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Granal M, Brokhes-Le Calvez S, Dimitrov Y, Chantrel F, Borni-Duval C, Muller C, Délia M, Krummel T, Hannedouche T, Ducher M, Fauvel JP. External validation of the 2-year mortality prediction tool in hemodialysis patients developed using a Bayesian network. Clin Kidney J 2024; 17:sfae095. [PMID: 38915433 PMCID: PMC11195611 DOI: 10.1093/ckj/sfae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Indexed: 06/26/2024] Open
Abstract
Background In recent years, a number of predictive models have appeared to predict the risk of medium-term mortality in hemodialysis patients, but only one, limited to patients aged over 70 years, has undergone sufficiently powerful external validation. Recently, using a national learning database and an innovative approach based on Bayesian networks and 14 carefully selected predictors, we have developed a clinical prediction tool to predict all-cause mortality at 2 years in all incident hemodialysis patients. In order to generalize the results of this tool and propose its use in routine clinical practice, we carried out an external validation using an independent external validation database. Methods A regional, multicenter, observational, retrospective cohort study was conducted to externally validate the tool for predicting 2-year all-cause mortality in incident and prevalent hemodialysis patients. This study recruited a total of 142 incident and 697 prevalent adult hemodialysis patients followed up in one of the eight Association pour l'Utilisation du Rein Artificiel dans la région Lyonnaise (AURAL) Alsace dialysis centers. Results In incident patients, the 2-year all-cause mortality prediction tool had an area under the receiver curve (AUC-ROC) of 0.73, an accuracy of 65%, a sensitivity of 71% and a specificity of 63%. In prevalent patients, the performance for the external validation were similar in terms of AUC-ROC, accuracy and specificity, but was lower in term of sensitivity. Conclusion The tool for predicting all-cause mortality at 2 years, developed using a Bayesian network and 14 routinely available explanatory variables, obtained satisfactory external validation in incident patients, but sensitivity was insufficient in prevalent patients.
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Affiliation(s)
- Maelys Granal
- Department of Nephrology, Hospices Civils de Lyon, Hôpital Edouard Herriot, UMR 5558 CNRS Lyon, Université Lyon 1, Lyon, France
| | | | - Yves Dimitrov
- Renal Research Division, AURAL Strasbourg, Strasbourg, France
- Department of Nephrology, CH Haguenau, Haguenau, France
| | - François Chantrel
- Renal Research Division, AURAL Strasbourg, Strasbourg, France
- Department of Nephrology Groupe Hospitalier de la Région Mulhouse et Sud Alsace, Hôpital Emile Muller, Strasbourg, France
| | | | - Clotilde Muller
- Renal Research Division, AURAL Strasbourg, Strasbourg, France
- Department of Nephrology Groupe Hospitalier Saint-Vincent, Clinique Ste-Anne, Service de Néphrologie, Strasbourg, France
| | - May Délia
- Renal Research Division, AURAL Strasbourg, Strasbourg, France
| | - Thierry Krummel
- Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Néphrologie et Hémodialyse, Strasbourg, France
| | | | - Micher Ducher
- Department of Nephrology, Hospices Civils de Lyon, Hôpital Edouard Herriot, UMR 5558 CNRS Lyon, Université Lyon 1, Lyon, France
| | - Jean-Pierre Fauvel
- Department of Nephrology, Hospices Civils de Lyon, Hôpital Edouard Herriot, UMR 5558 CNRS Lyon, Université Lyon 1, Lyon, France
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2
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Moranne O, Hamroun A, Couchoud C. What does the French REIN registry tell us about Stage 4-5 CKD care in older adults? FRONTIERS IN NEPHROLOGY 2023; 2:1026874. [PMID: 37675001 PMCID: PMC10479600 DOI: 10.3389/fneph.2022.1026874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/02/2022] [Indexed: 09/08/2023]
Abstract
The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.
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Affiliation(s)
- Olivier Moranne
- Service Néphrologie-Dialyse-Aphérèse, Hôpital Universitaire de Nîmes, Hôpital Carémeau, Nîmes, France
- UMR Inserm-UM, Institut Desbrest d'Epidemiologie et Santé publique (IDESP), Montpellier, France
| | - Aghilès Hamroun
- Service de Santé Publique, Service de Néphrologie-Dialyse-Transplantation rénale-Aphérèse, Hôpital Universitaire de Lille, Hôpital Huriez, Lille, France
| | - Cécile Couchoud
- French REIN registry, Agence de la biomédecine, La Plaine Saint-Denis, France
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3
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Gelfand SL, Hentschel DM. Dialysis Access Considerations in Kidney Palliative Care. Semin Nephrol 2023; 43:151397. [PMID: 37579517 DOI: 10.1016/j.semnephrol.2023.151397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
In this review, we discuss common challenges at the interface between dialysis access planning, prognostication, and patient-centered decision making. Particularly for patients whose survival benefit from dialysis is attenuated by advanced age or other serious illness, knowing the potential complications and anticipated frequency of access procedures is essential for patients and families to be able to conceptualize what life on dialysis will look like. Although starting dialysis with a functioning graft or fistula is associated with reduced infection rates, mortality, hospitalizations, and cost compared with a central venous catheter, these benefits must be weighed against the chance that early access placement in an elderly or seriously ill patient is an unnecessary surgery because the chronic kidney disease never progresses, the patient dies before developing an indication to start dialysis, or, the patient prefers conservative kidney management over dialysis. Kidney palliative care is a growing subspecialty of nephrology focused on helping seriously ill patients navigate complex medical decisions, and may be useful for intensive goals-of-care discussions about treatment and access options for patients with limited anticipated survival because of age or other serious illness.
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Affiliation(s)
- Samantha L Gelfand
- Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston MA; Department of Medicine, Division of Palliative Care, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Interventional Nephrology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Dirk M Hentschel
- Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston MA; Department of Medicine, Interventional Nephrology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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4
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Damron KC, Friedman R, Inker LA, Thompson A, Grams ME, Guðmundsdóttir H, Willis K, Manley T, Heerspink HL, Weiner DE. Treating Early Stage CKD with New Medication Therapies: Results of a CKD Patient Survey Informing the 2020 NKF-FDA Scientific Workshop on Clinical Trial Considerations for Developing Treatments for Early Stages of Common, Chronic Kidney Diseases. Kidney Med 2022; 4:100442. [PMID: 35372821 PMCID: PMC8967726 DOI: 10.1016/j.xkme.2022.100442] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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5
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Ladin K, Neckermann I, D’Arcangelo N, Koch-Weser S, Wong JB, Gordon EJ, Rossi A, Rifkin D, Isakova T, Weiner DE. Advance Care Planning in Older Adults with CKD: Patient, Care Partner, and Clinician Perspectives. J Am Soc Nephrol 2021; 32:1527-1535. [PMID: 33827902 PMCID: PMC8259659 DOI: 10.1681/asn.2020091298] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/09/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Older patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement. METHODS In semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4-5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data. RESULTS We conducted 68 semistructured interviews with 23 patients, 19 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients' wishes are known). CONCLUSIONS Patients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.
