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Montoya V, Conner N. Nephrology Provider Engagement in Comprehensive Shared Decision-Making Discussions With Older Adults: Results of a Cross-Sectional Survey. Am J Hosp Palliat Care 2025; 42:517-524. [PMID: 39172907 DOI: 10.1177/10499091241276537] [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: 08/24/2024] Open
Abstract
Background: The largest patient group initiating dialysis for end-stage renal disease is persons over 75 years. Evidence indicates pre-dialysis shared decision-making discussions between nephrology providers and older adults are infrequent and often do not include an option for conservative management of symptoms without dialysis. Aims: To assess and compare behavioral determinants of nephrology providers' use of comprehensive pre-dialysis shared decision-making discussions with older adults. A secondary aim was to prepare the bases for tailored behavioral intervention(s) for nephrology providers by identifying the determinant(s) that should be targeted to elicit change in comprehensive shared decision-making intentions and the resulting behavior. Methods: A cross-sectional survey based on the Theory of Planned Behavior was completed by nephrologists from a state organization and nephrology advance practitioners from a national organization, either in person or online via Qualtrics. Results: Survey respondents included nephrologists (n=29), and nurse practitioners (n=37) and physician assistants (n=7), combined, were predominantly female (83%) and White American (67%). Spearman rho correlation results showed attitude, social norm, and perceived behavioral control were correlated with shared decision-making behavior for one or both groups. Significant differences were present between the two groups for determinants and behaviors. Conclusion: Based on the determinants predominantly influencing SDM behavior of nephrology advance practitioners, behavioral interventions targeting the determinants of Social Norm and Perceived Behavioral Control are warranted. All determinants can be utilized in behavioral interventions for nephrologists.Opportunity exists for collaboration between providers to develop consistent and effective methods of SDM discussion that fit into a typical workday.
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Affiliation(s)
- Vicki Montoya
- College of Nursing, University of Central Florida, Orlando, FL, USA
| | - Norma Conner
- College of Nursing, University of Central Florida, Orlando, FL, USA
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Zoccali C, Vervloet MG, Evenepoel P, Massy Z, Cozzolino M, Mallamaci F, Lederer ED, Andia JC, Drueke TB. The autonomic nervous system and bone health in chronic kidney disease. Eur J Clin Invest 2025; 55:e70007. [PMID: 39985733 DOI: 10.1111/eci.70007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 01/12/2025] [Indexed: 02/24/2025]
Abstract
Besides the well-known role of hormonal factors in mineral and bone metabolism, the sympathetic nervous system participates in this regulation by inhibiting bone formation and promoting bone resorption, primarily via β-adrenergic receptors expressed on osteoblasts. Conversely, the parasympathetic system, through cholinergic signalling, inhibits osteoclast activity, promoting bone formation and maintaining skeletal homeostasis. This review presents the role of the autonomic nervous system, with particular focus on the potential role of β-blockers, especially β1-selective blockers, in modulating bone health in people with normal kidney function and those with CKD. While early studies with non-selective β-blockers like propranolol showed mixed results, recent findings in postmenopausal women suggested that β1-selective β-blockers could enhance bone density by modulating sympathetic activity. Trial emulation using large databases and eventually randomized controlled trials are needed to test the hypothesis that β-blockade can favourably impact bone disease in patients with kidney failure.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, New York, New York, USA
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), Reggio di Calabria, Italy
| | - Marc G Vervloet
- Nephrology Department, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pieter Evenepoel
- Department of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ziad Massy
- Inserm Unit 1018, Team 5, CESP, Hôpital Paul Brousse, Paris-Sud University (UPS) and Versailles Saint-Quentin-En-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Villejuif, France
- Association Pour l'Utilisation du Rein Artificiel Dans la région Parisienne (AURA), Paris, France
- Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, Paris, France
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Francesca Mallamaci
- Unità Operativa di Nefrologia e Trapianto Renale, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Clinical Epidemiology Unit of the CNR Institute of Clinical Physiology, Grande Ospedale Metropolitan, Reggio Calabria, Italy
| | - Eleanor D Lederer
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Veterans Affairs North Texas Health Care Services, Dallas, Texas, USA
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jorge Cannata Andia
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, Kidney Disease), Madrid, Spain
- Department of Medicine, Universidad de Oviedo, Oviedo, Spain
| | - Tilman B Drueke
- Inserm Unit 1018, Team 5, CESP, Hôpital Paul Brousse, Paris-Sud University (UPS), Villejuif, France
- Versailles Saint-Quentin-En-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Villejuif, France
