Conservative management of end-stage renal disease without dialysis: a systematic review

Health system related kidney supportive care interventions for adults with chronic kidney disease: A systematic review

INTRODUCTION

Kidney failure can be managed either conservatively or via kidney replacement therapy. Kidney supportive care combines the expertise of nephrology with palliative care in a multidisciplinary team with a focus on improving quality of life.

OBJECTIVE

To identify and appraise evidence-based health system kidney supportive care interventions DESIGN: Systematic review (PROSPERO Registration - CRD42022333650).

PARTICIPANTS

Adults with chronic kidney failure.

MEASUREMENTS

Six databases were searched, using terms "palliative care" and "chronic kidney disease" for publications between January 2010 and March 2024. The Cochrane "Effective Practice and Organisation of Care" and "Clinical Practice Guidelines for Quality Palliative Care" domains informed data extraction.

RESULTS

Of the 60 studies included, one-third were randomised controlled trials. The most common "Effective Practice and Organisation of Care" domain described was care delivery (58/60). End-of-life care (33/60), and physical aspects of care (19/60), were commonly described "Clinical Practice Guidelines for Quality Palliative Care" domains. Multidisciplinary shared care was highlighted in 26 studies. Least described domains were cultural (0/60) and ethical aspects (3/60). Almost 2/3 (39/60) of studies compared the outcomes of kidney supportive care interventions, and the most common outcome assessed was advance care planning (18/39). Key findings reported integrated palliative care reduced hospital admissions and costs, facilitated better patient-clinician communication, and improved symptom management. Gaps were identified in cultural and ethical/legal aspects of care.

CONCLUSIONS

The studies highlighted the effectiveness of kidney-supportive care interventions in improving patient outcomes, especially in end-of-life care and symptom management. However, significant existing gaps identified necessitate further research.

Conservative Management for Kidney Failure

Conservative kidney management (CKM) is active medical management of kidney failure without dialysis. The main focus of care is optimizing quality of life by preserving kidney function for as long as possible and medically managing symptoms of kidney failure.

Short-Term Safety of Nutri-Jelly in Adults Undergoing Hemodialysis

Excessive water consumption from liquid or reconstituted oral nutrition supplements may increase risk of fluid overload in renal patients. Nutri-jelly, a ready-to-eat texture-modified diet with 52.8% water, some protein, low potassium, phosphorus, and sodium, could be an alternative. However, its safety is unknown for adults undergoing hemodialysis (HD). This study investigated the short-term physiological safety of Nutri-Jelly intake and its preliminary impact on renal outcomes. A randomized open-label, single-arm, two-sequence, two-period cross-over trial was conducted in 20 adults undergoing HD with inadequate protein intake (0.50 - 0.70 g/ kg body weight/day). Participants were randomly allocated into 2 groups (n =10 each) and assigned in random sequence into both Without-Jelly (HD 3 times during 7 days) and With-Jelly periods (100 g Nutri-Jelly twice daily along with HD 3 times during 7 days). A two-week washout was between the periods. Outcome measures included adverse symptoms, changes in body weight, heart rate, blood pressure, and blood biochemical parameters relevant to renal outcomes. The results showed no intervention-related adverse symptoms or significant changes in body weight, heart rate, systolic blood pressure, creatinine, albumin, and sodium. Potassium level and pre-HD diastolic blood pressure were better controlled during the With Jelly than the Without Jelly Periods (p < 0.01 and p < 0.05, respectively). The eGFR was improved with no significant difference between the periods. The findings suggest that continuous intake of 100 g Nutri-Jelly twice daily for 7 days is safe in adults undergoing hemodialysis. Its efficacy on renal-related parameters warrants further investigations in long-term studies.

Nephrology providers' perspective and use of mortality prognostic tools in dialysis patients

BACKGROUND

Mortality prognostic tools exist to aid in shared decision making with kidney failure patients but are underutilized. This study aimed to elucidate nephrology providers' practice patterns and understand barriers to prognostic tool use.

METHODS

Nephrology providers (8 physicians and 2 nurse practitioners) at an academic medical center underwent semi-structured interviews regarding their experience and perspective on the utility of mortality prognostic tools. Common themes were identified independently by 2 reviewers using grounded theory. Three six-month mortality prognostic tools were applied to the 279 prevalent dialysis patients that the interviewed providers care for. The C statistic was calculated for each tool via logistic regression and subsequent ROC analysis. Nephrology providers reviewed the performance of the prognostication tools in their own patient population. A post interview reassessed perspectives and any change in attitudes regarding the tools.

RESULTS

Nephrology providers did not use these mortality prognostic tools in their practice. Key barriers identified were provider concern that the tools were not generalizable to their patients, providers' trust in their own clinical judgement over that of a prognostic tool, time constraints, and lack of knowledge about the data behind these tools. When re-interviewed with the results of the three prognostic tools in their patients, providers thought the tools performed as expected, but still did not intend to use the tools in their practice. They reported that these tools are good for populations, but not individual patients. The providers preferred to use clinical gestalt for prognostication.