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Affiliation(s)
- Keren Ladin
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts,Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Isabel Neckermann
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health, Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts
| | - Elisa J. Gordon
- Center for Health Services and Outcomes Research, Center for Bioethics and Medical Humanities, Division of Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Dena Rifkin
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel E. Weiner
- William B Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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6
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Ramspek CL, Evans M, Wanner C, Drechsler C, Chesnaye NC, Szymczak M, Krajewska M, Torino C, Porto G, Hayward S, Caskey F, Dekker FW, Jager KJ, van Diepen M. Kidney Failure Prediction Models: A Comprehensive External Validation Study in Patients with Advanced CKD. J Am Soc Nephrol 2021; 32:1174-1186. [PMID: 33685974 PMCID: PMC8259669 DOI: 10.1681/asn.2020071077] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks. METHODS To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration. RESULTS The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts. CONCLUSIONS Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years).
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Affiliation(s)
- Chava L. Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Wurzburg, Wurzburg, Germany
| | - Christiane Drechsler
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Wurzburg, Wurzburg, Germany
| | - Nicholas C. Chesnaye
- Department of Medical Informatics, European Renal Association–European Dialysis and Transplant Association Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Claudia Torino
- Department of Clinical Epidemiology of Renal Diseases and Hypertension, Consiglio Nazionale della Ricerche - Istituto di fisiologia clinica, Reggio Calabria, Italy
| | - Gaetana Porto
- Department of Clinical Epidemiology of Renal Diseases and Hypertension, Consiglio Nazionale della Ricerche - Istituto di fisiologia clinica, Reggio Calabria, Italy
| | - Samantha Hayward
- Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom,United Kingdom Renal Registry, Bristol, United Kingdom
| | - Fergus Caskey
- Departmen of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J. Jager
- Department of Medical Informatics, European Renal Association–European Dialysis and Transplant Association Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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7
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Prouvot J, Pambrun E, Couchoud C, Vigneau C, Roche S, Allot V, Potier J, Francois M, Babici D, Prelipcean C, Moranne O. Low performance of prognostic tools for predicting dialysis in elderly people with advanced CKD. J Nephrol 2021; 34:1201-1213. [PMID: 33394346 DOI: 10.1007/s40620-020-00919-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Clinical decision-making about care plans can be difficult for very elderly people with advanced chronic kidney disease (CKD). Current guidelines propose the use of prognostic tools predicting end stage renal disease (ESRD) to assist in a patient-centered shared decision-making approach. Our objective was to evaluate the existing risk model scores predicting ESRD, from data collected for a French prospective multicenter cohort of mainly octogenarians with advanced CKD. METHODS We performed a rapid review to identify the risk model scores predicting ESRD developed from CKD patient cohorts and evaluated them with data from a prospective multicenter French cohort of elderly (> 75 years) patients with advanced CKD (estimated glomerular filtration rate [eGFR] < 20 mL/min/1.75m2), followed up for 5 years. We evaluated these scores (in absolute risk) for discrimination, calibration and the Brier score. For scores using the same time frame, we made a joint calibration curve and compared areas under the curve (AUCs). RESULTS The PSPA cohort included 573 patients; their mean age was 83 years and their median eGFR was 13 mL/min/1.73 m2. At the end of follow-up, 414 had died and 287 had started renal replacement therapy (RRT). Our rapid review found 12 scores that predicted renal replacement therapy. Five were evaluated: the TANGRI 4-variable, DRAWZ, MARKS, GRAMS, and LANDRAY scores. No score performed well in the PSPA cohort: AUCs ranged from 0.57 to 0.65, and Briers scores from 0.18 to 0.25. CONCLUSIONS The low predictiveness for ESRD of the scores tested in a cohort of octogenarian patients with advanced CKD underlines the need to develop new tools for this population.
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Affiliation(s)
- Julien Prouvot
- EA2415, Université de Montpellier, Montpellier, France.,Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Emilie Pambrun
- Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Cecile Couchoud
- Registre REIN, Agence de la Biomedecine, Saint-Denis La Plaine, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France
| | - Cecile Vigneau
- CHU Pontchaillou, Service de Néphrologie-Dialyse-Transplantation, Université Rennes 1, IRSET 1085, Rennes, France
| | - Sophie Roche
- Service de Néphrologie-Dialyse, CH Macon, Macon, France
| | - Vincent Allot
- CHU Limoges, Service de Néphrologie, Dialyse, Transplantation, Limoges, France
| | - Jerome Potier
- Service de Néphrologie-Dialyse, CH St Brieuc, Saint Brieuc, France
| | - Maud Francois
- CHU Tours, Service de Néphrologie-Dialyse-Transplantation, Tours, France
| | - Daniela Babici
- Hôpital Emile Muller, Service Néphrologie-Dialyse, GHR MSA, Mulhouse, France
| | - Camelia Prelipcean
- Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France
| | - Olivier Moranne
- EA2415, Université de Montpellier, Montpellier, France. .,Service de Nephrologie, Dialyse et Apherese, Hôpital Universitaire de Caremeau, Nimes, France.
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8
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Blum MF, Sozio SM. Conservative Kidney Management Versus Dialysis Initiation: Can New Statistical Tools Help Understand the Bias in This Choice? Kidney Med 2021; 3:18-19. [PMID: 33605944 PMCID: PMC7873830 DOI: 10.1016/j.xkme.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Matthew F. Blum
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
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9
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Harris DCH, Davies SJ, Finkelstein FO, Jha V, Bello AK, Brown M, Caskey FJ, Donner JA, Liew A, Muller E, Naicker S, O'Connell PJ, Filho RP, Vachharajani T. Strategic plan for integrated care of patients with kidney failure. Kidney Int 2020; 98:S117-S134. [PMID: 33126957 DOI: 10.1016/j.kint.2020.07.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022]
Abstract
There is a huge gap between the number of patients worldwide requiring versus those actually receiving safe, sustainable, and equitable care for kidney failure. To address this, the International Society of Nephrology coordinated the development of a Strategic Plan for Integrated Care of Patients with Kidney Failure. Implementation of the plan will require engagement of the whole kidney community over the next 5-10 years.
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Affiliation(s)
- David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia.
