Recommendations for the Care of Patients Receiving Conservative Kidney Management: Focus on Management of CKD and Symptoms

Dialysis for Chronic Kidney Failure: A Review

Importance

More than 3.5 million people worldwide and 540 000 individuals in the US receive maintenance hemodialysis or peritoneal dialysis for the treatment of chronic kidney failure. The 5-year survival rate is approximately 40% after initiation of maintenance dialysis.

Observations

Hemodialysis and peritoneal dialysis remove metabolic waste and excess body water and rebalance electrolytes to sustain life. There is no recommended estimated glomerular filtration rate (eGFR) threshold for initiating dialysis, and patient-clinician shared decision-making should help determine when to initiate dialysis. Persistent signs and symptoms of uremia (eg, nausea, fatigue) and volume overload (eg, dyspnea, peripheral edema), worsening eGFR, metabolic acidosis, and hyperkalemia inform the timing of therapy initiation. A randomized clinical trial reported no mortality benefit to starting dialysis at higher eGFR (10-14 mL/min/1.73 m2) vs lower eGFR (5-7 mL/min/1.73 m2) levels. Observational data suggested no differences in 5-year mortality with use of hemodialysis vs peritoneal dialysis. Cardiovascular (eg, arrhythmias, cardiac arrest) and infection-related complications of maintenance dialysis are common. In the US, hemodialysis catheter-related bloodstream infections occur at a rate of 1.1 to 5.5 episodes per 1000 catheter-days and affect approximately 50% of patients within 6 months of catheter placement. Peritonitis occurs at a rate of 0.26 episodes per patient-year and affects about 30% of individuals in the first year of peritoneal dialysis therapy. Chronic kidney failure-related systemic complications, such as anemia, hyperphosphatemia, hypocalcemia, and hypertension, often require pharmacologic treatment. Hypotension during dialysis, refractory symptoms (eg, muscle cramps, itching), and malfunction of dialysis access can interfere with delivery of dialysis.

Conclusions and Relevance

In 2021, more than 540 000 patients in the US received maintenance hemodialysis or peritoneal dialysis for treatment of chronic kidney failure. Five-year survival rate after initiation of maintenance dialysis is approximately 40%, and the mortality rate is similar with hemodialysis and peritoneal dialysis. Decisions about dialysis initiation timing and modality are influenced by patient symptoms, laboratory trajectories, patient preferences, and therapy cost and availability and should include shared decision-making.

How to make a shared decision with older persons for end-stage kidney disease treatment: the added value of geronto-nephrology

Improving care for older people with end-stage kidney disease (ESKD) requires the adaptation of standards to meet their needs. This may be complex due to their heterogeneity in terms of multimorbidity, frailty, cognitive decline and healthcare priorities. As benefits and risks are uncertain for these persons, choosing an appropriate treatment is a daily challenge for nephrologists. In this narrative review, we aimed to describe the issues associated with healthcare for older people, with a specific focus on decision-making processes; apply these concepts to the context of ESKD; identify components and modalities of shared decision-making and suggest means to improve care pathways. To this end, we propose a geronto-nephrology dynamic, described here as the necessary collaboration between these specialties. Underscoring gaps in the current evidence in this field led us to suggest priority research orientations.

Global access and quality of conservative kidney management

BACKGROUND

Conservative kidney management (CKM) describes supportive care for people living with kidney failure who choose not to receive or are unable to access kidney replacement therapy (KRT). This study captured the global availability of CKM services and funding.

METHODS

Data came from the International Society of Nephrology Global Kidney Health survey conducted between June and September 2022. Availability of CKM, infrastructure, guidelines, medications and training were evaluated.

RESULTS

CKM was available in some form in 61% of the 165 responding countries. CKM chosen through shared decision-making was available in 53%. Choice-restricted CKM-for those unable to access KRT-was available in 39%. Infrastructure to provide CKM chosen through shared decision-making was associated with national income level, reported as being "generally available" in most healthcare settings for 71% of high-income countries, 50% of upper-middle-income countries, 33% of lower-middle-income countries and 42% of low-income countries. For choice-restricted CKM, these figures were 29%, 50%, 67% and 58%, respectively. Essential medications for pain and palliative care were available in just over half of the countries, highly dependent upon income setting. Training for caregivers in symptom management in CKM was available in approximately a third of countries.