CONCLUSION

Although several well validated prognostic tools are available for predicting mortality, the nephrology providers studied do not use them in routine practice, even after an educational intervention. Other approaches should be explored to help incorporate prognostication in shared-decision-making for patients receiving dialysis.

Utilization of Potassium Binders for the Management of Hyperkalemia in Chronic Kidney Disease: A Position Statement by US Nephrologists

Two potassium (K+) binders-patiromer sorbitex calcium and sodium zirconium cyclosilicate-are recommended by international guidelines for the management of hyperkalemia. There is, however, no universally accepted best practice for how to appropriately utilize K+ binders in the long-term clinical management of CKD. A panel of eight US-based nephrologists convened in October 2022 to develop a consensus statement regarding utilizing K+ binders in clinical practice to help manage patients with nonemergent, persistent/recurrent hyperkalemia in CKD. Consensus was reached on the following topics: (1) identifying risk factors for hyperkalemia; (2) serum K+ monitoring before and during K+ binder use; (3) utilizing K+ binders in patients receiving renin-angiotensin-aldosterone system inhibitors and dialysis; and (4) when to initiate K+ binders and their duration of use. These consensus statements for the use of K+ binders may assist the nephrology community in optimizing management of hyperkalemia in patients across the spectrum of CKD.

The Broader Effects of Delayed Progression to End-Stage Kidney Disease: Delaying the Inevitable or a Meaningful Change?

A global rise in the prevalence of patients with chronic kidney disease (CKD) with end-stage kidney disease (ESKD) has led to a considerable and increasing burden to health systems, patients, and society. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are proven to reduce incidence of cardio-renal outcomes, including onset of ESKD. Recent post hoc analyses of SGLT2 inhibitor trials extrapolate substantial delays in the average time to ESKD over a patient's lifetime. In this article, we explore the possible real-world effects of such a delay by considering the available evidence reporting outcomes following onset of ESKD. From the patient perspective, a delay in reaching ESKD could substantially improve health-related quality of life and result in additional life years without the need for kidney replacement therapies, a target relevant to all CKD subpopulations. Furthermore, should a patient initiate dialysis at an older age as a result of CKD progression, the time spent in receipt of dialysis, and therefore associated healthcare costs, may also be reduced. A delay in progression may also lead to changes in the management of ESKD, such as increased election of conservative care in preference to dialysis, particularly in elderly populations. For younger patients with CKD, those who reach ESKD while employed face considerable work impairment and productivity loss, as may families and care partners of working age. Therefore, a delay to the onset of ESKD will reduce the proportion of their working lives affected by productivity losses or unemployment due to medical reasons. In conclusion, optimised treatment of CKD may lead to a shift in treatment options, but proper and timely implementation is essential for the realisation of improved outcomes.

Effects of additional physical exercise on the nutritional status and disease progression during the low-protein diet in Chronic Kidney Disease Patients: a systematic review and meta-analysis

Low-protein diet (LPD) is the core of dietary and nutritional therapy for non-dialysis chronic kidney disease (CKD) patients. In addition, physical exercise could prevent and treat various illnesses and chronic diseases. The objective of the study was to search for and appraise evidence on the effect of additional physical exercise on patients' nutritional status and indicators of disease progression when compared with the LPD alone. PubMed Central, Embase, Cochrane, and Web of Knowledge for randomized controlled trials (published between January 1, 1956 and May 17, 2023) were searched. A total of 8698 identified studies, 9 were eligible and were included in our analysis (N = 250 participants). Compared with the LPD alone, additional physical exercise reduced serum creatinine by a mean of -0.21 mg/dL (95% CI -0.39 to -0.03) in CKD patients. Similarly, blood pressure decreased after physical exercise, with systolic blood pressure decreasing by -7.05 mm Hg (95% CI -13.13 to -0.96) and diastolic blood pressure decreasing by -5.31 mm Hg (95% CI -7.99 to -2.62). Subgroup analyses revealed that resistance exercise (RE) was effective in decreasing estimated glomerular filtration rate (eGFR) of -1.71 mL/min per 1.73 m² (95% CI -3.29 to -0.14). In addition, the VO2peak increasing by 2.41 mL/kg/min (95% CI 0.13 to 4.70) when physical exercise was continued for 24 weeks. The above results suggest that the LPD with additional physical exercise care is more beneficial for patients with CKD.

Care of Adults with Advanced Chronic Kidney Disease

Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.

Nephrology-tailored geriatric assessment as decision-making tool in kidney failure

BACKGROUND

Dialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients.

OBJECTIVE

We aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure.

DESIGN

In an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis.

PARTICIPANTS AND MEASUREMENTS

Patients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis.

RESULTS

Three main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics.

