Shared decision making in elderly patients with kidney failure

Association of geriatric nutritional risk index with renal prognosis and all-cause mortality among older patients with chronic kidney disease: a secondary analysis of CKD-ROUTE study

OBJECTIVES

The aim of the study was to assess the association between the geriatric nutritional risk index (GNRI) and incidence of CKD progression, all-cause mortality, and cardiovascular events in the elderly patients with chronic kidney disease (CKD) before dialysis initiation.

METHODS

We performed a post hoc analysis of the CKD-ROUTE database, which included 538 pre-dialysis CKD patients aged ≥65 years in this prospective cohort study. Associations between GNRI and clinical outcomes were estimated using Cox proportional hazards model analysis. Multivariable linear mixed regression models with random intercepts were used to assess the association between GNRI and estimated glomerular filtration rate (eGFR) decline per year.

RESULTS

During the median follow-up period of 2.92 years, there were 123 (22.86%) CKD progression events, 44 (8.18%) deaths, and 76 (14.13%) cardiovascular events. After adjusting for multiple confounding factors, the hazard ratios (HRs) for CKD progression in patients with GNRI <92 were 1.99 (95% CI, 1.34-2.97; p < 0.001), when compared with a GNRI of ≥92. Patients with a lower GNRI also had a significantly greater rate of eGFR decline over time than well-nourished patients (mean annual difference, -1.69; 95% CI, -2.62 to -0.77; p < 0.001). In the secondary outcomes, this association was consistent for all-cause mortality. Moreover, the associations were generally consistent across several subgroup and sensitivity analyses.

CONCLUSIONS

The lower GNRI is significantly associated with higher risks of renal prognosis and all-cause mortality in elderly patients with CKD.

Questions older people and caregivers ask about kidney therapies: A computer-assisted analysis

BACKGROUND

Older adults with advanced chronic kidney disease (CKD) face complex and often overwhelming decisions regarding kidney therapy (KT), yet little is known about the specific information they and their caregivers seek during these discussions. Understanding informational needs is critical for improving shared decision-making.

OBJECTIVES

To identify and compare questions asked by patients and caregivers during KT decision-making visits.

METHODS

A dataset of 36 transcribed kidney therapy (KT) decision-making focused outpatient palliative care encounters-conducted by a single clinician in patient homes and/or a single clinic-was analyzed using computational linguistic techniques supplemented by manual verification. Participants included 25 patients aged ≥ 75 years with an estimated glomerular filtration rate ≤ 25 ml/min/1.73 m², identified by nephrologists as needing KT decision-making support. Caregivers (n = 15) were included when present. All patients received a decision aid and question prompt list. Visits were led by a nephrologist board-certified in palliative care.

RESULTS

Across 36 visits, 640 questions were recorded, averaging 17.78 per visit. The presence of a caregiver did not significantly affect the number of questions patients asked (10.42 vs. 10.00). Patients were more likely to ask conversational cooperation questions (37 % vs. caregivers' 19 %), while caregivers focused more on dialysis (38 % vs. patients' 25 %). Both groups asked a similar amount of questions about chronic kidney disease (patients 11 %, caregivers 10 %) and conservative kidney management (patients 4 %, caregivers 5 %). End-of-life inquiries were minimal, with patients asking 4 % of questions and caregivers none.

CONCLUSIONS

Patients and caregivers have different information needs during KT decision-making, highlighting the importance of addressing educational, decisional, and EOL planning gaps.

PRACTICE IMPLICATIONS

Targeted educational interventions that address patients' and caregivers' unique preferences and information gaps are essential, including question prompt lists and decision aids with coaching, which AI-driven approaches could further optimize.

Shared Decision-Making in Choosing Dialysis Modalities for Patients With Chronic Kidney Disease: An Evolutionary Concept Analysis

The concept of shared decision-making, which respects the autonomy of patients with chronic kidney disease in the process of choosing dialysis modalities, has been emphasized. Studies clearly defining the process of selecting dialysis methods for chronic kidney disease patients remain limited. Thus, this study aimed to conduct a Rodgers' evolutionary concept analysis of shared decision-making in choosing dialysis modalities among patients with chronic kidney disease. A comprehensive literature review was conducted using data from six electronic databases from 2013 to 2024. In total, 36 papers were included in this analysis. We found the seven key attributes of shared decision-making in dialysis modalities: "Setting goals for treatment sustainability and life after treatment," "Building a trusting and respectful relationship," "Developing a collaborative partnership," "Effective patient-doctor communication," "Choosing the right dialysis treatment options," "Making personalized and informed decisions" and "Voluntary participation and interactive process." Our knowledge can promote patient-centered communication and contribute to the development of tailored interventions for patients with chronic kidney disease and their family caregivers. TRIAL REGISTRATION: (PROSPERO) CRD42023453585 (https://www.crd.york.ac.uk/prospero/).

Global, regional, and national burden of chronic kidney disease, 1990-2021: a systematic analysis for the global burden of disease study 2021

Background

Chronic kidney disease (CKD) continues to represent a significant public health concern, with both prevalence and incidence rates on the rise globally. Therefore, the study employed the Global Burden of Disease (GBD) database to investigate the global burden of CKD from 1990 to 2021.