CONCLUSIONS

Most countries report some capacity for CKM. However, there is considerable variability in terms of how CKM is defined, as well as what and how much care is provided. Poor access to CKM perpetuates unmet palliative care needs, and must be addressed, particularly in low-resource settings where death from untreated kidney failure is common.

Treatment of chronic kidney disease in older populations

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Observational cohort study using target trial emulation.

SETTING

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

PARTICIPANTS

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

INTERVENTION

Starting dialysis within 30 days versus continuing medical management.

MEASUREMENTS

Mean survival and number of days at home.

RESULTS

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

LIMITATION

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

CONCLUSION

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

PRIMARY FUNDING SOURCE

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

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.

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.

Potentially modifiable factors associated with health-related quality of life among people with chronic kidney disease: baseline findings from the National Unified Renal Translational Research Enterprise CKD (NURTuRE-CKD) cohort

Background

Many non-modifiable factors are associated with poorer health-related quality of life (HRQoL) experienced by people with chronic kidney disease (CKD). We hypothesize that potentially modifiable factors for poor HRQoL can be identified among CKD patients, providing potential targets for intervention.

Method

The National Unified Renal Translational Research Enterprise Chronic Kidney Disease (NURTuRE-CKD) cohort study recruited 2996 participants from nephrology centres with all stages of non-dialysis-dependent CKD. Baseline data collection for sociodemographic, anthropometric, biochemical and clinical information, including Integrated Palliative care Outcome Scale renal, Hospital Anxiety and Depression score (HADS) and the 5-level EuroQol-5D (EQ-5D-5L) as HRQoL measure, took place between 2017 and 2019. EQ-5D-5L dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) were mapped to an EQ-5D-3L value set to derive index value. Multivariable mixed effects regression models, adjusted for known factors affecting HRQoL with recruitment region as a random effect, were fit to assess potentially modifiable factors associated with index value (linear) and within each dimension (logistic).

Results

Among the 2958/2996 (98.7%) participants with complete EQ-5D data, 2201 (74.4%) reported problems in at least one EQ-5D-5L dimension. Multivariable linear regression identified independent associations between poorer HRQoL (EQ-5D-3L index value) and obesity (body mass index ≥30.0 kg/m2, β -0.037, 95% CI -0.058 to -0.016, P = .001), HADS depression score ≥8 (β -0.159, -0.182 to -0.137, P < .001), anxiety score ≥8 (β -0.090, -0.110 to -0.069, P < .001), taking ≥10 medications (β -0.065, -0.085 to -0.046, P < .001), sarcopenia (β -0.062, -0.080 to -0.043, P < .001) haemoglobin <100 g/L (β -0.047, -0.085 to -0.010, P = .012) and pain (β -0.134, -0.152 to -0.117, P < .001). Smoking and prescription of prednisolone independently associated with problems in self-care and usual activities respectively. Renin-angiotensin system inhibitor (RASi) prescription associated with fewer problems with mobility and usual activities.

Conclusion

Potentially modifiable factors including obesity, pain, depression, anxiety, anaemia, polypharmacy, smoking, steroid use and sarcopenia associated with poorer HRQoL in this cohort, whilst RASi use was associated with better HRQoL in two dimensions.

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 .

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.

Factors associated with quality of life in patients with kidney failure managed conservatively and with dialysis: a cross-sectional study

BACKGROUND

Later stage chronic kidney disease (CKD) is associated with poorer self-perceived health-related quality of life (HRQOL), a major consideration for many patients. Psychological factors such as depression and anxiety have been linked with poorer HRQOL. We aimed to determine if anxiety or depressive symptoms are significantly associated with self-perceived health-related quality of life, in patients with CKD Stage 5. The secondary aim was to determine which patient-associated factors are associated with HRQOL in patients with CKD Stage 5.