CONCLUSIONS

nephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy.

Management of Anemia in Renal Palliative Care Clinic: A Patient-Centered Approach

BACKGROUND

Despite the growing needs in nondialytic alternatives for conservative kidney management, few studies have examined the management of anemia in palliative care (PC) outpatient clinics, which represent the key point of entry for timely access to PC.

OBJECTIVE

A retrospective study to review for a patient-centered approach in anemia management and symptom control.

RESULTS

Over the study period from July 2020 to March 2023, a total of 158 patients were seen at our renal PC clinic, 47 were included in data analysis. Patients had a mean age and glomerular filtration rate of 81.3 (9.5) years and 8.6 (5.3) mL/min/1.73 m2, and 68.1% and 44.7% were receiving erythropoiesis-stimulating agents (ESAs) and iron supplements respectively, with only 4.3% of patients required transfusion over past six months. Mean hemoglobin was maintained at 9.8 (1.4) g/dL, with a mean POS-S renal score of 4.7 (3.2). Majority of patients (93.6%) had satisfactory rating on "weakness and lack of energy" item.

CONCLUSION

A patient-centered approach in anemia management at renal PC outpatient clinics may alleviate symptom burden and minimize transfusion requirement.

A National Survey of Conservative Kidney Management Practices for Patients Who Forgo RRT

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.

Consensus document on palliative care in cardiorenal patients

There is an unmet need to create consensus documents on the management of cardiorenal patients since, due to the aging of the population and the rise of both pathologies, these patients are becoming more prevalent in daily clinical practice. Chronic kidney disease coexists in up to 40%-50% of patients with chronic heart failure cases. There have yet to be consensus documents on how to approach palliative care in cardiorenal patients. There are guidelines for patients with heart failure and chronic kidney disease separately, but they do not specifically address patients with concomitant heart failure and kidney disease. For this reason, our document includes experts from different specialties, who will not only address the justification of palliative care in cardiorenal patients but also how to identify this patient profile, the shared planning of their care, as well as knowledge of their trajectory and the palliative patient management both in the drugs that will help us control symptoms and in advanced measures. Dialysis and its different types will also be addressed, as palliative measures and when the decision to continue or not perform them could be considered. Finally, the psychosocial approach and adapted pharmacotherapy will be discussed.

Quality of life in advanced renal disease managed either by haemodialysis or conservative care in older patients

OBJECTIVE

Consideration of quality of life (QoL) in people with end-stage renal disease has become an important part of treatment decision-making. The aim of this study was to report on QoL and other functional outcomes in patients with advanced chronic kidney disease (CKD).

METHOD

This was a cross-sectional study. Two samples of older patients (>60 years old) either conservatively managed (CM) or receiving hospital-based haemodialysis (HD), compared Kidney Disease Quality of Life (KDQoL-36) outcomes.

RESULTS

Data from 263 CM patients (CKD 4 n=188, mean age 73.6 years, 48 women; CKD 5 n=75, mean age 74.4 years, 26 women) and 74 patients on HD (mean age 73.8 years, 24 women) were analysed. Significant group differences were identified for two subscales of KDQoL-36. Symptoms/Problems List subscale was significantly better for those receiving HD compared with those CM with CKD 5 (p=<0.001). Symptom/Problem List scores of CM CKD stage 4 patients were not significantly different compared with HD patients but were significantly better than CM CKD stage 5 patients (p<0.001). Burden of Kidney Disease subscale was significantly better for both CKD 4 (p<0.001) and CKD 5 (p<0.001) CM patients when compared with those receiving HD.

CONCLUSION

Symptoms of advanced CKD significantly impact QoL for patients CM with CKD stage 5. Conversely, QoL is significantly impacted for those in receipt of HD due to the burden of treatment. These findings provide evidence for the use of QoL tools to help with clinical prognostication in advanced CKD. Using QoL tools will ensure specialist support is available for appropriate management of patients with CKD.

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

BACKGROUND

Shared decision-making (SDM) is important when considering whether an older patient with advanced chronic kidney disease (CKD) should be managed with dialysis or conservative kidney management (CKM). Physicians may find these conversations difficult because of the relative paucity of data on patients managed without dialysis.

METHODS

This prospective observational study was conducted in a unit supported by a multidisciplinary Kidney Supportive Care (KSC) programme, in a cohort of 510 patients (280 CKM and 230 dialysis) ≥65 years of age with CKD stages 4 and 5. Survival was evaluated using logistic regression and Cox proportional hazards models. Linear mixed models were utilized to assess symptoms over time.