- Inserm U 1038, Centre de Recherche Des Cordeliers, Paris-Cité University, Sorbonne-University, Paris, France
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Scherer JS, Gore RJ, Georgia A, Cohen SE, Caplin N, Zhadanova O, Chodosh J, Charytan D, Brody AA. Implementation of Ambulatory Kidney Supportive Care in a Safety Net Hospital. J Pain Symptom Manage 2025; 69:e272-e282. [PMID: 39788301 PMCID: PMC11867855 DOI: 10.1016/j.jpainsymman.2024.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 11/15/2024] [Accepted: 12/28/2024] [Indexed: 01/12/2025]
Abstract
CONTEXT Chronic kidney disease (CKD) disproportionately impacts lower socioeconomic groups and is associated with many symptoms and complex decisions. Integration of Kidney Supportive Care (KSC) with CKD care can address these needs. To our knowledge, this approach has not been described in an underserved population. OBJECTIVES We describe our adaptation of an ambulatory integrated KSC and CKD clinic for implementation in a safety net hospital. We report our utilization metrics; characteristics of the population served; and visit activities. METHODS We considered modifications from the perspectives of people with CKD, their providers, and the health system. Modifications were informed by meeting notes with key participants (hospital administrators [n = 5], funders [n = 1], and content experts [n = 2]), as well as literature on palliative care program building, safety net hospitals, and KSC. We extracted utilization data for the first 15 months of the clinic's operations, demographics, clinical characteristics, unmet health related social needs, and symptom burden, measured by the Integrated Palliative Outcome Scale-Renal (total Score, and sub-scores of physical, psychological, and practical impact of CKD) from the electronic health record. Results are reported using descriptive statistics. RESULTS Adaptions were proactive and done by clinical and administrative leaders. Meetings identified challenges of the safety net setting including people presenting with advanced disease and having several social needs. Modifications to our base model were made in staffing, data collection, and work flow. Show rate was approximately 68%, with a majority of people identifying as Black or Hispanic, and uninsured or on Medicaid. Symptom burden was lower than previous reports, driven by a better psychological sub-score. CONCLUSIONS We describe a feasible ambulatory care model of KSC in a safety net setting that can serve as a framework for the development of other noncancer palliative care ambulatory clinics. Future work will optimize our model.
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Affiliation(s)
- Jennifer S Scherer
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA.
| | - Radhika J Gore
- Department of Population Health (R.J.G.), NYU Grossman School of Medicine, New York, New York, USA; Family Health Centers at NYU Langone Health (R.J.G.), New York, New York, USA
| | - Annette Georgia
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - Susan E Cohen
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - Nina Caplin
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - Olga Zhadanova
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - Joshua Chodosh
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - David Charytan
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA
| | - Abraham A Brody
- Department of Medicine (J.S.S., A.G., S.E.C., N.C., O.Z., J.C., D.C., A.A.B.), NYU Grossman School of Medicine, New York, New York, USA; HIGN, NYU Rory Meyers College of Nursing (A.A.B.), New York, New York, USA
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Sota Y, Fujimaru T, Kobayashi K, Urayama KY, Kadota N, Konishi K, Ito Y, Nagahama M, Taki F, Suzuki M, Nakayama M. Barriers to conservative kidney management for Japanese healthcare professionals involved in the treatment of end-stage renal disease. Clin Exp Nephrol 2024; 28:1261-1271. [PMID: 38914911 DOI: 10.1007/s10157-024-02529-z] [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] [Received: 03/28/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Conservative kidney management (CKM) is a treatment alternative for patients with end-stage kidney disease (ESKD). Despite the increasing population of elderly dialysis patients in Japan, CKM is not as readily available compared with that in North America and Europe. Therefore, it is important to clarify the barriers to CKM in Japan. METHODS We interviewed 11 experts to explore their beliefs and issues regarding CKM. Based on the interviews, we categorized the CKM barriers into eight categories and created a 24-item questionnaire. A questionnaire survey was conducted among 112 medical professionals involved in ESKD management. To investigate the types of barriers, we conducted an exploratory factor analysis using the questionnaire results. RESULTS Responses were obtained from 53 (47.3%) of 112 subjects (18 doctors, 29 nurses, 6 clinical engineers), with 94.3% considering CKM as a treatment option for ESKD. Factor analysis categorized the questions into the following: (1) Lack of palliative care experience, (2) Ethics and responsibility, (3) Patient's problem, (4) Dialog with patients and families, and (5) Lack of support system. Regarding barriers to CKM, "lack of experience in palliative care" and "lack of support system" scored the highest, and "ethics and responsibility" scored the lowest. CONCLUSIONS Barriers to CKM may be classified into five factors, with "lack of experience in palliative care" and "lack of support system" being the important barriers to overcome. Additionally, most healthcare professionals consider CKM as the fourth option for renal replacement therapy.