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales (UNSW), New Delhi, India; Manipal Academy of Higher Education (MAHE), Manipal, Kamataka, India
| | - Aminu K Bello
- Division of Nephrology and Immunity, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Brown
- Department of Renal Medicine, St. George Hospital and University of New South Wales, Sydney, New South Wales, Australia
| | - Fergus J Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK; Population Health Sciences, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
| | - Jo-Ann Donner
- International Society of Nephrology, Brussels, Belgium
| | - Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore
| | - Elmi Muller
- Transplant Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Saraladevi Naicker
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Roberto Pecoits Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil; Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Tushar Vachharajani
- Department of Nephrology & Hypertension, Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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10
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Lai CF, Cheng CI, Chang CH, Chen YT, Hwang HC, Lin SL, Huang JW, Huang SJ. Integrating the Surprise Question, Palliative Care Screening Tool, and Clinical Risk Models to Identify Peritoneal Dialysis Patients With High One-Year Mortality. J Pain Symptom Manage 2020; 60:613-621.e6. [PMID: 32278098 DOI: 10.1016/j.jpainsymman.2020.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
CONTEXT Universal screening to identify vulnerable patients who may receive limited benefits from life-sustaining treatments can facilitate palliative care in dialysis populations. OBJECTIVES We aimed to develop prediction models for one-year mortality in peritoneal dialysis (PD) patients. METHODS This prospective cohort study included 401 adult Taiwanese prevalent PD patients (average age 56.2 ± 14 years). In addition to obtaining clinical characteristics and laboratory data, the primary care nurses evaluated the surprise question (SQ) and palliative care screening tool (PCST) for each patient in March 2015. Multivariate logistic regression models were conducted to predict the primary outcome of one-year all-cause mortality. RESULTS There were 34 (8.5%) patients who died during the first year of follow-up. Patients allocated to the not surprised group according to the SQ and those who received a score of ≥4 on the PCST had increased odds of death (odds ratio 24.68 [95% CI 10.66-57.13] and 12.18 [95% CI 5.66-26.21], respectively). We also developed a clinical risk model for one-year mortality that included sex, dialysis vintage, coronary artery disease, malignancy, normalized protein nitrogen appearance, white blood cell count, and serum albumin and sodium levels. Integrating the SQ, PCST, and clinical risk model exhibited good discrimination with an area under the receiver operating characteristic curve of 0.95. Kaplan-Meier analysis showed worse survival in high-risk patients predicted by the integrated model (log-rank P < 0.001). CONCLUSION Screening with the use of the integrated measurement can identify high-risk PD patients. This approach may facilitate palliative care interventions for at-risk subpopulations.
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Affiliation(s)
- Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-I Cheng
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ting Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiau-Chien Hwang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jenq-Wen Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Sheng-Jean Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Taipei City Hospital, Taipei, Taiwan
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11
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Verberne WR, van den Wittenboer ID, Voorend CGN, Abrahams AC, van Buren M, Dekker FW, van Jaarsveld BC, van Loon IN, Mooijaart SP, Ocak G, van Delden JJM, Bos WJW. Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review. Nephrol Dial Transplant 2020; 36:1418-1433. [DOI: 10.1093/ndt/gfaa078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/18/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.
Methods
We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.
Results
Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.
Conclusions
The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.
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Affiliation(s)
- Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carlijn G N Voorend
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, Haga Hospital, The Hague, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands
| | - Ismay N van Loon
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gurbey Ocak
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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12
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Contribution of medico-administrative data to the development of a comorbidity score to predict mortality in End-Stage Renal Disease patients. Sci Rep 2020; 10:8582. [PMID: 32444698 PMCID: PMC7244576 DOI: 10.1038/s41598-020-65612-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/07/2020] [Indexed: 02/08/2023] Open
Abstract
Comorbidity scores to predict mortality are very useful to facilitate decision-making for personalized patient management. This study aim was to assess the contribution of medico-administrative data in addition to French Renal Epidemiology and Information Network (REIN) data to the development of a risk score to predict the 1-year all-cause mortality in patients with End Stage Renal Disease (ESRD), and to compare it with previous scores. Data from a derivation sample (n = 6336 patients who started dialysis in 2015 in France) obtained by linking the REIN and the French National Health Insurance Information System databases were analyzed with multivariate Cox models to select risk factors to establish the score. A randomly chosen validation sample (n = 2716 patients who started dialysis in 2015) was used to validate the score and to compare it with the comorbidity indexes developed by Wright and Charlson. The ability to predict one-year mortality of the score constructed using REIN data linked to the medico-administrative database was not higher than that of the score constructed using only REIN data (i.e., Rennes score). The Rennes score included five comorbidities, albumin, and age. This score (AUC = 0.794, 95%CI: 0.768–0.821) outperformed both the Wright (AUC = 0.631, 95%CI: 0.621–0.639; p < 0.001) and Charlson (AUC = 0.703, 95%CI: 0.689–0.716; p < 0.001) indexes. Data from the REIN registry alone, collected at dialysis start, are sufficient to develop a risk score that can predict the one-year mortality in patients with ESRD. This simple score might help identifying high risk patients and proposing the most adapted care.
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13
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Duarte I, Gameiro J, Resina C, Outerelo C. In-hospital mortality in elderly patients with acute kidney injury requiring dialysis: a cohort analysis. Int Urol Nephrol 2020; 52:1117-1124. [PMID: 32372303 DOI: 10.1007/s11255-020-02482-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine risk factors for in-hospital mortality in elderly patients with acute kidney injury (AKI) requiring dialysis. INTRODUCTION AKI requiring dialysis is frequent in elderly and is associated with an increased intra-hospital mortality. With the growing number of older individuals among hospitalized patients with AKI demands a thorough investigation of the factors that contribute to their mortality to improve outcomes. METHODS We performed a retrospective analysis of patients older than 80 years, admitted due to AKI requiring dialysis between January 2016 and December 2017. Patients who need intensive-care units (ICU) admission were excluded. The primary outcome was all-cause in-hospital mortality. RESULTS A total of 154 patients were evaluated. The mean age was 85.3 ± 4.0 years and 76 patients (49.4%) were male. The overall mortality rate was 26.6%. On the multivariate analysis, serum albumin (OR 0.42 [95% CI 0.21-0.85], p 0.016), C reactive protein/albumin ratio (OR 1.04 [95% CI 0.99-1.09], and renal function recovery (OR 018 [95% CI 0.49-0.65], p 0.009) were the factors associated with higher in-hospital mortality. CONCLUSIONS Lower albumin level, higher C reactive protein/albumin ratio at admission, and absence of renal function recovery are associated with increased in-hospital mortality's risk in elderly with acute kidney injury requiring dialysis.
