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Kennard AL, Glasgow NJ, Rainsford SE, Talaulikar GS. Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD. Kidney Int Rep 2024; 9:791-806. [PMID: 38765572 PMCID: PMC11101734 DOI: 10.1016/j.ekir.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 05/22/2024] Open
Abstract
Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.
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Affiliation(s)
- Alice L. Kennard
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas J. Glasgow
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Suzanne E. Rainsford
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Girish S. Talaulikar
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
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Pawar AS, Thorsteinsdottir B, Whitman S, Pine K, Lee A, Espinoza Suarez NR, Organick Lee P, Thota A, Lorenz E, Beck A, Albright R, Feely M, Williams A, Behnken E, Boehmer KR. Decisional Regret Surrounding Dialysis Initiation: A Comparative Analysis. Kidney Med 2024; 6:100785. [PMID: 38435065 PMCID: PMC10907211 DOI: 10.1016/j.xkme.2023.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 03/05/2024] Open
Abstract
Rationale & Objective Dialysis comes with a substantial treatment burden, so patients must select care plans that align with their preferences. We aimed to deepen the understanding of decisional regret with dialysis choices. Study Design This study had a mixed-methods explanatory sequential design. Setting & Participants All patients from a single academic medical center prescribed maintenance in-center hemodialysis or presenting for home hemodialysis or peritoneal dialysis check-up during 3 weeks were approached for survey. A total of 78 patients agreed to participate. Patients with the highest (15 patients) and lowest decisional regret (20 patients) were invited to semistructured interviews. Predictors Decisional regret scale and illness intrusiveness scale were used in this study. Analytical Approach Quantitatively, we examined correlations between the decision regret scale and illness intrusiveness scale and sorted patients into the highest and lowest decision regret scale quartiles for further interviews; then, we compared patient characteristics between those that consented to interview in high and low decisional regret. Qualitatively, we used an adapted grounded theory approach to examine differences between interviewed patients with high and low decisional regret. Results Of patients invited to participate in the interviews, 21 patients (8 high regret, 13 low regret) agreed. We observed that patients with high decisional regret displayed resignation toward dialysis, disruption of their sense of self and social roles, and self-blame, whereas patients with low decisional regret demonstrated positivity, integration of dialysis into their identity, and self-compassion. Limitations Patients with the highest levels of decisional regret may have already withdrawn from dialysis. Patients could complete interviews in any location (eg, home, dialysis unit, and clinical office), which may have influenced patient disclosure. Conclusions Although all patients experienced disruption after dialysis initiation, patients' approach to adversity differs between patients experiencing high versus low regret. This study identifies emotional responses to dialysis that may be modifiable through patient-support interventions.
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Affiliation(s)
- Aditya S. Pawar
- Beth Israel Deaconess Medical Center, Boston, MA
- Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Bjorg Thorsteinsdottir
- Community Internal Medicine, Mayo Clinic, Rochester, MN
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Sam Whitman
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | - Katherine Pine
- Human and Social Dimensions of Science and Technology, Arizona State University, Phoenix, AZ
| | - Alexander Lee
- Health Services Research, Mayo Clinic, Rochester, MN
| | - Nataly R. Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
- VITAM Research Center on Sustainable Health, Québec Integrated University Health and Social Services Center (CIUSSS de la Capitale-Nationale), Québec, Canada
| | - Paige Organick Lee
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Anjali Thota
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy Williams
- Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Emma Behnken
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Kasey R. Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
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Stedman MR, Kurella Tamura M, Chertow GM. Using Relative Survival to Estimate the Burden of Kidney Failure. Am J Kidney Dis 2024; 83:28-36.e1. [PMID: 37678740 PMCID: PMC10841440 DOI: 10.1053/j.ajkd.2023.05.015] [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: 11/07/2022] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 09/09/2023]
Abstract
RATIONALE & OBJECTIVE Estimates of mortality from kidney failure are misleading because the mortality from kidney failure is inseparable from the mortality attributed to comorbid conditions. We sought to develop an alternative method to reduce the bias in estimating mortality due to kidney failure using life table methods. STUDY DESIGN Longitudinal cohort study. SETTING & PARTICIPANTS Using data from the US Renal Data System and the Medicare 5% sample, we identified an incident cohort of patients, age 66+, who first had kidney failure in 2009 and a similar general population cohort without kidney failure. EXPOSURE Kidney failure. OUTCOME Death. ANALYTICAL APPROACH We created comorbidity, age, sex, race, and year-specific life tables to estimate relative survival of patients with incident kidney failure and to attain an estimate of excess kidney failure-related deaths. Estimates were compared with those based on standard life tables (not adjusted for comorbidity). RESULTS The analysis included 31,944 adults with kidney failure with a mean age of 77±7 years. The 5-year relative survival was 31% using standard life tables (adjusted for age, sex, race, and year) versus 36% using life tables also adjusted for comorbidities. Compared with other chronic diseases, patients with kidney failure have among the lowest relative survival. Patients with incident kidney failure ages 66-70 and 76-80 have a survival comparable to adults without kidney failure roughly 86-90 and 91-95 years old, respectively. LIMITATIONS Relative survival estimates can be improved by narrowing the specificity of the covariates collected (eg, disease severity and ethnicity). CONCLUSIONS Estimates of survival relative to a matched general population partition the mortality due to kidney failure from other causes of death. Results highlight the immense burden of kidney failure on mortality and the importance of disease prevention efforts among older adults. PLAIN-LANGUAGE SUMMARY Estimates of death due to kidney failure can be misleading because death information from kidney failure is intertwined with death due to aging and other chronic diseases. Life tables are an old method, commonly used by actuaries and demographers to describe the life expectancy of a population. We developed life tables specific to a patient's age, sex, year, race, and comorbidity. Survival is derived from the life tables as the percentage of patients who are still alive in a specified period. By comparing survival of patients with kidney failure to the survival of people from the general population, we estimate that patients with kidney failure have one-third the chance of survival in 5 years compared with people with similar demographics and comorbidity but without kidney failure. The importance of this measure is that it provides a quantifiable estimate of the immense mortality burden of kidney failure.