RESULTS

CKM patients were older (mean 84 versus 74 years; P < .001) and almost 2-fold more likely to have three or more comorbidities (P < .001). The median survival of CKM patients was lower compared with dialysis from all time points: 14 months [interquartile range (IQR) 6-32] versus 53 (IQR 28-103) from decision of treatment modality or dialysis start date (P < .001); 15 months (IQR 7-34) versus 64 (IQR 30-103) from the time the estimated glomerular filtration rate (eGFR) was ≤15 mL/min/1.73 m2 (P < .001); and 8 months (IQR 3-18) versus 49 (19-101) from eGFR ≤10 mL/min/1.73 m2. A total of 59% of CKM patients reported an improvement in symptoms by their third KSC clinic visit (P < .001). The rate of unplanned hospitalization was 2-fold higher in the dialysis cohort.

CONCLUSIONS

CKM patients survive a median of 14 months from the time of modality choice and have a lower rate of hospitalization than dialysis patients. Although the symptom burden in advanced CKD is high, most elderly CKM patients managed through an integrated KSC programme and can achieve improvement in their symptoms over time. These data might help with SDM.

Hospice Care in Conservative Kidney Management

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

Treatment decision-making and care among older adults with kidney failure: protocol for a multicentre, prospective observational cohort study with nested substudies and linked qualitative research (the Elderly Advanced CKD Programme)

INTRODUCTION

Shared treatment decision-making and planning of care are fundamental in advanced chronic kidney disease (CKD) management. There are limited data on several key outcomes for the elderly population including survival, quality of life, symptom burden, changes in physical functioning and experienced burden of healthcare. Patients, caregivers and clinicians consequently face significant uncertainty when making life-impacting treatment decisions. The Elderly Advanced CKD Programme includes quantitative and qualitative studies to better address challenges in treatment decision-making and planning of care among this increasingly prevalent elderly cohort.

METHODS AND ANALYSIS

The primary component is OUTcomes of Older patients with Kidney failure (OUTLOOK), a multicentre prospective observational cohort study that will enrol 800 patients ≥75 years with kidney failure (estimated glomerular filtration rate ≤15 mL/min/1.73 m2) across a minimum of six sites in Australia. Patients entered are in the decision-making phase or have recently made a decision on preferred treatment (dialysis, conservative kidney management or undecided). Patients will be prospectively followed until death or a maximum of 4 years, with the primary outcome being survival. Secondary outcomes are receipt of short-term acute dialysis, receipt of long-term maintenance dialysis, changes in biochemistry and end-of-life care characteristics. Data will be used to formulate a risk prediction tool applicable for use in the decision-making phase. The nested substudies Treatment modalities for the InfirM ElderLY with end stage kidney disease (TIMELY) and Caregivers of The InfirM ElderLY with end stage kidney disease (Co-TIMELY) will longitudinally assess quality of life, symptom burden and caregiver burden among 150 patients and 100 caregivers, respectively. CONsumer views of Treatment options for Elderly patieNts with kiDney failure (CONTEND) is an additional qualitative study that will enrol a minimum of 20 patients and 20 caregivers to explore experiences of treatment decision-making and care.

ETHICS AND DISSEMINATION

Ethics approval was obtained through Sydney Local Health District Human Research Ethics Committee (2019/ETH07718, 2020/ETH02226, 2021/ETH01020, 2019/ETH07783). OUTLOOK is approved to have waiver of individual patient consent. TIMELY, Co-TIMELY and CONTEND participants will provide written informed consent. Final results will be disseminated through peer-reviewed journals and presented at scientific meetings.

Shared Decision Making Among Older Adults With Advanced CKD

RATIONALE & OBJECTIVE

Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown.

STUDY DESIGN

A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM.

SETTING & PARTICIPANTS

Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD.

PREDICTORS

Decisional readiness factors, treatment options education, and care partner support.

OUTCOMES

Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM.

ANALYTICAL APPROACH

We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors.

RESULTS

Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores.

LIMITATIONS

The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors.

CONCLUSIONS

Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.

A Machine Learning Model for Predicting Mortality within 90 Days of Dialysis Initiation

Background

The first 90 days after dialysis initiation are associated with high morbidity and mortality in end-stage kidney disease (ESKD) patients. A machine learning-based tool for predicting mortality could inform patient-clinician shared decision making on whether to initiate dialysis or pursue medical management. We used the eXtreme Gradient Boosting (XGBoost) algorithm to predict mortality in the first 90 days after dialysis initiation in a nationally representative population from the United States Renal Data System.

Methods

A cohort of adults initiating dialysis between 2008-2017 were studied for outcome of death within 90 days of dialysis initiation. The study dataset included 188 candidate predictors prognostic of early mortality that were known on or before the first day of dialysis and was partitioned into training (70%) and testing (30%) subsets. XGBoost modeling used a complete-case set and a dataset obtained from multiple imputation. Model performance was evaluated by c-statistics overall and stratified by subgroups of age, sex, race, and dialysis modality.

