialysis. In contrast, most providers felt comfortable discussing CKM; however, none reported working in an environment with a dedicated CKM clinic or protocol. Our data show the need for further CKM education in the United States as well as dedicated resources for its delivery.

The role of low health literacy in shared treatment decision-making in patients with kidney failure

The classic paternalist medicine in nephrology has been modified to a shared decision-making model that clearly offers a benefit in patients with kidney disease. One of the cornerstones of shared treatment decision in patients with kidney failure is the understanding of kidney disease. As kidney disease is silent until advanced stages and is also an entity with a complex pathophysiology with little knowledge in the general population, its presence and understanding are difficult for most people. Health literacy (HL) plays a crucial role in the care of patients with kidney disease and the shared treatment decision. Limited HL has been associated with inefficient use of health services, non-compliance of medications, worse quality of life and increased mortality. In this review, we will address the importance of low HL in nephrology in terms of diagnosis, measurement, its effect on shared decision-making and how to increase it in people with kidney disease.

Kannada Translation and Validation of the ESAS-r Renal for Symptom Burden Survey in Patients with End-Stage Kidney Disease

Objectives

End-stage kidney disease (ESKD) is a life-limiting illness that leads to significant health-related suffering for the patients and their caregivers. Moreover, disease-directed options such as dialysis and renal transplant might not be universally accessible. Inadequate assessment and management of symptoms often lead to diminished quality of life. For evaluating symptoms and their associated distress, various tools have been identified. However, these are not available for the native Kannada-speaking population for assessing ESKD symptom burden. In this study, we determined the reliability and validity of the Edmonton Symptom Assessment System Revised Renal (ESAS-r: Renal) in Kannada-speaking ESKD patients.

Materials and Methods

ESAS-r: Renal English version was translated into Kannada using the forward and backward method. The translated version was endorsed by Nephrology, Palliative care, Dialysis technology and Nursing experts. As a pilot study, 12 ESKD patients evaluated the content of the questionnaires for appropriateness and relevance. The ESAS-r: Renal Kannada version was validated by administering this tool to 45 patients twice a fortnight.

Result

The translated ESAS-r: Renal Kannada version questionnaire had an acceptable face and content validity. Experts' opinion was assessed by content validity ratio (CVR), and the value of CVR of ESAS-r: Renal Kannada version was-'1'-. Internal consistency of the tool was assessed among Kannada-speaking ESKD patients; its Cronbach's α was 0.785, and test-retest validity was 0.896.

Conclusion

The validated Kannada version of ESAS-r: Renal was reliable and valid for assessing symptom burden in ESKD patients.

Survival, symptoms and hospitalization of older patients with advanced chronic kidney disease managed without dialysis

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.

Conservative Kidney Management: When, Why, and For Whom?

Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.

A novel programme of supportive two-exchange assisted continuous ambulatory peritoneal dialysis for frail patients with end-stage kidney disease

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.

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)

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.

Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease

BACKGROUND

Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams.

INTERVENTION

We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles.

MEASURES

We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions.

OUTCOMES

KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions.

LESSONS LEARNED

The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.

Quality of Life before and after the Start of Dialysis in Older Patients

BACKGROUND AND OBJECTIVES

In older people with kidney failure, improving health-related quality of life is often more important than solely prolonging life. However, little is known about the effect of dialysis initiation on health-related quality of life in older patients. Therefore, we investigated the evolution of health-related quality of life before and after starting dialysis in older patients with kidney failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality study is an ongoing prospective, multicenter study in patients aged ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m². Between April 2012 and December 2021, health-related quality of life was assessed every 3-6 months using the 36-item Short-Form Health Survey (SF-36), providing a mental component summary (MCS) and a physical component summary (PCS). Scores range from zero to 100, with higher scores indicating better health-related quality of life. With linear mixed models, we explored the course of health-related quality of life during the year preceding and following dialysis initiation.

RESULTS

In total, 457 patients starting dialysis were included who filled out at least one SF-36 during follow-up. At dialysis initiation, mean ± SD age was 76±6 years, eGFR was 8±3 ml/min per 1.73 m², 75% were men, 9% smoked, 45% had diabetes, and 46% had cardiovascular disease. Median (interquartile range) MCS was 53 (38-73), and median PCS was 39 (27-58). During the year preceding dialysis, estimated mean change in MCS was -13 (95% confidence interval, -17 to -9), and in PCS, it was -11 (95% confidence interval, -15 to -7). In the year following dialysis, estimated mean change in MCS was +2 (95% confidence interval, -7 to +11), and in PCS, it was -2 (95% confidence interval, -11 to +7). Health-related quality-of-life patterns were similar for most mental (mental health, role emotional, social functioning, vitality) and physical domains (physical functioning, bodily pain, role physical).

