Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study

Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study

RATIONALE & OBJECTIVE

Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population.

STUDY DESIGN

National explanatory sequential mixed methods study including an online survey and semistructured interviews.

SETTING & PARTICIPANTS

Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022.

ANALYTICAL APPROACH

Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data.

RESULTS

A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care.

LIMITATIONS

Potential selection bias.

CONCLUSIONS

Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them.

PLAIN-LANGUAGE SUMMARY

Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.

Patient engagement during the transition from nondialysis-dependent chronic kidney disease to dialysis: A meta-ethnography

INTRODUCTION

Patient engagement, encompassing both patient experience and opportunities for involvement in care, has been associated with increased patient satisfaction and the overall quality of care. Despite its importance, there is limited knowledge regarding patient engagement in the transition from nondialysis-dependent chronic kidney disease (CKD) to dialysis-dependent treatment. This systematic review employs meta-ethnography to synthesize findings from qualitative studies examining patients' experiences of engagement during this transition, with the aim of developing a comprehensive theoretical understanding of patient engagement in the transition from nondialysis-dependent CKD to dialysis.

METHODS

A systematic search of six databases, namely the Cochrane Library, PsycINFO, Scopus, Embase, PubMed and Web of Science was conducted to identify eligible articles published between 1990 and 2022. Meta-ethnography was utilized to translate and synthesize the findings and develop a novel theoretical interpretation of 'patient engagement' during the transition to dialysis.

RESULTS

A total of 24 articles were deemed eligible for review, representing 21 studies. Patient engagement during a transition to dialysis was found to encompass three major domains: psychosocial adjustment, decision-making and engagement in self-care. These three domains could be experienced as an iterative and mutually reinforcing process, guiding patients toward achieving control and proficiency in their lives as they adapt to dialysis. Additionally, patient engagement could be facilitated by factors including patients' basic capability to engage, the provision of appropriate education, the establishment of supportive relationships and the alignment with values and resources.

CONCLUSIONS

The findings of this review underscore the necessity of involving patients in transitional dialysis care, emphasizing the need to foster their engagement across multiple domains. Recommendations for future interventions include the provision of comprehensive support to enhance patient engagement during this critical transition phase. Additional research is warranted to explore the effects of various facilitators at different levels.

PATIENT OR PUBLIC CONTRIBUTION

The studies included in our review involved 633 participants (547 patients, 14 family members, 63 healthcare providers and 9 managers). Based on their experiences, views and beliefs, we developed a deeper understanding of patient engagement and how to foster it in the future.

Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.

Predicting outcomes in chronic kidney disease: needs and preferences of patients and nephrologists

INTRODUCTION

Guidelines on chronic kidney disease (CKD) recommend that nephrologists use clinical prediction models (CPMs). However, the actual use of CPMs seems limited in clinical practice. We conducted a national survey study to evaluate: 1) to what extent CPMs are used in Dutch CKD practice, 2) patients' and nephrologists' needs and preferences regarding predictions in CKD, and 3) determinants that may affect the adoption of CPMs in clinical practice.

METHODS

We conducted semi-structured interviews with CKD patients to inform the development of two online surveys; one for CKD patients and one for nephrologists. Survey participants were recruited through the Dutch Kidney Patient Association and the Dutch Federation of Nephrology.

RESULTS

A total of 126 patients and 50 nephrologists responded to the surveys. Most patients (89%) reported they had discussed predictions with their nephrologists. They most frequently discussed predictions regarded CKD progression: when they were expected to need kidney replacement therapy (KRT) (n = 81), and how rapidly their kidney function was expected to decline (n = 68). Half of the nephrologists (52%) reported to use CPMs in clinical practice, in particular CPMs predicting the risk of cardiovascular disease. Almost all nephrologists (98%) reported discussing expected CKD trajectories with their patients; even those that did not use CPMs (42%). The majority of patients (61%) and nephrologists (84%) chose a CPM predicting when patients would need KRT in the future as the most important prediction. However, a small portion of patients indicated they did not want to be informed on predictions regarding CKD progression at all (10-15%). Nephrologists not using CPMs (42%) reported they did not know CPMs they could use or felt that they had insufficient knowledge regarding CPMs. According to the nephrologists, the most important determinants for the adoption of CPMs in clinical practice were: 1) understandability for patients, 2) integration as standard of care, 3) the clinical relevance.

CONCLUSION

Even though the majority of patients in Dutch CKD practice reported discussing predictions with their nephrologists, CPMs are infrequently used for this purpose. Both patients and nephrologists considered a CPM predicting CKD progression most important to discuss. Increasing awareness about existing CPMs that predict CKD progression may result in increased adoption in clinical practice. When using CPMs regarding CKD progression, nephrologists should ask whether patients want to hear predictions beforehand, since individual patients' preferences vary.

Patient Perspectives on Integrating Risk Prediction Into Kidney Care: Opinion Piece

Although Chronic Kidney Disease is common, only a relatively small proportion of individuals will reach kidney failure requiring dialysis or transplantation. Validated risk equations using routine laboratory tests have been developed that can easily be used at the bedside to help clinicians accurately predict the risk of kidney failure in their patient population, in turn informing patient-centered conversations, guiding appropriate nephrology referrals, improving the timing of dialysis treatment planning, and identifying individuals who are most likely to benefit from interventions. In this article, individuals living with kidney disease share why access to individualized prediction of kidney failure risk can help patients manage their disease and why it should be considered an essential component of kidney care.