Results

The analysis included 1,150,195 patients with ESKD, of whom 86,083 (8%) died in the first 90 days after dialysis initiation. The XGBoost models discriminated mortality risk in the nonimputed (c=0.826, 95% CI, 0.823 to 0.828) and imputed (c=0.827, 95% CI, 0.823 to 0.827) models and performed well across nearly every subgroup (race, age, sex, and dialysis modality) evaluated (c>0.75). Across predicted risk thresholds of 10%-50%, higher risk thresholds showed declining sensitivity (0.69-0.04) with improving specificity (0.79-0.99); similarly, positive likelihood ratio was highest at the 40% threshold, whereas the negative likelihood ratio was lowest at the 10% threshold. After calibration using isotonic regression, the model accurately estimated the probability of mortality across all ranges of predicted risk.

Conclusions

The XGBoost-based model developed in this study discriminated risk of early mortality after dialysis initiation with excellent calibration and performed well across key subgroups.

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

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

Identification of core components and implementation strategies for a Conservative Kidney Management Pathway across a complex, multisector healthcare system in Canada using World Cafés and the Theoretical Domains Framework

OBJECTIVE

Develop a Conservative Kidney Management (CKM) Pathway for patients unlikely to benefit from dialysis. We sought to determine (1) core components of care and (2) implementation strategies across a multisector healthcare system.

DESIGN

We used the Knowledge to Action Cycle and the Theoretical Domains Framework to identify barriers and facilitators to CKM. Activities included a current state assessment, World Cafés, interviews, focus groups and readiness for change assessments.

SETTING

A provincial initiative in Alberta, Canada.

PARTICIPANTS

282 participants were purposively selected to reflect those involved in the care of patients receiving CKM. This included policy-makers, multidisciplinary healthcare professionals, patients and their family.

MAIN OUTCOME MEASURES

Theoretical domains linked to pathway content and implementation strategies.

RESULTS

Environmental context and resources, social/professional role and identity, knowledge and social influences were the most influential behaviour change domains identified. The most effective strategies for facilitating behaviour change were identified to be education, training, environmental restructuring and modelling. Core components of care were determined to be guidelines for treating symptoms and disease complications consistent with the philosophy of CKM, timely communication of the choice for CKM, coordination with community services, crisis planning, advance care planning and tools to enhance patients' capacity for self-management and shared decision-making. This resulted in development of Alberta's CKM Pathway, an interactive, digital, decision-support tool consisting of: (1) a patient decision aid; (2) a patient/family portal; and (3) a healthcare professional portal, where all resources can be freely accessed.

CONCLUSIONS

The pathway was codesigned by patients and healthcare professionals and involves tailor-made combinations of tools to address unique patient needs and system-community circumstances. Most of the strategies are adaptable to local context and are likely translatable to the implementation of sustainable CKM in other national and international jurisdictions.

Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease

Background

Most patients are unaware of approaches to treating advanced chronic kidney disease (CKD) other than dialysis.

Methods

We developed a dedicated decision aid on conservative kidney management using human-centered design principles in three phases: (1) discovery: engagement of informants to understand their needs and preferences; (2) design: multiple rapid cycles of ideation, prototyping, and testing of a decision aid with a small group of informants; and (3) implementation: testing the decision aid in real-world settings with attention to how the decision aid can be further refined. Informants included a national patient advisory committee on kidney diseases, 50 patients with stage 4 or 5 CKD and 35 of their family members, and 16 clinicians recruited from the greater Seattle area between June 2019 and September 2021.

Results

Findings from the discovery phase informed an initial prototype of the decision aid, which included five sections: a description of kidney disease and its signs and symptoms, an overview of conservative kidney management and the kinds of supports provided, self-reflection exercises to elicit patients' values and goals, the pros and cons of conservative kidney management, and the option of changing one's mind about conservative kidney management. The prototype underwent several rounds of iteration during its design phase, which resulted in the addition of an introductory section describing the intended audience and more detailed information in other sections. Findings from its implementation phase led to the addition of examples of common questions that patients and family members had about conservative kidney management and a final section on other related educational resources.

Conclusions

Human-centered design principles supported a systematic and collaborative approach between researchers, patients, family members, and clinicians for developing a decision aid on conservative kidney management.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

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

Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.

Dialysis therapy and mortality in older adults with heart failure and advanced chronic kidney disease: A high-dimensional propensity-matched cohort study

BACKGROUND

Heart failure (HF) and chronic kidney disease (CKD) frequently coexist, and the combination is linked to poor outcomes, but limited data exist to guide optimal management. We evaluated the outcome of dialysis therapy in older patients with HF and advanced CKD.

METHODS

We examined adults aged ≥70 years with HF and eGFR ≤20 ml/min/1.73 m2 between 2008-2012 and no prior renal replacement therapy, cancer, cirrhosis or organ transplant. We identified patients who initiated chronic dialysis through 2013 and matched patients who did not initiate dialysis on age, gender, diabetes status, being alive on dialysis initiation date, and a high-dimensional propensity score for starting dialysis. Deaths were identified through 2013. We used Cox regression to evaluate the association of chronic dialysis and all-cause death.