METHODS

This retrospective cross-sectional study included patients that attended the St George Hospital Kidney Supportive Care (KSC) clinic between 1 and 2015 and 30 June 2022 with CKD Stage 5 (either conservatively-managed or receiving dialysis). Patients completed surveys of their functional 'domains' and quality of life (EQ-5D-5L) and symptom surveys (IPOS-Renal) at their first visit. We performed multivariable linear regression analysis with the outcome of interest being HRQOL, measured using the EQ-VAS, a continuous 100-point scale, for patients undergoing conservative management or dialysis. Pre-specified variables included age, sex, eGFR (for those conservatively-managed), "feeling depressed" (IPOS-Renal), "feeling anxious" (IPOS-Renal) and "anxiety/depression" (EQ-5D-5L).

RESULTS

We included 339 patients. 216 patients received conservative kidney management (CKM) and 123 patients received dialysis. Patients receiving CKM were significantly older than those on dialysis, (median age 83 years vs. 73 years, p < 0.001). For conservatively-managed patients, variables independently associated with poorer EQ-VAS were difficulty performing usual activities (EQ-5D-5L), drowsiness (IPOS-Renal) and shortness of breath (IPOS-Renal). For patients receiving dialysis, variables that were independently associated with poorer EQ-VAS were reduced ability to perform self-care (EQ-5D-5L) and lack of energy (IPOS-Renal). Anxiety and depressive symptoms were not significantly associated with poorer EQ-VAS for either group of patients.

CONCLUSIONS

Symptoms associated with reduced HRQOL include shortness of breath, drowsiness and impaired functional ability. Optimization of multidisciplinary teams focusing on these issues are likely to be of benefit.

Healthcare professional education in shared decision making in the context of chronic kidney disease: a scoping review

RATIONALE & OBJECTIVE

Shared decision making (SDM) is a collaborative effort between healthcare professionals, individuals with CKD whereby clinical evidence, expected outcomes and potential side-effects are balanced with individual values and beliefs to provide the best mutually decided treatment option. Meaningful SDM is supported by effective training and education. We aimed to identify the available evidence on SDM training and education of healthcare professionals caring for people with chronic kidney disease. We aimed to identify existing training programs and to explore what means are used to evaluate the quality and effectiveness of these educational efforts.

METHODOLOGY

We performed a scoping review to study the effectiveness of training or education about shared decision making of healthcare professionals treating patients with kidney disease. EMBASE, MEDLINE, CINAHL and APA PsycInfo were searched.

RESULTS

After screening of 1190 articles, 24 articles were included for analysis, of which 20 were suitable for quality appraisal. These included 2 systematic reviews, 1 cohort study, 7 qualitative studies, and 10 studies using mixed methods. Study quality was varied with high quality (n = 5), medium quality (n = 12), and low quality (n = 3) studies. The majority of studies (n = 11) explored SDM education for nurses, and physicians (n = 11). Other HCP profiles included social workers (n = 6), dieticians (n = 4), and technicians (n = 2). Topics included education on SDM in withholding of dialysis, modality choice, patient engagement, and end-of-life decisions.

LIMITATIONS

We observed significant heterogeneity in study design and varied quality of the data. As the literature search is restricted to evidence published between January 2000 and March 2021, relevant literature outside of this time window has not been taken into account.

CONCLUSIONS

Evidence on training and education of SDM for healthcare professionals taking care of patients with CKD is limited. Curricula are not standardized, and educational and training materials do not belong to the public domain. The extent to which interventions have improved the process of shared-decision making is tested mostly by pre-post testing of healthcare professionals, whereas the impact from the patient perspective for the most part remains untested.

Conservative Kidney Management in Kidney Transplant Populations

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

Hospice Care in Conservative Kidney Management

Hospice care offers multidisciplinary expertise to optimize symptom management and quality of life for patients with limited life expectancy and help ensure that patients receive care that reflects their personal goals and values. Many patients receiving conservative kidney management (CKM) and their loved ones can benefit from the additional support that hospice provides, particularly as symptom burdens and functional status worsen over the last few months of life. We provide an overview of hospice services and how they may benefit patients receiving CKM, describe the evolution of optimal CKM strategies and collaboration between nephrology and hospice clinicians over the course of disease progression, and explore challenges to effective hospice care delivery for patients with chronic kidney disease and how to address them.