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Affiliation(s)
- Margaret R Stedman
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford.
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford; Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford; Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford
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Sousa H, Ribeiro O, Christensen AJ, Figueiredo D. Mapping Patients' Perceived Facilitators and Barriers to In-Center Hemodialysis Attendance to the Health Belief Model: Insights from a Qualitative Study. Int J Behav Med 2023; 30:97-107. [PMID: 35275346 DOI: 10.1007/s12529-022-10075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous research has shown that deliberate withdrawal, skipping, and/or shortening hemodialysis sessions has become a major health problem associated with poor clinical outcomes and early mortality in patients with end-stage renal disease (ESRD). However, patients' experiences with this treatment remain largely unexplored. This study aimed to explore patients' perceived facilitators and barriers to in-center hemodialysis attendance and map these findings to the Health Belief Model. METHODS A qualitative exploratory study was conducted with a purposive sample. Semi-structured interviews were conducted and submitted to thematic analysis. RESULTS Twenty-four patients (66.2 ± 12.3 years old; length of time on hemodialysis: 35.2 ± 51.5 months) were interviewed. Five major facilitators (social support, perceived benefits, self-efficacy, time on dialysis, and risk/susceptibility perception) and two barriers (lack of knowledge about ESRD and hemodialysis, and psychosocial costs) were identified. CONCLUSION Adherence to the prescribed regimen of hemodialysis attendance is a complex and multidimensional phenomenon that involves an interaction between modifying factors (social support, disease and treatment knowledge, time on dialysis) and patients' perceived benefits, perceived risks, self-efficacy, and treatment costs. This study findings expand knowledge by suggesting that perceiving health benefits from the beginning of treatment, self-efficacy to deal with dialysis demands, and purpose in life are important facilitators of adherence to in-center hemodialysis sessions. Furthermore, it suggests that the impact of the hemodialysis regimen on the emotional well-being of family members is an important barrier. Future interventions should focus on skills training to promote self-efficacy and family coping with the demands of in-center hemodialysis, improve disease and treatment knowledge, and help balance perceived benefits with dialysis costs.
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Affiliation(s)
- Helena Sousa
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro, Campus Universitário de Santiago, Aveiro, 3810-193, Portugal.
| | - Oscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro, Campus Universitário de Santiago, Aveiro, 3810-193, Portugal
| | - Alan J Christensen
- Department of Psychology, East Carolina University, North Carolina, 27858, USA
| | - Daniela Figueiredo
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro, Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
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Toapanta N, Comas J, León Román J, Ramos N, Azancot M, Bestard O, Tort J, Soler MJ. Mortality in elderly patients starting hemodialysis program. Semin Dial 2022. [PMID: 35817409 DOI: 10.1111/sdi.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/31/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidence of older patients over 80 years old with chronic kidney disease who start hemodialysis (HD) program has been increasing in the last decade. METHODS We aimed to identify risk factors for morbidity and mortality in patients older than 80 years with end-stage renal disease who started HD. We conducted a retrospective observational study of the Catalan Renal registry (RMRC). RESULTS A total of 2833 patients equal or older than 80 years (of 15,137) who started HD between 2002 and 2019 from the RMRC were included in the study. In this group, the first dialysis was performed through an arteriovenous fistula in 44%, percutaneous catheter in 28.2%, and tunneled catheter in 26.6%. Conventional dialysis was used in 65.7% and online HD in 34.3%. The most frequent cause of death was cardiac disease (21.8%), followed by social problems (20.4%) and infections (15.9%). Overall survival in older HD during the first year was 84% versus 91% in younger than 80 years (p < 0.001). Cox regression analysis identified the start of HD in the period 2002-2010, chronic obstructive pulmonary disease (COPD), and the onset of HD through vascular graft depicted as risk factors for first-year mortality after dialysis initiation in patients older than 80 years with end-stage renal disease who started HD. CONCLUSIONS In conclusion, patients older than 80 years who started HD program had higher mortality, especially those who presented exacerbation of kidney disease, those with COPD, and those who started with a vascular graft.
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Affiliation(s)
- Néstor Toapanta
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jordi Comas
- Catalan Transplantation Organization, Barcelona, Spain
| | - Juan León Román
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Natalia Ramos
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - María Azancot
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Oriol Bestard
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jaume Tort
- Catalan Transplantation Organization, Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
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Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton) 2022; 27:551-565. [PMID: 35201646 PMCID: PMC9315017 DOI: 10.1111/nep.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jenny H C Chen
- Faculty of Medicine, University of Wollongong, Wollongong, Australia.,Wollongong Hospital, Wollongong, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Medicine, University of Western Australia, Perth, Australia
| | - Prue Howson
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
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Brunori G, Aucella F. Choosing the best renal care for our patients. Nephrol Dial Transplant 2021; 37:617-619. [PMID: 34718765 DOI: 10.1093/ndt/gfab309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giuliano Brunori
- Department of Nephrology and Dialysis, Santa Chiara Hospital, Trento, Italy
| | - Filippo Aucella
- Department of Nephrology and Dialysis, Fondazione "Casa Sollievo della Sofferenza" IRCCS, San Giovanni Rotondo, Italy
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