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Affiliation(s)
- Inês Duarte
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Cristina Resina
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Cristina Outerelo
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
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14
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Ramspek CL, Verberne WR, van Buren M, Dekker FW, Bos WJW, van Diepen M. Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease. Clin Kidney J 2020; 14:189-196. [PMID: 33564418 PMCID: PMC7857791 DOI: 10.1093/ckj/sfaa021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background Conservative care (CC) may be a valid alternative to dialysis for certain older patients with advanced chronic kidney disease (CKD). A model that predicts patient prognosis on both treatment pathways could be of value in shared decision-making. Therefore, the aim is to develop a prediction tool that predicts the mortality risk for the same patient for both dialysis and CC from the time of treatment decision. Methods CKD Stage 4/5 patients aged ≥70 years, treated at a single centre in the Netherlands, were included between 2004 and 2016. Predictors were collected at treatment decision and selected based on literature and an expert panel. Outcome was 2-year mortality. Basic and extended logistic regression models were developed for both the dialysis and CC groups. These models were internally validated with bootstrapping. Model performance was assessed with discrimination and calibration. Results In total, 366 patients were included, of which 126 chose CC. Pre-selected predictors for the basic model were age, estimated glomerular filtration rate, malignancy and cardiovascular disease. Discrimination was moderate, with optimism-corrected C-statistics ranging from 0.675 to 0.750. Calibration plots showed good calibration. Conclusions A prediction tool that predicts 2-year mortality was developed to provide older advanced CKD patients with individualized prognosis estimates for both dialysis and CC. Future studies are needed to test whether our findings hold in other CKD populations. Following external validation, this prediction tool could be used to compare a patient’s prognosis on both dialysis and CC, and help to inform treatment decision-making.
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Affiliation(s)
- Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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15
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Thuillier Lecouf A, Videloup L, Letrecher S, Béchade C, Recorbet M, Chatelet V. L’hypnose Ericksonienne et la méditation pleine conscience : vers une médecine comportementale en néphrologie. Nephrol Ther 2020; 16:93-96. [DOI: 10.1016/j.nephro.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
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16
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Engels N, de Graav G, van der Nat P, van den Dorpel M, Bos WJ, Stiggelbout AM. Shared decision-making in advanced kidney disease: a scoping review protocol. BMJ Open 2020; 10:e034142. [PMID: 32111615 PMCID: PMC7050317 DOI: 10.1136/bmjopen-2019-034142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Patients with advanced kidney disease (AKD) have to make difficult treatment modality decisions as their disease progresses towards end-stage kidney disease. International guidelines in nephrology suggest shared decision-making (SDM) to help patients make timely treatment modality decisions that align with their values and preferences. However, systematic reviews or scoping reviews on these SDM interventions and on their reported use or outcomes are lacking. This limits the adoption of SDM in clinical practice and hampers further research and development on the subject. Our aim is to provide a comprehensive and up-to-date overview of these SDM interventions by means of a scoping review of the literature. Scoping reviews can provide a broad overview of a topic, identify gaps in the research knowledge base and report on the types of evidence that address and inform practices. This paper presents our study protocol. METHODS AND ANALYSIS The proposed scoping review will be performed in accordance with the Joanna Briggs Institute's (JBI) methodology for scoping reviews. It will cover both qualitative and quantitative scientific literature, as well as the grey literature on SDM interventions for treatment modality decisions in AKD. Only literature written in English will be considered for inclusion. Two independent reviewers will participate in an iterative process of screening the literature, paper selection and data extraction. Disagreements between the reviewers will be resolved by discussion until consensus is reached or after consultation with the research team when needed. Results will be reported with descriptive statistics and diagrammatic or tabular displayed information, accompanied by narrative summaries as explained in the JBI guidelines. ETHICS AND DISSEMINATION Ethical approval for the conduct of this study is not required. We will analyse previously collected data for the proposed scoping review. Our results will be published in a peer-reviewed journal and disseminated through conferences and/or seminars.
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Affiliation(s)
- Noel Engels
- Shared decision making, Santeon, Utrecht, Utrecht, The Netherlands
| | - Gretchen de Graav
- Internal Medicine, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | | | | | - Willem Jan Bos
- Internal Medicine, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Leiden University Medical Center, Leiden, Zuid Holland, The Netherlands
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17
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Nair D, El-Sourady M, Bonnet K, Schlundt DG, Fanning JB, Karlekar MB. Barriers and Facilitators to Discussing Goals of Care among Nephrology Trainees: A Qualitative Analysis and Novel Educational Intervention. J Palliat Med 2020; 23:1045-1051. [PMID: 32045328 DOI: 10.1089/jpm.2019.0570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Goals of care (GOC) conversations are critical to advance care planning but occur infrequently in nephrology. National workshops have improved trainee comfort with initiating GOC conversations but lack interface with palliative subspecialists and can incur travel-related costs. We developed an educational intervention focused on GOC conversations for nephrology trainees that incorporated into routine schedules and offered feedback from palliative subspecialists. Objective: To explore barriers and facilitators to discussing GOC and uncover perceptions of GOC-related behavior change post-intervention. Design: Qualitative study. Setting/Subjects: Sixteen nephrology trainees at an academic medical center. Measurements: Analyses of semistructured interviews occurred in phases: (1) isolation of quotes; (2) development of a coding system; and (3) creation of a framework of interrelationships between quotes using an inductive/deductive approach. Results: We captured the following themes: (1) prior knowledge (ability to define GOC, knowledge of communication frameworks and prognostic data, exposure to outpatient GOC conversations; (2) attitudes related to GOC conversations (responsibility, comfort, therapeutic alliance, patient preparedness, partnership with care teams); and (3) potential change in behaviors (increased likelihood to initiate GOC conversations early, more accurate identification of patients appropriate for a GOC conversation). Conclusions: Prior knowledge of, exposure to, and attitudes toward advance care planning were key determinants of a nephrology trainees' ability to initiate timely GOC conversations. After our intervention, trainees reported increased comfort with and likelihood to initiate GOC conversations and an improved ability to identify appropriate candidates. Our intervention may be a novel, feasible way to coach nephrologists to initiate timely GOC conversations.
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Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Center for Health Services Research, Nashville, Tennessee, USA.,Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA
| | - Maie El-Sourady
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph B Fanning
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee, USA
| | - Mohana B Karlekar
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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18
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Oskoui T, Pandya R, Weiner DE, Wong JB, Koch-Weser S, Ladin K. Advance Care Planning Among Older Adults With Advanced Non-Dialysis-Dependent CKD and Their Care Partners: Perceptions Versus Reality? Kidney Med 2020; 2:116-124. [PMID: 32734232 PMCID: PMC7384367 DOI: 10.1016/j.xkme.2019.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale & Objective Older patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non–dialysis-dependent population. Study Design In-person interviewer-administered surveys of patients 70 years and older with non–dialysis-dependent CKD stage 4 or 5 and their self-identified care partners. Setting & Participants 42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston. Outcomes Completion of advance directives and self-reported perceptions, preferences, and experiences of ACP. Analytical Approach Descriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses. Results Most patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians’ judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team. Limitations Single metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size. Conclusions Patients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.