CONCLUSIONS

Patients experienced a clinically relevant decline of both mental and physical health-related quality of life before dialysis initiation, which stabilized thereafter. These results may help inform older patients with kidney failure who decided to start dialysis.

Delivery of Active Medical Management without Dialysis through an Embedded Kidney Palliative Care Model

Background

Patients with CKD have high symptom burden, low rates of advance care planning (ACP), and frequently receive care that is not goal concordant. Improved integration of palliative care into nephrology and access to active medical management without dialysis (AMMWD) have the potential to improve outcomes through better symptom management and enhanced shared decision making.

Methods

We describe the development of a kidney palliative care (KPC) clinic and how palliative care practices are integrated within an academic nephrology clinic. We performed a retrospective electronic health record (EHR) review for patients seen in this clinic between January 2015 and February 2019 to describe key clinical activities and delivery of AMMWD.

Results

A total of 165 patients were seen in the KPC clinic (139 with CKD and 26 who were already receiving dialysis). Fatigue, mobility issues, and pain were the three most prevalent symptoms (85%, 66%, 58%, respectively). Ninety-one percent of patients had a surrogate decision maker documented in the EHR; 87% of patients had a goals-of-care conversation documented in the EHR. Of the 139 patients with CKD, 67 (48%) chose AMMWD as their disease progressed. Sixty-eight percent (41 of 60) of patients who died during the study were referred to hospice.

Conclusions

Our findings suggest that the integration of palliative care into nephrology can assist in identification of symptoms, lead to high rates of ACP, and provide a mechanism for patients to choose and receive AMMWD. The percentage of patients choosing AMMWD in our study suggests that increased shared decision making may lower rates of dialysis initiation in the United States. Additional prospective research and registries for assessing the effects of AMMWD have the potential to improve care for people living with CKD.

Quality of Life in Patients with Chronic Kidney Disease Managed with or without Dialysis: An Observational Study

Background

Emerging research suggests that quality of life (QOL) outcomes, such as maintenance of independence, rather than length of life, are the main priority for many patients with end stage kidney disease (ESKD). There is therefore a need to focus on whether QOL for older patients on dialysis differs significantly from conservative kidney management (CKM). This study aimed to describe the QOL trajectory for patients with ESKD, comparing CKM to dialysis and transplantation.

Methods

This retrospective, observational study included all patients who attended the Kidney Supportive Care Clinic at St. George Hospital and had one or more EuroQOL (EQ5D5L) questionnaires between July 2014 and May 2020. Kruskal-Wallis tests compared QOL scores between groups at baseline and 12 months. Wilcoxon signed rank tests compared QOL scores from baseline to 18 months within groups. Chi-squared tests compared proportions of patients reporting problems with QOL "domains" between the groups at baseline and 12 months. McNemar's tests compared changes in proportions of patients reporting problems with QOL "domains" within groups from baseline to 12 months.

Results

A total of 604 patients had an initial survey. At baseline, patients who were managed conservatively reported more problems with mobility, self-care, and ability to perform usual activities. However, pain/discomfort and anxiety/depression were no higher in the conservative population. CKM patients reported no significant decline in mobility, self-care, ability to perform their usual activities, pain/discomfort, or anxiety/depression after 12 months or in QOL scores after 18 months compared with the other groups.

Conclusions

QOL scores or symptom burdens did not change significantly in patients receiving CKM compared with dialysis, suggesting that appropriately supported CKM can maintain patients' QOL.

Mortality in elderly patients starting hemodialysis program

BACKGROUND

The incidence of older patients over 80 years old with chronic kidney disease who start hemodialysis (HD) program has been increasing in the last decade.

METHODS

We aimed to identify risk factors for morbidity and mortality in patients older than 80 years with end-stage renal disease who started HD. We conducted a retrospective observational study of the Catalan Renal registry (RMRC).

RESULTS

A total of 2833 patients equal or older than 80 years (of 15,137) who started HD between 2002 and 2019 from the RMRC were included in the study. In this group, the first dialysis was performed through an arteriovenous fistula in 44%, percutaneous catheter in 28.2%, and tunneled catheter in 26.6%. Conventional dialysis was used in 65.7% and online HD in 34.3%. The most frequent cause of death was cardiac disease (21.8%), followed by social problems (20.4%) and infections (15.9%). Overall survival in older HD during the first year was 84% versus 91% in younger than 80 years (p < 0.001). Cox regression analysis identified the start of HD in the period 2002-2010, chronic obstructive pulmonary disease (COPD), and the onset of HD through vascular graft depicted as risk factors for first-year mortality after dialysis initiation in patients older than 80 years with end-stage renal disease who started HD.