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Affiliation(s)
- Yumi Sota
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Takuya Fujimaru
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan.
| | - Kyoko Kobayashi
- Department of Child Health Nursing, St. Luke's International University, 10-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-0044, Japan
| | - Kevin Y Urayama
- Graduate School of Public Health, St. Luke's International University, 10-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-0044, Japan
| | - Nozomi Kadota
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Kasumi Konishi
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Yugo Ito
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Masahiko Nagahama
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | | | | | - Masaaki Nakayama
- Department of Nephrology, St. Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
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Wong SP, Chotivatanapong J, Lee D, Lam DY, van Eijk MS. Providers' Experiences Discussing Care for Patients with Kidney Failure Who Forgo KRT: A National Qualitative Study. Clin J Am Soc Nephrol 2024; 19:1284-1291. [PMID: 39437985 PMCID: PMC11469789 DOI: 10.2215/cjn.0000000000000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024]
Abstract
Background Many nephrology providers express difficulty in discussing care options for patients who forgo KRT, which hampers their ability to help patients make decisions about their current and future treatment of kidney disease. Methods We conducted a qualitative study using interviews with a national sample of nephrology providers (i.e., physicians and advanced practice providers) who participated in US professional societies between July and December 2022. We performed a thematic analysis of interviews to identify emergent themes reflecting providers' experiences discussing care for patients who forgo KRT. Results There were 21 providers (age 54±13 years, female 81%, White 32%) who participated in interviews, of whom 43% were physicians and most (57%) practiced in academic settings. Three dominant themes emerged from interviews reflecting challenges to discussing the option to forgo KRT: (1) Inconsistent terminology: while providers sought to use terms to describe care for patients who forgo KRT that affirmed patients' decision, clearly conveyed that KRT would not be pursued, and were already familiar to patients and other providers, they disagreed about which terms satisfied these priorities; (2) blurred distinctions between KRT and its alternative: providers' descriptions of their care practices suggested that differences in their approaches to caring for patients who forgo KRT and those who are planning to pursue KRT could be opaque; and (3) deciphering patients' decision to forgo KRT: providers did not readily accept patients' expressed preferences to forgo KRT at face value and described using a variety of methods to assess whether patients would follow through with their decision. Conclusions Providers used different, inconsistent terms to describe care for patients who forgo KRT. They disagreed about what this care entailed and were uncertain about what patients might mean when they express not wanting to undergo KRT.
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Affiliation(s)
- Susan P.Y. Wong
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Deborah Lee
- Department of Medicine, Virginia Mason Medical Center, Seattle, Washington
| | - Daniel Y. Lam
- Department of Medicine, University of Washington, Seattle, Washington
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Chotivatanapong J, Prince DK, Davison SN, Kestenbaum BR, Oestreich T, Wong SP. A National Survey of Conservative Kidney Management Practices for Patients Who Forgo RRT. KIDNEY360 2024; 5:363-369. [PMID: 38254255 PMCID: PMC11000734 DOI: 10.34067/kid.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Key Points In the largest survey of US nephrology providers on conservative kidney management (CKM), most reported limited experience with CKM and varied approaches and local resources to provide CKM. There is need to enhance provider training and surveillance of CKM practices and to develop models of CKM that optimize care delivery and outcomes for these patients. Background Clinical practice guidelines advocate for conservative kidney management (CKM), a planned, holistic, patient-centered approach to caring for patients who forgo initiation of RRT. Little is known about the extent to which current care practices meet these expectations. Methods We conducted a cross-sectional survey of a national sample of nephrology providers recruited through US professional societies between March and July 2022 and inquired about their experiences with caring for patients who forgo RRT and their capacity to provide CKM. Results Overall, 203 nephrology providers (age 47±12 years, 53.2% White, 66.0% female), of which 49.8% were nephrologists and 50.2% advanced practice providers, completed the survey. Most (70.3%) reported that <10% of their practice comprised patients who had forgone RRT. Most indicated that they always or often provided symptom management (81.8%), multidisciplinary care (68.0%), tools to support shared decision making about treatment of advanced kidney disease (66.3%), and psychological support (52.2%) to patients who forgo RRT, while less than half reported that they always or often provided staff training on the care of these patients (47.8%) and spiritual support (41.4%). Most providers reported always or often working with primary care (72.9%), palliative medicine (68.8%), hospice (62.6%), social work (58.1%), and dietitian (50.7%) services to support these patients, while only a minority indicated that they always or often offered chaplaincy (23.2%), physical and/or occupational therapy (22.8%), psychology or psychiatry (31.5%), and geriatric medicine (28.1%). Conclusions Many nephrology providers have limited experience with caring for patients who forgo RRT. Our findings highlight opportunities to optimize comprehensive CKM care for these patients.
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Affiliation(s)
| | - David K. Prince
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sara N. Davison
- Department of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Taryn Oestreich
- Department of Medicine, University of Washington, Seattle, Washington
| | - Susan P.Y. Wong
- Department of Medicine, University of Washington, Seattle, Washington
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Gelfand SL. Conservative Kidney Management in the United States: What It Is and What It Could Be. Kidney Med 2023; 5:100740. [PMID: 37954191 PMCID: PMC10632098 DOI: 10.1016/j.xkme.2023.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Affiliation(s)
- Samantha L. Gelfand
- Address for Correspondence: Samantha L. Gelfand, MD, 450 Brookline Avenue, JF8, Boston MA 02215.
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