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Affiliation(s)
- Tira Oskoui
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA
| | - Renuka Pandya
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA
| | - Daniel E Weiner
- Department of Medicine, Tufts Medical Center, Boston, MA.,William B Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
| | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Susan Koch-Weser
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA.,Department of Occupational Therapy, Tufts University, Medford, MA.,Department of Community Health, Tufts University, Medford, MA
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19
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Berzoff J, Kitsen J, Klingensmith J, Cohen LM. Advance Care Planning Training for Renal Social Workers. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2020; 16:5-18. [PMID: 32026760 DOI: 10.1080/15524256.2020.1721396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
End Stage Renal Disease (ESRD) is a life-limiting condition for which hospice and palliative care are not routinely provided to patients and families. While the ESRD mortality rate is close to 25%, patients on dialysis are half as likely to receive hospice services than patients with other life-limiting diagnoses. Nephrologists and dialysis social workers receive little training to effectively lead patients with ESRD and their families through the stages of dying and the completion of advance care planning. The lack of professional training, a need for greater commitment to advanced care planning from dialysis corporations, and reimbursement problems for hospice care, all contribute to low rates of hospice use within the ESRD population. An ESRD advance care training program for social workers is described that was developed as a part of a larger research project designed to increase advance care planning and referrals for hospice for those with ESRD. The goals were to help social workers become better advocates for patients and families, appreciate cultural, spiritual, racial and ethnic differences, and understand the ethical and legal issues in advance care planning. The challenges that emerged included high staff turnover and a paucity of corporate commitment to training.
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Affiliation(s)
- Joan Berzoff
- End of Life Certificate Program, School for Social Work, Smith College, Northampton, Massachusetts, USA
| | - Jenny Kitsen
- Former Executive Director, ESRD Network of New England, Woodbridge, CT, USA
| | | | - Lewis M Cohen
- University of Massachusetts-Baystate Medical School, Springfield, Massachusetts, USA
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20
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Older patients' experiences with a shared decision-making process on choosing dialysis or conservative care for advanced chronic kidney disease: a survey study. BMC Nephrol 2019; 20:264. [PMID: 31311511 PMCID: PMC6635995 DOI: 10.1186/s12882-019-1423-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Many older patients approaching end-stage kidney disease have to decide whether to go for dialysis or non-dialytic conservative care (CC). Shared decision-making is recommended to align the treatment plan with the patient’s preferences and values. Little is known about older patients’ experiences with shared decision-making on dialysis or CC. Methods We performed a survey study, in collaboration with the Dutch Kidney Patients Association, in 99 patients aged ≥70 years who had chosen dialysis (n = 75) or CC (n = 24) after a shared decision-making process involving an experienced multidisciplinary team. Results Patients stated to be overall satisfied with the shared decision-making process (% with score 6–10 on 11-point Likert scale, dialysis versus CC: 93% vs. 91%, P = 0.06), and treatment decision (87% vs. 91%, P = 0.03). However, patients also reported negative experiences, especially those who had chosen dialysis. Such negative experiences were related to the timing, informing, and level of decision-making being shared. More patients who selected dialysis indicated to have felt forced to make a decision, mostly due to the circumstances, such as their deteriorating health or kidney function, or by their nephrologist (31% vs. 5%, P = 0.01). Also, patients who selected dialysis mentioned a perceived lack of choice as most common reason for choosing dialysis, and 55% considered their own opinion as most important rather than their nephrologists’ or relatives’ opinion compared to 90% of the patients who had chosen CC (P = 0.02). A subset of patients who had chosen dialysis still doubted their treatment decision compared to no patient who had chosen CC (17% vs. 0%, P = 0.03). Conclusions Older patients reported contrasting experiences with shared decision-making on dialysis or CC. Despite high overall satisfaction, the underlying negative experiences illustrate important but modifiable barriers to an optimal shared decision-making process. Electronic supplementary material The online version of this article (10.1186/s12882-019-1423-x) contains supplementary material, which is available to authorized users.
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21
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Machine Learning to Identify Dialysis Patients at High Death Risk. Kidney Int Rep 2019; 4:1219-1229. [PMID: 31517141 PMCID: PMC6732773 DOI: 10.1016/j.ekir.2019.06.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/30/2019] [Accepted: 06/10/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction Given the high mortality rate within the first year of dialysis initiation, an accurate estimation of postdialysis mortality could help patients and clinicians in decision making about initiation of dialysis. We aimed to use machine learning (ML) by incorporating complex information from electronic health records to predict patients at risk for postdialysis short-term mortality. Methods This study was carried out on a contemporary cohort of 27,615 US veterans with incident end-stage renal disease (ESRD). We implemented a random forest method on 49 variables obtained before dialysis transition to predict outcomes of 30-, 90-, 180-, and 365-day all-cause mortality after dialysis initiation. Results The mean (±SD) age of our cohort was 68.7 ± 11.2 years, 98.1% of patients were men, 29.4% were African American, and 71.4% were diabetic. The final random forest model provided C-statistics (95% confidence intervals) of 0.7185 (0.6994–0.7377), 0.7446 (0.7346–0.7546), 0.7504 (0.7425–0.7583), and 0.7488 (0.7421–0.7554) for predicting risk of death within the 4 different time windows. The models showed good internal validity and replicated well in patients with various demographic and clinical characteristics and provided similar or better performance compared with other ML algorithms. Results may not be generalizable to non-veterans. Use of predictors available in electronic medical records has limited the assessment of number of predictors. Conclusion We implemented and ML-based method to accurately predict short-term postdialysis mortality in patients with incident ESRD. Our models could aid patients and clinicians in better decision making about the best course of action in patients approaching ESRD.
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22
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Guerrero Riscos MA, Toro Prieto FJ, Batalha Caetano P, Salgueira Lazo M, González Cabrera F, Marrero Robayna S, Santana Estupiñán R, Álvarez Martín C. Advanced chronic renal failure (ACRF) study. Baseline characteristics, evaluation of the application of the structured information for the election of renal replacement therapy and one-year evolution of the incident patients in the ACRF medical office. Nefrologia 2019; 39:629-637. [PMID: 31027895 DOI: 10.1016/j.nefro.2019.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/26/2019] [Accepted: 02/20/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Analyze evolution Renal Chronic Failure stage 4-5 (ACRF) patients and influence information they receive (educational process, EP) in modality Renal Replacement Therapy (RRT) or conservative treatment (CT) in multidisciplinar ACRF Office. MATERIAL AND METHODS Prospective, multicenter study (3 centers). Inclusion: from June-01-2014 to October-01-2015; observation: 12 months or until start RRT or death if they occur before 12 months; ends October-01-2016. RESULTS 336 patients were included (60% males), median and intercuartile rank 71.5 (17), 55% ≥ 70 years; Follow up initiation eGFR CKD-EPI: 21 (9) ml / min / 1.73m2; Charlson Index (ChI) with / without age 8 (3) / 4 (2); Diabetic patients: 52,4%. The EP was carried out in 168, eGFR 15 (10) ml / min / 1.73m2. The initial treatment election: 26% peritoneal dialysis (PD), 45% hemodyalisis (HD), 26% CT, kidney trasplant 3%; 60 patients started RRT: 3.3% kidney traspant; 30% PD, 66% HD; 104 admissions in 73 patients, the most frequent cause: cardiovascular disease (42%). Fallecimiento: 23 patients (6.8%). Age was higher (78.4 (6) vs. 67.8 (13.4), P<.001), higher ChI 9.8 (2.1) vs. 7.4 (2.5), P<.001). All deceased who received EP had chosen CT; 61% of deceased had at least one hospital admission vs. 39% alive (P<0.001). Cox regression: age and Charlson index were the predictive mortality variables. CONCLUSIONS The population of ACRF patients is elder, comorbid, with high rate hospitalizations rate. The PD election is higher than usual. The EP has been very useful tool and has favored the PD choice.