RESULTS

Among 348 adults with HF and advanced CKD who initiated dialysis and 947 matched patients who did not start dialysis, mean age was 80±5 years, 51% were women and 33% were Black. The crude rate of death was high overall but lower in those initiating vs. not initiating chronic dialysis (26.1 vs. 32.1 per 100 person-years, respectively, P = 0.02). In multivariable analysis, dialysis was associated with a 33% (95% Confidence Interval:17-46%) lower adjusted rate of death compared with not initiating dialysis.

CONCLUSIONS

Among older adults with HF and advanced CKD, dialysis initiation was associated with lower mortality, but absolute rates of death were very high in both groups. Randomized trials should evaluate net outcomes of dialysis vs. conservative management on length and quality of life in this high-risk population.

OUP accepted manuscript

Background

Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice.

Methods

Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions.

Results

A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m² ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted.

Conclusions

Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.

Development and psychometric evaluation of the perceived care tension questionnaire for caregivers of hemodialysis patients: A mixed method study

BACKGROUND

The complex, multifaceted care environment and the threatening situation of caring for hemodialysis patients cause tension in their family caregivers. Due to the severe tension, family caregivers are likely to ignore their basic needs and only pay attention to the patient's needs and related issues. This study was conducted with the aim of designing and evaluating the Perceived Care tension Questionnaire for Caregivers of Hemodialysis Patients (PCTQHFC).

MATERIALS AND METHODS

The present study was a sequential exploratory mixed methods study of scale development variant conducted in two phases: qualitative and quantitative. This study was conducted in 2019 in Shahrekord. The qualitative phase included item development and scale development. In the quantitative phase (Item Analysis), the validation characteristics of the tool were examined using face, content and construct validity, and its reliability by internal consistency and stability. Findings were performed using software SPSS 18.

RESULTS

Principal components analysis with orthogonal rotation to generate factors, showed that five factors, namely emotional exhaustion, inadequate social support, care burden, confusion and ambiguity and lack of adaptability skills had an eigenvalue of higher than 1, so that they explained, respectively, 75.98%, 61.36%, 72.49%, 76.33%, and 70.31% of the total variance. The internal consistency was obtained 0.811 and the inter-class correlation coefficient for the whole instrument 0.832.

CONCLUSION

PCTQHFC is a culturally appropriate measure with strong psychometric properties. The instrument designed in this study measures the care tension of hemodialysis patients. Therefore, researchers, health-care providers, and community health policymakers can plan and implement interventions to reduce the tension of caregivers of hemodialysis patients by analyzing and identifying the tensions of caregivers.

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

Individuals receiving peritoneal dialysis (PD)—similar to those receiving hemodialysis —may experience high mortality coupled with a high symptom burden and reduced health-related quality of life. In this context, a discussion of the risks, benefits, and tradeoffs of PD and/or other kidney treatment modalities should be explored based on individual goals and preferences. Through these principles, kidney supportive care provides a person-centered approach to kidney disease care throughout the spectrum of kidney failure and earlier stages of chronic kidney disease. Kidney supportive care is offered in conjunction with life-prolonging therapies, including dialysis and kidney transplants, and is increasingly recognized as an integral part of advancing the care of PD patients. Using “My Kidney Care Roadmap” for shared decision making, kidney supportive care guides patients undergoing PD and their clinicians to (1) elicit patient goals, values, and priorities; (2) convey medical prognosis and suitable treatment options; and (3) ask “Which of these kidney treatment options will best help me achieve my goals and priorities?” to inform both current and future decisions, including choice of dialysis modalities, time-limited trials, and/or nondialysis management. Recognizing that patient priorities and choices may evolve, this framework ultimately allows patients to continually reassess their PD care to better achieve goal-directed dialysis.

Age-old musings: twenty-first century management of advanced kidney disease in older individuals

Quality geriatric kidney care extends beyond traditional therapy to care that balances the impact of both disease and treatment around how individuals manage their daily routines. In this Comment, we discuss clinical and policy changes that could benefit older people with advanced kidney disease.

Síntomas asociados al sufrimiento en pacientes con enfermedad renal crónica en hemodiálisis

Introducción: Los síntomas insuficientemente controlados pueden constituir un factor determinante o agravante del sufrimiento en los pacientes sometidos a hemodiálisis; sin embargo, escasean las investigaciones que aborden este tema. Objetivos: El presente estudio tiene como objetivo describir el sufrimiento según la severidad de determinados síntomas en pacientes con enfermedad renal crónica en hemodiálisis. Material y Método: El estudio es observacional descriptivo transversal, con algunas tareas de correlación en una muestra de 31 pacientes. Se emplearon la entrevista, el instrumento para detección de bienestar/malestar propuesto por Bayés y colaboradores y una serie de sub-escalas de la Escala de Evaluación de Síntomas de Edmonton/ESAS para identificar la presencia de síntomas (intensidad y frecuencia) que pudieran estar asociados al sufrimiento. Resultados: El 87,1 % del total mostró un bajo predominio de síntomas con severa intensidad asociados al sufrimiento en las últimas 24 horas, el 77,4 % bajo predominio en la semana anterior y el 61,3 % un bajo predominio en un periodo de un mes. No se encontró asociación significativa entre el predominio de los síntomas con intensidad severa asociados al sufrimiento en 24 horas. Conclusiones: En la mayoría de los sujetos predominó el bajo predominio de síntomas con severa intensidad asociados al sufrimiento; la magnitud de la sintomatología no constituyó un factor importante asociado al sufrimiento en estos pacientes.