Teaching Conservative Kidney Management and Other Palliative Care Skills in Nephrology Fellowships

Offering and providing effective conservative kidney management (CKM) for patients with end-stage kidney disease who do not want dialysis is a foundational skill that all nephrology fellows should learn during fellowship training. However, the current educational landscape in fellowship training programs is sparse and is not recognized currently as a skill within the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Moreover, there is no standardized curriculum, methods of assessment of this learning objective, and no structure for implementation within general and subspecialty nephrology training programs. In this article, we discuss the current educational resources available for fellowship training programs, including interactive communication skills workshops such as NephroTalk, that address core concepts of CKM and assess communication skills and attitudes of trainees. Additional assessment tools should be prioritized when developing a CKM curriculum, including assessment of symptom management and medical knowledge acquisition. We propose that the ACGME nephrology milestones specifically highlight CKM as an important component within the ACGME nephrology milestones, thus ensuring that trainees understand how and when to offer CKM (knowledge), implement it effectively (skills), and conceptualize it as an appropriate course for patients in a number of varied situations (attitudes). We also outline a subspecialty pathway for palliative nephrology, to align with the recent American Society of Nephrology Task Force Recommendation to provide subspecialty training beyond core competencies, for those interested in pursuit of advanced training that ultimately can shape the CKM landscape in education and policy making.

Shared decision-making in advanced kidney disease: a scoping review

OBJECTIVES

To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation.

DESIGN

The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.

DATA SOURCES

MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature.

ELIGIBILITY FOR INCLUSION

Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m2. Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support.

RESULTS

One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users.

CONCLUSION

There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.

Ethical Challenges When Caring for African American Older Adults Requesting to Withdraw From Dialysis

The number of African American adults 65 years and older with end-stage kidney disease receiving maintenance hemodialysis is increasing. The high symptom burden (ie, pain, fatigue, depression) can make it challenging for many to continue dialysis, which can lead to request to withdraw from dialysis. This can present ethical challenges when someone has diminished decision-making capacity and no advance directives or family to assist with this complex decision. This article will provide a brief overview of ethical issues to consider when responding to an older adult's request to withdraw from a life-sustaining treatment such as dialysis. Suggestions for research to address the gaps in knowledge will be presented.

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.

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

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.

Symptom clusters in chronic kidney disease and their association with people's ability to perform usual activities

Background

People living with a long-term condition, such as chronic kidney disease (CKD), often suffer from multiple symptoms simultaneously, making symptom management challenging. This study aimed to identify symptom clusters in adults with CKD across treatment groups and investigate their association with people’s ability to perform their usual activities.

Methods

We conducted a secondary analysis of both cross-sectional and longitudinal data collected as part of a national service improvement programme in 14 kidney centres in England, UK. This data included symptom severity (17 items, POS-S Renal) and the extent to which people had problems performing their usual activities (single item, EQ-5D-5L). We categorised data by treatment group: haemodialysis (n = 1,462), transplantation (n = 866), peritoneal dialysis (n = 127), or CKD without kidney replacement therapy (CKD non-KRT; n = 684). We used principal component analysis to identify symptom clusters per treatment group, and proportional odds models to assess the association between clusters and usual activities.

Results

Overall, clusters related to: lack of energy and mobility; gastrointestinal; skin; and mental health. Across groups, the ‘lack of energy and mobility’ clusters were associated with having problems with usual activities, with odds ratios (OR) ranging between 1.24 (95% confidence interval [CI], 1.21–1.57) for haemodialysis and 1.56 for peritoneal dialysis (95% CI, 1.28–1.90). This association was confirmed longitudinally in haemodialysis (n = 399) and transplant (n = 249) subgroups.

Implications

Our findings suggest that healthcare professionals should consider routinely assessing symptoms in the ‘lack of energy & mobility’ cluster in all people with CKD, regardless of whether they volunteer this information; not addressing these symptoms is likely to be related to them having problems with performing usual activities. Future studies should explore why symptoms within clusters commonly co-occur and how they interrelate. This will inform the development of cluster-level symptom management interventions with enhanced potential to improve outcomes for people with CKD.