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Affiliation(s)
| | | | | | | | - Fayna González Cabrera
- Servicio de Nefrología, Hospital Universitario Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Silvia Marrero Robayna
- Servicio de Nefrología, Hospital Universitario Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Raquel Santana Estupiñán
- Servicio de Nefrología, Hospital Universitario Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
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23
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Zaoui P, Hannedouche T, Combe C. [Cardiovascular protection of diabetic patient with chronic renal disease and particular case of end-stage renal disease in elderly patients]. Nephrol Ther 2018; 13:6S16-6S24. [PMID: 29463395 DOI: 10.1016/s1769-7255(18)30036-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Type 2 diabetes has an increasing prevalence. Life expectancy is dominated by cardiovascular risk, which is the leading cause of death in these patients. Up to one third of diabetic patients will develop diabetic nephropathy related to micro-angiopathy. Renal impairment further increases cardiovascular risk. Reducing cardiovascular morbidity and mortality is a major public health issue, as well as early preventing and managing chronic kidney disease (CKD). Good glycemic control prevents the micro-vascular complications of the disease (retinopathy, nephropathy, etc.) and, more recently recognized through prolonged monitoring of the VADT cohort, prevents cardiovascular complications. Control of blood pressure and dyslipidemia are essential in primary or secondary cardiovascular prevention. In addition, the blockers of the renin-angiotensin system slow down the progression of the MRC. Elderly patients with chronic kidney disease (CKD) form another growing group of the nephrologist daily patient pool. Especially for very elderly patients with comorbidities, the question of favoring conservative treatment rather than starting or pursuing dialysis may arise. Survival and quality of life are indeed not necessarily better in elderly patients undergoing dialysis, complications can occur eventually leading to discontinuation, and are occasionally associated with a feeling of stubbornness. Creation of prognostic score is a useful tool to help the decision-making process. However, dialogue with the patient and his/her family, as well as multidisciplinary collaboration remain fundamentals to determine the most suitable care.
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Affiliation(s)
- P Zaoui
- Pôle Digestif Uro-Néphro-Endocrinologie (DIGIDUNE), AGDUC, CHU Université Grenoble Alpes, Pole Santé, France.
| | - T Hannedouche
- Service de Néphrologie, Hôpitaux Universitaires de Strasbourg, Faculté de Médecine, Strasbourg, France.
| | - C Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France Unité INSERM 1026 Biotis, Université de Bordeaux, Bordeaux, France.
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24
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Obi Y, Nguyen DV, Zhou H, Soohoo M, Zhang L, Chen Y, Streja E, Sim JJ, Molnar MZ, Rhee CM, Abbott KC, Jacobsen SJ, Kovesdy CP, Kalantar-Zadeh K. Development and Validation of Prediction Scores for Early Mortality at Transition to Dialysis. Mayo Clin Proc 2018; 93:1224-1235. [PMID: 30104041 DOI: 10.1016/j.mayocp.2018.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/10/2018] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To develop and validate a risk prediction model that would help individualize treatment and improve the shared decision-making process between clinicians and patients. PATIENTS AND METHODS We developed a risk prediction tool for mortality during the first year of dialysis based on pre-end-stage renal disease characteristics in a cohort of 35,878 US veterans with incident end-stage renal disease who transitioned to dialysis treatment between October 1, 2007, and March 31, 2014 and then externally validated this tool among 4284 patients in the Kaiser Permanente Southern California (KPSC) health care system who transitioned to dialysis treatment between January 1, 2007, and September 30, 2015. RESULTS To ensure model goodness of fit, 2 separate models were selected for patients whose last estimated glomerular filtration rate (eGFR) before dialysis initiation was less than 15 mL/min per 1.73 m2 or 15 mL/min per 1.73 m2 or higher. Model discrimination in the internal validation cohort of veterans resulted in C statistics of 0.71 (95% CI, 0.70-0.72) and 0.66 (95% CI, 0.65-0.67) among patients with eGFR lower than 15 mL/min per 1.73 m2 and 15 mL/min per 1.73 m2 or higher, respectively. In the KPSC external validation cohort, the developed risk score exhibited C statistics of 0.77 (95% CI, 0.74-0.79) in men and 0.74 (95% CI, 0.71-0.76) in women with eGFR lower than 15 mL/min per 1.73 m2 and 0.71 (95% CI, 0.67-0.74) in men and 0.67 (95% CI, 0.62-0.72) in women with eGFR of 15 mL/min per 1.73 m2 or higher. CONCLUSION A new risk prediction tool for mortality during the first year after transition to dialysis (available at www.DialysisScore.com) was developed in the large national Veterans Affairs cohort and validated with good performance in the racially, ethnically, and gender diverse KPSC cohort. This risk prediction tool will help identify high-risk populations and guide management strategies at the transition to dialysis.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Danh V Nguyen
- Division of General Internal Medicine and Primary Care, University of California, Irvine Medical Center, Orange, CA
| | - Hui Zhou
- Kaiser Permanente Southern California, Pasadena, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Lishi Zhang
- Institute for Clinical and Translational Science, University of California, Irvine, CA
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - John J Sim
- Kaiser Permanente Southern California, Pasadena, CA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
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25
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Personalized Approach and Precision Medicine in Supportive and End-of-Life Care for Patients With Advanced and End-Stage Kidney Disease. Semin Nephrol 2018; 38:336-345. [PMID: 30082054 DOI: 10.1016/j.semnephrol.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Kidney supportive care requires a highly personalized approach to care. Precision medicine holds promise for a deeper understanding of the pathophysiology of symptoms and related syndromes and more precise individualization of prognosis and treatment estimates, therefore providing valuable opportunities for greater personalization of supportive care. However, the major drivers of quality of life are psychosocial, economic, lifestyle, and preference-based, and consideration of these factors and skilled communication are integral to the provision of excellent and personalized kidney supportive care. This article discusses the concepts of personalized and precision medicine in the context of kidney supportive care and highlights some opportunities and limitations within these fields.