CONCLUSIONS

In conclusion, patients older than 80 years who started HD program had higher mortality, especially those who presented exacerbation of kidney disease, those with COPD, and those who started with a vascular graft.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

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).

Análisis del tratamiento conservador en el paciente con enfermedad renal crónica terminal. Revisión sistemática

Introducción: Desde hace unos años, debido a la inclusión de pacientes con enfermedad renal crónica cada vez más mayores en tratamiento renal sustitutivo, se viene ofreciendo como otra opción, tratamiento renal conservador, con resultados similares en algunas series al tratamiento dialítico.Objetivo: Revisar la literatura científica existente sobre el tratamiento renal conservador en pacientes con enfermedad renal crónica, su supervivencia y calidad de vida.Metodología: Se ha llevado a cabo una revisión sistemática. Se realizó una búsqueda en las bases de datos PubMed, ProQuest, Scielo y Scopus. Se incluyeron artículos científicos en español e inglés, y texto completo disponible. Se analizaron aquellos artículos que trataban sobre pacientes renales en estadío final de la enfermedad renal crónica terminal, tratados con tratamiento paliativo únicamente o en comparación con el tratamiento renal sustitutivo.Resultados: Se han incluido 15 artículos publicados entre los años 2010 y 2020. La enfermedad renal crónica es un problema de alta prevalencia en nuestra población, lo cual condiciona los tratamientos sustitutivos de la función renal. El tratamiento renal conservador surge como opción al sustitutivo, en aquellos pacientes mayores o con una corta expectativa de vida. Como factores más importantes a tener en cuenta surgen la supervivencia y la calidad de vida.Conclusiones: En el paciente con enfermedad renal crónica en tratamiento renal sustitutivo la supervivencia es mayor, aunque con peor calidad de vida, mientras que en el caso del tratamiento renal conservador suele ser al contrario. En pacientes mayores de 75-80 años la supervivencia se iguala, siendo necesario potenciar la calidad de vida y paliar los síntomas de la enfermedad

End Stage Kidney Disease Patient Experiences of Renal Supportive Care in an Australian Teaching Hospital - A Qualitative Study

CONTEXT

Renal Supportive Care Services (RSCS) were introduced in Australia to provide patient-centred care with a focus on better symptom management and improved quality of life in end stage kidney disease (ESKD) patients managed with or without dialysis. While RSCS have demonstrated clinical benefits with reduced length of hospital stay and symptom burden, there is a gap in understanding the experience of patients referred to RSCS.

OBJECTIVES

To identify patient attitudes, beliefs, and perspectives on the RSCS.

METHODS

Qualitative interviews were conducted with 20 participants from both dialysis and conservative treatment pathways. Transcripts were then thematically analysed and primary themes identified, which were reviewed with a stakeholder group that included doctors, nurses and allied health staff to provide triangulation.

RESULTS

Patients perceived the RSCS as a provider of multidisciplinary, holistic and patient-centred care that, in addition, helped to ensure prognostic awareness and timely end-of-life care planning. This contributed to an overall sense of patient empowerment with healthcare decisions. This study identified three major themes: (1) Expectations of care; (2) Experience of care; and (3) Understanding patient needs.

CONCLUSION

The study found that RSCS support patient-centred and family-orientated initiatives in decision making and control over healthcare management. This is empowering for patients. Additional patient values, needs and wants from the RSCS were also identified and these could be addressed to improve the patient experience. Our findings support the ongoing use of RSCS to improve the experience of ESKD patients.

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

INTRODUCTION

Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes.

METHODS AND ANALYSIS

The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites.

ETHICS AND DISSEMINATION

Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results.

TRIAL REGISTRATION NUMBER

NCT04347629.

Frailty in chronic kidney disease: challenges in nephrology practice. A review of the current literature

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.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

OBJECTIVE

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

DESIGN

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

SETTING

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

PATIENTS

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.

MEASUREMENTS

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

METHODS

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

RESULTS

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

LIMITATIONS

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

CONCLUSIONS

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

TRIAL REGISTRATION

Not applicable.

Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review

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.