Palliative Care for Patients With Cancer and Kidney Disease

Patients with cancer and kidney disease experience a range of symptoms that impact their quality of life. Pain, fatigue, decreased appetite, and depression are all common in this population. Kidney palliative care is patient-centered medical care focused on reducing symptoms and defining individualized goals of care for patients and their families. Pharmacologic management of pain in patients with cancer and kidney disease requires recognition of the type of pain, its cause, and the risks and benefits of different medication classes. This review describes basic symptom management options as well as considerations for discussing goals of care, prognosis, and end of life.

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.

Cannabinoids for Symptom Management in Patients with Kidney Failure

People with kidney failure can experience a range of symptoms that lead to suffering and poor quality of life. Available therapies are limited, and evidence for new treatment options is sparse, often resulting in incomplete relief of symptoms. There is growing interest in the potential for cannabinoids, including cannabidiol and tetrahydrocannabinol, to treat symptoms across a wide range of chronic diseases. As legal prohibitions are withdrawn or minimized in many jurisdictions, patients are increasingly able to access these agents. Cannabinoid receptors, CB1 and CB2, are widely expressed in the body, including within the nervous and immune systems, and exogenous cannabinoids can have anxiolytic, anti-emetic, analgesic and anti-inflammatory effects. Considering their known physiological actions and successful studies in other patient populations, cannabinoids may be viewed as potential therapies for a variety of common symptoms affecting those with kidney failure, including pruritus, nausea, insomnia, chronic neuropathic pain, anorexia, and restless legs syndrome. In this review, we summarize the pharmacology and pharmacokinetics of cannabinoids, along with what is known about the use of cannabinoids for symptom relief in those with kidney disease, and the evidence available concerning their role in management of common symptoms. Presently, while these agents show varying efficacy with a reasonable safety profile in other patient populations, evidence-based prescribing of cannabinoids for people with symptomatic kidney failure is not possible. Given the symptom burden experienced by individuals with kidney failure, there is an urgent need to understand the tolerability and safety of these agents in this population, which must ultimately be followed by robust, randomized controlled trials to determine if they are effective for symptom relief.

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.

Shared decision making for the initiation and continuation of dialysis: a proposal from the Japanese Society for Dialysis Therapy

Background

In Japan, forgoing life-sustaining treatment to respect the will of patients at the terminal stage is not stipulated by law. According to the Guidelines for the Decision-Making Process in Terminal-Stage Healthcare published by the Ministry of Health, Labor and Welfare in 2007, the Japanese Society for Dialysis Therapy (JSDT) developed a proposal that was limited to patients at the terminal stage and did not explicitly cover patients with dementia. This proposal for the shared decision-making process regarding the initiation and continuation of maintenance hemodialysis was published in 2014.

Methods and results

In response to changes in social conditions, the JSDT revised the proposal in 2020 to provide guidance for the process by which the healthcare team can provide the best healthcare management and care with respect to the patient's will through advance care planning and shared decision making. For all patients with end-stage kidney disease, including those at the nonterminal stage and those with dementia, the decision-making process includes conservative kidney management.

Conclusions

The proposal is based on consensus rather than evidence-based clinical practice guidelines. The healthcare team is therefore not guaranteed to be legally exempt if the patient dies after the policies in the proposal are implemented and must respond appropriately at the discretion of each institution.

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.

Symptom Management among Patients with Chronic Kidney Disease

Patients with chronic kidney disease (CKD) experience high symptom burden, both physical and psychological, that is underrecognized and undertreated. The high symptom burden significantly impacts the quality of life for patients and their families. This review enumerates the various physical and psychological symptoms that patients with CKD often experience and guides in the management of these symptoms. This review follows the recommended international guidelines and has been tailored to suit the Indian context.

A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD

Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.

Availability, Accessibility, and Quality of Conservative Kidney Management Worldwide

BACKGROUND AND OBJECTIVES

People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management.

RESULTS

Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery.

CONCLUSIONS

Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.

Novel conservative management of chronic kidney disease via dialysis-free interventions

PURPOSE OF REVIEW

In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population.