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Eckardt KU, Bansal N, Coresh J, Evans M, Grams ME, Herzog CA, James MT, Heerspink HJL, Pollock CA, Stevens PE, Tamura MK, Tonelli MA, Wheeler DC, Winkelmayer WC, Cheung M, Hemmelgarn BR. Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 93:1281-1292. [PMID: 29656903 PMCID: PMC5998808 DOI: 10.1016/j.kint.2018.02.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/24/2018] [Accepted: 02/05/2018] [Indexed: 12/22/2022]
Abstract
Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marie Evans
- Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Swedish Renal Registry, Jönköping, Sweden
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA; Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carol A Pollock
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals, University NHS Foundation Trust, Canterbury, Kent, UK
| | - Manjula Kurella Tamura
- VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, California, USA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marcello A Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Hall RK, Luciano A, Pieper C, Colón-Emeric CS. Association of Kidney Disease Quality of Life (KDQOL-36) with mortality and hospitalization in older adults receiving hemodialysis. BMC Nephrol 2018; 19:11. [PMID: 29334904 PMCID: PMC5769495 DOI: 10.1186/s12882-017-0801-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/18/2017] [Indexed: 11/17/2022] Open
Abstract
Background For older adults receiving dialysis, health-related quality of life is not often considered in prognostication of death or future hospitalizations. To determine if routine health-related quality of life measures may be useful for prognostication, the objective of this study is to determine the extent of association of Kidney Disease Quality of Life (KDQOL-36) subscales with adverse outcomes in older adults receiving dialysis. Methods This is a longitudinal study of 3500 adults aged ≥75 years receiving dialysis in the United States in 2012 and 2013. We used Cox and Fine and Gray models to evaluate the association of KDQOL-36 subscales with risk of death and hospitalization. We adjusted for sociodemographic variables, hemodialysis access type, laboratory values, and Charlson index. Results Three thousand one hundred thirty-two hemodialysis patients completed the KDQOL-36. From KDQOL-36 completion date in 2012, 880 (28.1%) died and 2023 (64.6%) had at least one hospitalization over a median follow-up of 512 and 203 days, respectively. Cohort members with a SF-12 physical component summary (PCS) in the lowest quintile had an increased adjusted risk of death [hazard ratio (HR), 1.55, 95% confidence interval (CI) 1.19–2.03] and hospitalization (HR, 1.29, 95% CI 1.09–1.54) compared with those with scores in the highest quintile. Cohort members with a SF-12 mental component summary in the lowest quintile had an increased risk of hospitalization (HR, 1.39, 95% CI 1.17–1.65) compared with those in the highest quintile. In adjusted analyses, there was no association between the symptoms of kidney disease, effects of kidney disease, and burden of kidney disease subscales with time to death or first hospitalization. Competing risk models showed similar HRs. Conclusions Among the KDQOL-36 subscales, the SF-12 PCS demonstrates the strongest association with both death and future hospitalizations in older adults receiving hemodialysis Further research is needed to assess the value this subscale may add to prognostication. Electronic supplementary material The online version of this article (10.1186/s12882-017-0801-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rasheeda K Hall
- Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA. .,Duke University Medical Center, Division of Nephrology, Department of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC, 27710, USA.
| | - Alison Luciano
- Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC, 27710, USA
| | - Carl Pieper
- Duke University, Department of Biostatistics and Bioinformatics, Box DUMC 2721, 2424 Erwin Road, Suite 1102, Durham, NC, 27710, USA
| | - Cathleen S Colón-Emeric
- Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA.,Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC, 27710, USA
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28
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Malhotra R, Tao X, Wang Y, Chen Y, Apruzzese RH, Balter P, Xiao Q, Usvyat LA, Kotanko P, Thijssen S. Performance of the Surprise Question Compared to Prediction Models in Hemodialysis Patients: A Prospective Study. Am J Nephrol 2017; 46:390-396. [PMID: 29130949 DOI: 10.1159/000481920] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/22/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND The surprise question (SQ) ("Would you be surprised if this patient were still alive in 6 or 12 months?") is used as a mortality prognostication tool in hemodialysis (HD) patients. We compared the performance of the SQ with that of prediction models (PMs) for 6- and 12-month mortality prediction. METHODS Demographic, clinical, laboratory, and dialysis treatment indicators were used to model 6- and 12-month mortality probability in a HD patients training cohort (n = 6,633) using generalized linear models (GLMs). A total of 10 nephrologists from 5 HD clinics responded to the SQ in 215 patients followed prospectively for 12 months. The performance of PM was evaluated in the validation (n = 6,634) and SQ cohorts (n = 215) using the areas under receiver operating characteristics curves. We compared sensitivities and specificities of PM and SQ. RESULTS The PM and SQ cohorts comprised 13,267 (mean age 61 years, 55% men, 54% whites) and 215 (mean age 62 years, 59% men, 50% whites) patients, respectively. During the 12-month follow-up, 1,313 patients died in the prediction model cohort and 22 in the SQ cohort. For 6-month mortality prediction, the GLM had areas under the curve of 0.77 in the validation cohort and 0.77 in the SQ cohort. As for 12-month mortality, areas under the curve were 0.77 and 0.80 in the validation and SQ cohorts, respectively. The 6- and 12-month PMs had sensitivities of 0.62 (95% CI 0.35-0.88) and 0.75 (95% CI 0.56-0.94), respectively. The 6- and 12-month SQ sensitivities were 0.23 (95% CI 0.002-0.46) and 0.35 (95% CI 0.14-0.56), respectively. CONCLUSION PMs exhibit superior sensitivity compared to the SQ for mortality prognostication in HD patients.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - Xia Tao
- Renal Research Institute, New York, New York, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California - Santa Barbara, Santa Barbara, California, USA
| | - Yuqi Chen
- Department of Statistics and Applied Probability, University of California - Santa Barbara, Santa Barbara, California, USA
| | | | - Paul Balter
- Renal Research Institute, New York, New York, USA
| | | | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | - Peter Kotanko
- Renal Research Institute, New York, New York, USA
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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van Loon IN, Goto NA, Boereboom FT, Bots ML, Verhaar MC, Hamaker ME. Frailty Screening Tools for Elderly Patients Incident to Dialysis. Clin J Am Soc Nephrol 2017; 12:1480-1488. [PMID: 28716855 PMCID: PMC5586582 DOI: 10.2215/cjn.11801116] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES A geriatric assessment is an appropriate method for identifying frail elderly patients. In CKD, it may contribute to optimize personalized care. However, a geriatric assessment is time consuming. The purpose of our study was to compare easy to apply frailty screening tools with the geriatric assessment in patients eligible for dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 123 patients on incident dialysis ≥65 years old were included <3 weeks before to ≤2 weeks after dialysis initiation, and all underwent a geriatric assessment. Patients with impairment in two or more geriatric domains on the geriatric assessment were considered frail. The diagnostic abilities of six frailty screening tools were compared with the geriatric assessment: the Fried Frailty Index, the Groningen Frailty Indicator, Geriatric8, the Identification of Seniors at Risk, the Hospital Safety Program, and the clinical judgment of the nephrologist. Outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In total, 75% of patients were frail according to the geriatric assessment. Sensitivity of frailty screening tools ranged from 48% (Fried Frailty Index) to 88% (Geriatric8). The discriminating features of the clinical judgment were comparable with the other screening tools. The Identification of Seniors at Risk screening tool had the best discriminating abilities, with a sensitivity of 74%, a specificity of 80%, a positive predictive value of 91%, and a negative predictive value of 52%. The negative predictive value was poor for all tools, which means that almost one half of the patients screened as fit (nonfrail) had two or more geriatric impairments on the geriatric assessment. CONCLUSIONS All frailty screening tools are able to detect geriatric impairment in elderly patients eligible for dialysis. However, all applied screening tools, including the judgment of the nephrologist, lack the discriminating abilities to adequately rule out frailty compared with a geriatric assessment.