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

IMPORTANCE

An understanding of the long-term outcomes of patients with advanced chronic kidney disease not treated with maintenance dialysis is needed to improve shared decision-making and care practices for this population.

OBJECTIVE

To evaluate survival, use of health care resources, changes in quality of life, and end-of-life care of patients with advanced kidney disease who forgo dialysis.

EVIDENCE REVIEW

MEDLINE, Embase (Excerpta Medica Database), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) were searched from inception through December 3, 2021, for all English language longitudinal studies of adults in whom there was an explicit decision not to pursue maintenance dialysis. Two investigators independently reviewed all studies and selected those reporting survival, use of health care resources, changes in quality of life, or end-of-life care during follow-up. Studies of patients who initiated and then discontinued maintenance dialysis and patients in whom it was not clear that there was an explicit decision to forgo dialysis were excluded. One author abstracted all study data, of which 12% was independently adjudicated by a second author (<1% error rate).

FINDINGS

Forty-one cohort studies comprising 5102 patients (range, 11-812 patients) were included in this systematic review (5%-99% men; mean age range, 60-87 years). Substantial heterogeneity in study designs and measures used to report outcomes limited comparability across studies. Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate ranging from 7 to 19 mL/min/1.73 m2. Patients generally experienced 1 to 2 hospital admissions, 6 to 16 in-hospital days, 7 to 8 clinic visits, and 2 emergency department visits per person-year. During an observation period of 8 to 24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the illness course. Among patients who died during follow-up, 20% to 76% had enrolled in hospice, 27% to 68% died in a hospital setting and 12% to 71% died at home; 57% to 76% were hospitalized, and 4% to 47% received an invasive procedure during the final month of life.

CONCLUSIONS AND RELEVANCE

Many patients who do not pursue dialysis survived several years and experienced sustained quality of life until late in the illness course. Nonetheless, use of acute care services was common and intensity of end-of-life care highly variable across cohorts. These findings suggest that consistent approaches to the study of conservative kidney management are needed to enhance the generalizability of findings and develop models of care that optimize outcomes among conservatively managed patients.

Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice

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.

The Role of Kidney Supportive Care and Active Medical Management Without Dialysis in Supporting Well-Being in Kidney Care

People living with kidney failure often experience a higher symptom burden (including anxiety and depression) and lower quality of life than patients with other serious chronic diseases. The end of life for these patients is characterized by high intensity of treatment (such as intensive care unit stays) and lack of support for family. Kidney supportive care, which emphasizes quality of life, person-centered care, and holistic care for the person and their family, is an approach that improves well-being by aligning care with the patient's preferences and goals. Kidney supportive care encompasses identifying seriously ill patients, eliciting patient values and goals through shared decision making and advance care planning, assessing and managing symptoms, communicating prognosis, offering active medical management without dialysis, and planning and managing care transitions, especially at the end of life. Models, strategies, and tools for incorporating kidney supportive care and active medical management without dialysis into existing workflows are available. However, barriers to implementation in the United States include clinician knowledge gaps, current workflows, and financial incentives, which make it difficult to break from the de facto default practice of starting dialysis for patients with kidney failure regardless of age, frailty, or debilitating condition. Policy changes are needed to fully implement kidney supportive care in the United States.

OUP accepted manuscript

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.

Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment

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).

Kidney Supportive Care in Peritoneal Dialysis: Developing a Person-Centered Kidney Disease Care Plan

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.

Challenges to Shared Decision Making About Treatment of Advanced CKD: A Qualitative Study of Patients and Clinicians

RATIONALE AND OBJECTIVE

Greater understanding of the challenges to shared decision-making about treatment of advanced CKD is needed to support implementation of shared decision-making in clinical practice.

STUDY DESIGN

Qualitative study.

SETTING AND PARTICIPANTS

Patients aged ≥65 years with advanced CKD and their clinicians recruited from 3 medical centers participated in semi-structured interviews. In-depth review of patients' electronic medical records was also performed.

ANALYTICAL APPROACH

Interview transcripts and medical record notes were analyzed using inductive thematic analysis.

RESULTS

Twenty-nine patients (age 73±6 years, 66% male, 59% Caucasian) and 10 of their clinicians (age 52±12 years, 30% male, 70% Caucasian) participated in interviews. Four themes emerged from qualitative analysis: 1) Competing priorities - patients and their clinicians tended to differ on when to prioritize CKD and dialysis planning above other personal or medical problems; 2) Focusing on present or future -patients were more focused on living well now while clinicians were more focused on preparing for dialysis and future adverse events; 3) Standardized versus individualized approach to CKD - although clinicians tried to personalize care recommendations to their patients, patients perceived their clinicians as taking a monolithic approach to CKD that was predicated on clinical practice guidelines and medical literature rather than patients' lived experiences with CKD and personal values and goals; and 4) Power dynamics - while patients described cautiously navigating a power differential in their therapeutic relationship with their clinicians, clinicians seemed less attuned to these power dynamics.