RECENT FINDINGS

The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden.

SUMMARY

As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.

Palliative Care in the Advancing American Kidney Health Initiative: A Call for Inclusion in Kidney Care Delivery Models

The Advancing American Kidney Health (AAKH) Initiative aims to promote high-value patient-centered care by improving access to and quality of treatment options for kidney failure. The 3 explicit goals of the initiative are to reduce the incidence of kidney failure, increase the number of available kidneys for transplantation, and increase transplantation and home dialysis. To ensure a patient-centered movement toward home dialysis modalities, actionable principles of palliative care, including systematic communication and customized treatment plans, should be incorporated into this policy. In this perspective, we describe 2 opportunities to strengthen the patience-centeredness of the AAKH Initiative through palliative care: (1) serious illness conversations should be required for all dialysis initiations in the End-Stage Renal Disease Treatment Choices model, and (2) conservative kidney management should be counted as a home modality alongside peritoneal dialysis and home hemodialysis. A serious illness conversation can help clinicians discern whether a patient’s goals and values are best respected by a home dialysis modality or whether a nondialytic strategy such as conservative kidney management should be considered. An intensive and careful patient- and family-centered selection process will be necessary to ensure that no patient is pressured to forego conventional dialysis.

Perspectives on Conservative Care in Advanced Kidney Disease: A Qualitative Study of US Patients and Family Members

Rationale & Objective:

Little is known about perceptions of conservative care among patients with advanced kidney disease in the United States.

Study Design:

Qualitative study using cognitive interviewing about attitudes regarding conservative care using decision aids on treatments for advanced kidney disease developed outside the United States.

Setting & Participants:

14 patients 75 years or older with advanced kidney disease, defined as estimated glomerular filtration rate ≤ 20 mL/min/1.73 m² and not receiving maintenance dialysis, and 6 of their family members.

Analytical Approach:

Thematic analysis of participants’ reactions to descriptions of conservative care taken from various clinical care decision aids.

Results:

Participants were mostly White (n = 15) and had at least some college education (n = 16). Four themes emerged from analysis of interviews: (1) core elements of conservative care: aspects of conservative care that were appealing to participants included a whole-person, team-based, and structured approach to care that focused on symptom management, maintaining current lifestyle, and managing health setbacks; (2) importance of how conservative care is framed: participants were more receptive to conservative care when this was framed as an active rather than passive treatment approach and were receptive to statements of uncertainty about future course of illness and prognosis; (3) an explicit approach to shared decision making: participants believed decisions about conservative care and dialysis should address considerations about risk and benefits of treatment options, family and clinician perspectives, and patients’ goals, values, and preferences; and (4) relationship between conservative care and dialysis: although conservative care models outside the United States are generally intended to serve as an alternative to dialysis, participants’ comments implied that they did not see conservative care and dialysis as mutually exclusive.

Limitations:

Themes identified may not generalize to the broader population of US patients with advanced kidney disease and their family members.

Conclusions:

Participants were favorably disposed to a whole-person multidisciplinary approach to conservative care, especially when framed as an active treatment approach. Models of conservative care excluding the possibility of dialysis were less embraced, suggesting that current models will require adaptation to meet the needs of US patients and their families.

Conservative care is an important therapeutic option for patients with advanced kidney disease who believe that the burdens of dialysis are not outweighed by its potential benefits. However, efforts in this country to develop conservative options for patients who wish to pursue dialysis have lagged considerably behind those in other countries. In this study, we interviewed older patients with advanced kidney disease but not receiving maintenance dialysis and their family members about their reactions to descriptions of conservative care taken from decision aids developed in other countries. The findings suggest how models of conservative care developed in other countries could be adapted to meet the needs and preferences of US patients and their family members.

Kidney supportive care: an update of the current state of the art of palliative care in CKD patients

Chronic kidney disease (CKD) has become a public health burden worldwide for its increasing incidence and prevalence, high impact on the health related quality of life (HRQoL) and life expectancy, and high personal and social cost. Patients with advanced CKD, in dialysis or not, suffer a burden from symptoms very similar to other chronic diseases and have a life span not superior to many malignancies. Accordingly, in recent years, renal palliative care has been recommended to be integrated in the traditional care delivered to this population. This research provides an updated overview on renal palliative care from the relevant literature.

Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder

Purpose of review:

(1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients.

Sources of information:

The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD.

Methods:

The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions.

Key findings:

We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool.

Limitations:

The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.

Palliative Care in Nephrology: The Work and the Workforce

Kidney palliative care is a growing subspecialty of clinical practice, education, and research in nephrology. It is an essential aspect of care for patients across the continuum of advanced kidney disease who have high symptom burden, multidimensional communication needs, and limited life expectancy. Training in kidney palliative care can occur in a variety of ways, from didactic curricula and clinical experiences embedded in nephrology fellowship training to the pursuit of additional dedicated fellowship training in palliative care. At this time, a minority of nephrologists pursue formal fellowship training in specialty palliative care. This article will discuss opportunities and challenges in building a skilled workforce that will address the palliative needs of patients living with advanced kidney disease.

Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review

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.

Conservative management of patients with end-stage kidney disease

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.

Prescribing in renal supportive care

Renal supportive care incorporates the principles of palliative care into the management of patients with advanced kidney disease. Its focus is on improving the quality of life for patients with a high burden of symptoms Common problems include pain, restless legs syndrome and uraemic pruritus. Symptom management must involve patient participation, education and non-pharmacological strategies to address both physical and psychosocial problems, and to prioritise patient-centred goals The patients are medically complex and polypharmacy is common. When prescribing, it is important to consider the altered pharmacokinetics, potential drug interactions and the clearance of drugs by dialysis

Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study

CONTEXT

Uremic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated.

OBJECTIVES

To explore reasons for underreporting of itch to provide pointers for improving itch reporting and management in people with CKD.

METHODS

We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n = 25), nephrologists (n = 10), and nurses (n = 12) from three kidney services in the U.K. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using framework analysis.

RESULTS

We identified the following three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD, and lack of knowledge of treatment options); attitudes toward importance of itch as a health issue (patients' and clinicians' attitudes); and prompts for itch assessment during consultations (routine practice, itch as a marker, and itch severity).

CONCLUSION

Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritizing other health issues, and the length and timing of consultations. Health care professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD.

Necesidades de cuidado paliativo en hemodiálisis percibidas por pacientes, cuidadores principales informales y profesionales de enfermería

Introducción: La hemodiálisis (HD) puede mejorar la supervivencia en los pacientes con Enfermedad Renal Crónica (ERC), pero trae consigo complicaciones y efectos físicos negativos, cambios emocionales y de autoimagen que disminuyen la calidad de vida y determinan la necesidad de cuidados paliativos desde el inicio del tratamiento. Objetivo: Comprender las necesidades paliativas percibidas por el profesional de enfermería, pacientes sometidos a hemodiálisis y sus cuidadores principales informales atendidos en una Unidad Renal de la cuidad de Bogotá-Colombia. Material y Método: Estudio descriptivo, fenomenológico. Se recolectaron los datos a través de la entrevista a profundidad individual semiestructurada. Se entrevistaron 16 personas (6 pacientes, 5 cuidadores principales y 5 enfermeras). El tamaño de la muestra se determinó por saturación de datos. El análisis se llevó a cabo mediante el método propuesto por Colaizzi. Resultados: Emergieron 10 categorías: Percepciones sobre la enfermedad, Red de apoyo e interacción familiar, Limitaciones laborales, económicas y sociales, Red de apoyo asistencial, Necesidades de afrontamiento de la persona y cuidador, Intervenciones del equipo de salud, Factores motivacionales para cuidar, Cambios en los estilos de vida, Generación de redes apoyo y Proyecto de vida. Conclusión: La imposibilidad de continuar con el trabajo, los estudios y el proyecto de vida es la necesidad de mayor impacto negativo en cuanto a la calidad de vida de los pacientes y cuidadores familiares. Sentimientos de tristeza, soledad y baja autoestima están presentes en la mayoría de los pacientes y cuidadores que requieren de la intervención oportuna del equipo interdisciplinario.