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

Background

Patients with stage 5 chronic kidney disease (CKD5) collaborate with their clinicians when choosing their future treatment modality. Most elderly patients with CKD5 may only have two treatment options: dialysis or conservative kidney management (CKM). The objective of this systematic review was to investigate whether CKM offers a quantity or quality of life benefit compared to dialysis for some patients with CKD5.

Methods

The databases MEDLINE, EMBASE, the Cochrane Library, and CINAHL were systematically searched for studies comparing patients with CKD5 who had chosen or were treated with either CKM or dialysis. The primary outcomes were mortality and quality of life (QoL). Hospitalization, symptom burden, and place of death were secondary outcomes. For studies reporting hazard ratios, pooled values were calculated, and forest plots conducted.

Results

Twenty-five primary studies, all observational, were identified. All studies reported an increased mortality in patients treated with CKM (pooled hazard ratio 0.47, 95 % confidence interval 0.34–0.65). For patients aged ≥ 80 years and for elderly individuals with comorbidities, results were ambiguous. In most studies, CKM seemed advantageous for QoL and secondary outcomes. Findings were limited by the heterogeneity of studies and biased outcomes favouring dialysis.

Conclusions

In general, patients with CKD5 who have chosen or are on CKM live for a shorter time than patients who have chosen or are on dialysis. In patients aged ≥ 80 years old, and in elderly individuals with comorbidities, the survival benefits of dialysis seem to be lost. Regarding QoL, symptom burden, hospitalization, and place of death, CKM may have advantages. Higher quality studies are needed to guide patients and clinicians in the decision-making process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02516-6.

Chronic kidney disease

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

Commentary on the NICE guideline on renal replacement therapy and conservative management

NICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).

There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Renal supportive care programs: An observational study assessing impact on hospitalization and survival outcomes

AIM

Renal supportive care (RSC) programs are used to manage non-dialysis end-stage kidney disease (ESKD) patients. The aim of this study was to analyse the impact of RSC programs on hospitalization and survival outcomes in these patients.

METHODS

A retrospective, single-centre observational cohort study of non-dialysis ESKD patients was undertaken. Hospitalizations and survival from eGFR≤15 ml/min was compared between patients managed in an RSC program (RSC group) and patients receiving standard conservative therapy (non-RSC group). Local databases, physician letters and electronic medical records were used for data collection. Prevalent patients from 2013 to 2017 with eGFR ≤15 ml/min were included. Cox proportion hazard testing and generalized linear modelling was undertaken to adjust for confounders.

RESULTS

A total of 172 patients were included (95 RSC; 75 non-RSC). The median age was 82 years [IQR 78-85], 46% were male, the median Charlson-comorbidity Index was 5 [IQR 4-7]. The RSC group had significantly lowered haemoglobin level (102 g/L vs. 111 g/L) and fewer English-speakers (34% vs. 44%). RSC was associated with the decreased number of days in hospital per year (estimated means 46.6 days [95% CI 21-67] vs. 83.2 days [95%CI 60.5-105.8]; p = .01) and decreased number of hospital admissions per year (estimated means 5.4 [95%CI 2.1-8.8] vs. 12.3 [95%CI 8.2-16.4]; p = .01) compared with non-RSC. Median overall survival from eGFR≤15 in the entire cohort was 735 days, with no significant difference between RSC and non-RSC groups (p = .9), both unadjusted and adjusted for confounders.

CONCLUSION

RSC programs can significantly decrease the number and length of hospitalizations in conservatively managed ESKD patients.

Exploring the Relationship Between Patient Activation, Treatment Satisfaction, and Decisional Conflict in Patients Approaching End-Stage Renal Disease

BACKGROUND

Patients approaching end-stage renal disease (ESRD) experience a high level of decisional conflict because they are often not provided with sufficient support and information regarding different treatment options prior to renal failure. Decisional conflict is an important correlate of treatment satisfaction, as it is associated with disease- and treatment-related knowledge that can inform decision-making. Patient activation, the willingness and ability to independently manage one's own health and healthcare, is an individual difference factor that may have important mitigating effects on decisional conflict.

PURPOSE

To identify modifiable factors that may enhance the decision-making process in patients approaching ESRD by exploring potential mediational effects between decisional conflict, treatment satisfaction, and patient activation.