LIMITATIONS

Thematic saturation was based on patient interviews. Themes presented might incompletely reflect clinicians' perspectives.

CONCLUSIONS

Efforts to improve shared decision-making for treatment of advanced CKD will likely need to explicitly address differences in approaches to decision-making about treatment of advanced CKD between patients and their clinicians and perceived power imbalances in the therapeutic relationship.

Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review

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.

Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature

PURPOSE OF REVIEW

To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM).

RECENT FINDINGS

Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making.

SUMMARY

We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.

Chronic kidney disease

Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.

Adding Life to Their Years: The Current State of Pediatric Palliative Care in CKD

Despite continued advances in medical treatment, pediatric CKD remains an unremitting, burdensome condition characterized by decreased quality of life and earlier death. These burdens underscore the need for integration of pediatric palliative care (PPC) into nephrology practice. PPC is an evolving field that strives to (1) relieve physical, psychologic, social, practical, and existential suffering; (2) improve quality of life; (3) facilitate decision making; and (4) assist with care coordination in children with life-threatening or life-shortening conditions. Integration of palliative care into routine care has already begun for adults with kidney disease and children with other chronic diseases; however, similar integration has not occurred in pediatric nephrology. This review serves to provide a comprehensive definition of PPC, highlight the unmet need in pediatric nephrology and current integration efforts, discuss the state of palliative care in adult nephrology and analogous chronic pediatric disease states, and introduce future opportunities for study.

NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows

Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, "flipped classroom" session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys. Mean self-reported preparedness (measured on a five-point Likert scale) increased significantly for all ten concepts taught in the curriculum. The mean correct score on eight knowledge questions increased from 69% to 82% following the curriculum (P<0.001). Fellows rated the curriculum highly and reported that they plan to practice skills learned. For the 19 nephrology program educators, the mean perceived preparedness to teach all curriculum domains increased after, compared with before, facilitating the flipped classroom, reaching significance for seven of the ten concepts measured. Data suggest that fellows' participation in a multimodal curriculum increased knowledge and preparation for fundamental conservative care concepts and communication skills. Fellows rated the curriculum highly. Educator participation appears to have increased preparedness for teaching the curriculum concepts, making it likely that future education in conservative care will become more widespread. Herein, we describe the curriculum content, which we have made publicly available in order to encourage broader implementation, and its effect on participating fellows and the nephrology educators who facilitated it.

The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease

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.

Kidney function and symptom development over time in elderly patients with advanced chronic kidney disease: results of the EQUAL cohort study

BACKGROUND

Initiation of renal replacement therapy often results from a combination of kidney function deterioration and symptoms related to chronic kidney disease (CKD) progression. We investigated the association between kidney function decline and symptom development in patients with advanced CKD.

METHODS

In the European Quality study on treatment in advanced CKD (EQUAL study), a European prospective cohort study, patients with advanced CKD aged ≥65 years and a kidney function that dropped <20 mL/min/1.73 m2 were followed for 1 year. Linear mixed-effects models were used to assess the association between kidney function decline and symptom development. The sum score for symptom number ranged from 0 to 33 and for overall symptom severity from 0 to 165, using the Dialysis Symptom Index.

RESULTS

At least one kidney function estimate with symptom number or overall symptom severity was available for 1109 and 1019 patients, respectively. The mean (95% confidence interval) annual kidney function decline was 1.70 (1.32; 2.08) mL/min/1.73 m2. The mean overall increase in symptom number and severity was 0.73 (0.28; 1.19) and 2.93 (1.34; 4.52) per year, respectively. A cross-sectional association between the level of kidney function and symptoms was lacking. Furthermore, kidney function at cohort entry was not associated with symptom development. However, each mL/min/1.73 m2 of annual kidney function decline was associated with an extra annual increase of 0.23 (0.07; 0.39) in the number of symptoms and 0.87 (0.35; 1.40) in overall symptom severity.

CONCLUSIONS

A faster kidney function decline was associated with a steeper increase in both symptom number and severity. Considering the modest association, our results seem to suggest that repeated thorough assessment of symptom development during outpatient clinic visits, in addition to the monitoring of kidney function decline, is important for clinical decision-making.