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Affiliation(s)
- Ismay N. van Loon
- Dianet Dialysis Center, Utrecht, The Netherlands
- Departments of Internal Medicine and
- Departments of Nephrology and Hypertension and
| | | | | | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Forzley B, Chiu HHL, Djurdjev O, Carson RC, Hargrove G, Martinusen D, Karim M. A Survey of Canadian Nephrologists Assessing Prognostication in End-Stage Renal Disease. Can J Kidney Health Dis 2017; 4:2054358117725294. [PMID: 28835851 PMCID: PMC5564856 DOI: 10.1177/2054358117725294] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) frequently have a relatively poor prognosis with complex care needs that depend on prognosis. While many means of assessing prognosis are available, little is known about how Canadian nephrologists predict prognosis, whether they routinely share prognostic information with their patients, and how this information guides management. OBJECTIVE To guide improvements in the management of patients with ESRD, we aimed to better understand how Canadian nephrologists consider prognosis during routine care. DESIGN AND METHODS A web-based multiple choice survey was designed, and administered to adult nephrologists in Canada through the e-mail list of the Canadian Society of Nephrology. The survey asked the respondents about their routine practice of estimating survival and the perceived importance of prognostic practices and tools in patients with ESRD. Descriptive statistics were used in analyzing the responses. RESULTS Less than half of the respondents indicated they always or often make an explicit attempt to estimate and/or discuss survival with ESRD patients not on dialysis, and 25% reported they do so always or often with patients on dialysis. Survival estimation is most frequently based on clinical gestalt. Respondents endorse a wide range of issues that may be influenced by prognosis, including advance care planning, transplant referral, choice of dialysis access, medication management, and consideration of conservative care. LIMITATIONS This is a Canadian sample of self-reported behavior, which was not validated, and may be less generalizable to non-Canadian health care jurisdictions. CONCLUSIONS In conclusion, prognostication of patients with ESRD is an important issue for nephrologists and impacts management in fairly sophisticated ways. Information sharing on prognosis may be suboptimal.
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Affiliation(s)
- Brian Forzley
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Interior Health Authority, Kelowna, British Columbia, Canada
| | | | | | - Rachel C. Carson
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Island Health Authority, Victoria, British Columbia, Canada
| | - Gaylene Hargrove
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Island Health Authority, Victoria, British Columbia, Canada
| | - Dan Martinusen
- Island Health Authority, Victoria, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamud Karim
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Fraser Health Authority, Surrey, British Columbia, Canada
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31
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Brennan F, Stewart C, Burgess H, Davison SN, Moss AH, Murtagh FE, Germain M, Tranter S, Brown M. Time to Improve Informed Consent for Dialysis: An International Perspective. Clin J Am Soc Nephrol 2017; 12:1001-1009. [PMID: 28377472 PMCID: PMC5460710 DOI: 10.2215/cjn.09740916] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The literature reveals that current nephrology practice in obtaining informed consent for dialysis falls short of ethical and legal requirements. Meeting these requirements represents a significant challenge, especially because the benefits and risks of dialysis have shifted significantly with the growing number of older, comorbid patients. The importance of informed consent for dialysis is heightened by several concerns, including: (1) the proportion of predialysis patients and patients on dialysis who lack capacity in decision making and (2) whether older, comorbid, and frail patients understand their poor prognosis and the full implications to their independence and functional status of being on dialysis. This article outlines the ethical and legal requirements for a valid informed consent to dialysis: (1) the patient was competent, (2) the consent was made voluntarily, and (3) the patient was given sufficient information in an understandable manner to make the decision. It then considers the application of these requirements to practice across different countries. In the process of informed consent, the law requires a discussion by the physician of the material risks associated with dialysis and alternative options. We argue that, legally and ethically, this discussion should include both the anticipated trajectory of the illness and the effect on the life of the patient with particular regard to the outcomes most important to the individual. In addition, a discussion should occur about the option of a conservative, nondialysis pathway. These requirements ensure that the ethical principle of respect for patient autonomy is honored in the context of dialysis. Nephrologists need to be open to, comfortable with, and skillful in communicating this information. From these clear, open, ethically, and legally valid consent discussions, a significant dividend will hopefully flow for patients, families, and nephrologists alike.
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Affiliation(s)
- Frank Brennan
- Departments of Nephrology and
- Palliative Care, St. George Hospital, Sydney, New South Wales, Australia
| | - Cameron Stewart
- Faculty of Law, University of Sydney, Sydney, New South Wales, Australia
| | | | - Sara N. Davison
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Alvin H. Moss
- Sections of Nephrology and
- Supportive Care, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Fliss E.M. Murtagh
- Department of Palliative Care, Cecily Saunders Institute, King’s College London, London, United Kingdom; and
| | - Michael Germain
- Division of Nephrology, Tufts University, Springfield, Massachusetts
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Davison SN, Moss AH. Supportive Care: Meeting the Needs of Patients with Advanced Chronic Kidney Disease. Clin J Am Soc Nephrol 2016; 11:1879-1880. [PMID: 28394760 PMCID: PMC5053793 DOI: 10.2215/cjn.06800616] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and
| | - Alvin H. Moss
- Sections of Nephrology and
- Supportive Care, West Virginia University School of Medicine, Morgantown, West Virginia
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Davison SN, Jassal SV. Supportive Care: Integration of Patient-Centered Kidney Care to Manage Symptoms and Geriatric Syndromes. Clin J Am Soc Nephrol 2016; 11:1882-1891. [PMID: 27510454 PMCID: PMC5053783 DOI: 10.2215/cjn.01050116] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Dialysis care is often associated with poor outcomes including low quality of life (QOL). To improve patient-reported outcomes, incorporation of the patient's needs and perspective into the medical care they receive is essential. This article provides a framework to help clinicians integrate symptom assessment and other measures such as QOL and frailty scores into a clinical approach to the contemporary supportive care of patients with advanced CKD. This approach involves (1) defining our understanding of kidney supportive care, patient-centered dialysis, and palliative dialysis; (2) understanding and recognizing common symptoms associated with advanced CKD; (3) discussing the concepts of physical function, frailty, and QOL and their role in CKD; and (4) identifying the structural and process barriers that may arise when patient-centered dialysis is being introduced into clinical practice.
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Affiliation(s)
- Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and
| | - Sarbjit Vanita Jassal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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