METHODS

Sixty-four patients approaching ESRD completed self-report measures (32% response rate). Measures included the Decisional Conflict Scale, the Kidney Disease Treatment Questionnaire, and the Patient Activation Measure Short Form.

RESULTS

There was a high level of self-reported decisional conflict in this sample. Linear regressions revealed main effects among treatment satisfaction, patient activation, and decisional conflict. These variables were entered into PROCESS to assess a mediational pattern. Results showed that higher chronic kidney disease-related treatment satisfaction predicted lower decisional conflict through higher patient activation in a statistical mediational relationship.

CONCLUSIONS

While the link between treatment satisfaction and decision-making is well established, these results suggest this relationship might be partially explained by patient activation, a potentially modifiable process in patients approaching ESRD. Therefore, interventions that encourage patients to become actively involved in their care could also reduce decisional conflict among patients approaching ESRD.

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

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

Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study

Background

Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana.

Methods

This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers.

Results

Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering.

Conclusions

This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement palliative care for ESKD management in such settings.

Use of a Supportive Kidney Care Video Decision Aid in Older Patients: A Randomized Controlled Trial

BACKGROUND

There are few studies of patient-facing decision aids that include supportive kidney care as an option. We tested the efficacy of a video decision aid on knowledge of supportive kidney care among older patients with advanced CKD.

METHODS

Participants (age ≥ 65 years with advanced CKD) were randomized to receive verbal or video education. Primary outcome was knowledge of supportive kidney care (score range 0-3). Secondary outcomes included preference for supportive kidney care, and satisfaction and acceptability of the video.

RESULTS

Among all participants (n = 100), knowledge of supportive kidney care increased significantly after receiving education (p < 0.01); however, there was no difference between study arms (p = 0.68). There was no difference in preference for supportive kidney care between study arms (p = 0.49). In adjusted analyses, total health literacy score (aOR 1.08 [95% CI: 1.003-1.165]) and nephrologists' answer of "No" to the Surprise Question (aOR 4.87 [95% CI: 1.22-19.43]) were associated with preference for supportive kidney care. Most felt comfortable watching the video (96%), felt the content was helpful (96%), and would recommend the video to others (96%).

CONCLUSIONS

Among older patients with advanced CKD, we did not detect a significant difference between an educational verbal script and a video decision aid in improving knowledge of supportive kidney care or preferences. However, patients who received video education reported high satisfaction and acceptability ratings. Future research will determine the effectiveness of a supportive kidney care video decision aid on real-world patient outcomes.

TRIAL REGISTRATION

NCT02698722 (ClinicalTrials.gov).

Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

Palliative Care in Nephrology: The Work and the Workforce

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

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

Background

Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.

Methods

We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.

Results

Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.

Conclusions

The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.

Exploring the choices and outcomes of older patients with advanced kidney disease

A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004–2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.

Caring for older patients with advanced chronic kidney disease and considering their needs: a qualitative study

BACKGROUND

Older patients with advanced chronic kidney disease often do not understand treatment options for renal replacement therapy, conservative kidney management, and advance care planning. It is unclear whether both clinicians and patients have similar perspectives on these treatments and end-of-life care. Thus, the aim of this study was to explore clinician and patient/caregiver perceptions of treatments for end-stage renal disease and advance care planning.

METHODS

This was a qualitative interview study of nephrologists (n = 8), primary care physicians (n = 8), patients (n = 10, ≥ 65 years and estimated glomerular filtration rate < 20), and their caregivers (n = 5). Interviews were conducted until thematic saturation was reached. Transcripts were transcribed using TranscribeMe. Using Nvivo 12, we identified key themes via narrative analysis.

RESULTS

We identified three key areas in which nephrologists', primary care physicians', and patients' expectations and/or experiences did not align: 1) dialysis discussions; 2) dialysis decision-making; and 3) processes of advance care planning. Nephrologist felt most comfortable specifically managing renal disease whereas primary care physicians felt their primary role was to advocate for patients and lead advance care planning discussions. Patients and caregivers had many concerns about the impact of dialysis on their lives and did not fully understand advance care planning. Clinicians' perspectives were aligned with each other but not with patient/caregivers.

CONCLUSIONS

Our findings highlight the differences in experiences and expectations between clinicians, patients, and their caregivers regarding treatment decisions and advance care planning. Despite clinician agreement on their responsibilities, patients and caregivers were unclear about several aspects of their care. Further research is needed to test feasible models of patient-centered education and communication to ensure that all stakeholders are informed and feel engaged.

Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000-2011

BACKGROUND

Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making.

OBJECTIVE

To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011.

EXPOSURE

Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record.

MAIN MEASURES

Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment.

KEY RESULTS

Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53-0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61-2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32-0.54) compared with patients without documentation of clinicians having considered consultation.

CONCLUSIONS

Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.