Methods

This study utilized data from the GBD 2021. Join-point regression models were developed for the estimation of the average annual percentage change (AAPC) in the prevalence and mortality rates of CKD. Subsequently, stepwise multiple linear regression analysis was conducted to examine the trends in disability adjusted life years (DALYs) and DALYs rate for CKD across diverse populations between 1990 and 2021. Moreover, the influence of age, gender, and socio-demographic index (SDI) on the burden of CKD among patients from 1990 to 2021 was examined. Furthermore, the projection of the burden of CKD from 2022 to 2032 was also conducted.

Results

The AAPC for prevalence and mortality rates across the entire period spanning 1990 to 2021 was 0.92 and 2.66, respectively. A notable increase in the DALYs and DALYs rate for CKD was demonstrated over time, indicating a growing CKD burden on society since 1990. Furthermore, the DALYs rates for CKD were lowest in the 5-9 year age group for both genders, rising thereafter with age. Notably, the DALYs rate for CKD was higher in males than in females. Regions with higher SDI, generally exhibited a lower burden of CKD, while less developed regions, demonstrated the opposite pattern. Additionally, the age-standardized prevalence and mortality rates for CKD would be projected to increase to 8,773.85 and 21.26 per 100,000 individuals, respectively, by 2032.

Conclusion

The research indicated a gradual increase in the global prevalence and mortality rates of CKD over time, which might prompt the formulation of more efficient health policies to alleviate its burden.

Kidney replacement therapies in the older person: challenges to decide the best option

A multitude of challenges exist when supporting older adults in deciding on the optimal kidney replacement therapy (KRT), including frailty, comorbidity, cognitive impairment, dialysis modality, as well as local availability of services. The combination of these factors can determine treatment outcomes and quality of life (QoL), and as such the care of older people should be tailored to take these into account. Frailty in older people with chronic kidney disease (CKD) leads to higher rates of hospitalization, increased mortality, and a diminished QoL, while cognitive impairment, present in up to 50% of people with CKD, exacerbates these challenges and affects decision making. Dialysis, particularly haemodialysis, can accelerate physical and cognitive decline in frail older adults. Conversely, peritoneal dialysis (PD) presents a home-based alternative that may better support QoL, particularly for people wanting to prioritize treatment flexibility and independence. Assisted PD programmes have emerged as a valuable option for older people who cannot manage home-based care independently, improving access to KRT. Ultimately shared decision making should be employed when discussing KRT, incorporating patient goals, prognostic awareness, and QoL measures. There is also the emerging role of the geriatrician and the need for an integrated Comprehensive Geriatric Assessment. These elements support older adults to make informed choices that align with the individuals' values and health needs. In designing future health services to meet the needs of increasing numbers of older people, there needs to be increased access to assisted PD as well as multidisciplinary working to ensure patient-focused care surrounding KRT in older adults.

How to make a shared decision with older persons for end-stage kidney disease treatment: the added value of geronto-nephrology

Improving care for older people with end-stage kidney disease (ESKD) requires the adaptation of standards to meet their needs. This may be complex due to their heterogeneity in terms of multimorbidity, frailty, cognitive decline and healthcare priorities. As benefits and risks are uncertain for these persons, choosing an appropriate treatment is a daily challenge for nephrologists. In this narrative review, we aimed to describe the issues associated with healthcare for older people, with a specific focus on decision-making processes; apply these concepts to the context of ESKD; identify components and modalities of shared decision-making and suggest means to improve care pathways. To this end, we propose a geronto-nephrology dynamic, described here as the necessary collaboration between these specialties. Underscoring gaps in the current evidence in this field led us to suggest priority research orientations.

Investigating the Impact of AI on Shared Decision-Making in Post-Kidney Transplant Care (PRIMA-AI): Protocol for a Randomized Controlled Trial

BACKGROUND

Patients after kidney transplantation eventually face the risk of graft loss with the concomitant need for dialysis or retransplantation. Choosing the right kidney replacement therapy after graft loss is an important preference-sensitive decision for kidney transplant recipients. However, the rate of conversations about treatment options after kidney graft loss has been shown to be as low as 13% in previous studies. It is unknown whether the implementation of artificial intelligence (AI)-based risk prediction models can increase the number of conversations about treatment options after graft loss and how this might influence the associated shared decision-making (SDM).

OBJECTIVE

This study aims to explore the impact of AI-based risk prediction for the risk of graft loss on the frequency of conversations about the treatment options after graft loss, as well as the associated SDM process.

METHODS

This is a 2-year, prospective, randomized, 2-armed, parallel-group, single-center trial in a German kidney transplant center. All patients will receive the same routine post-kidney transplant care that usually includes follow-up visits every 3 months at the kidney transplant center. For patients in the intervention arm, physicians will be assisted by a validated and previously published AI-based risk prediction system that estimates the risk for graft loss in the next year, starting from 3 months after randomization until 24 months after randomization. The study population will consist of 122 kidney transplant recipients >12 months after transplantation, who are at least 18 years of age, are able to communicate in German, and have an estimated glomerular filtration rate <30 mL/min/1.73 m2. Patients with multi-organ transplantation, or who are not able to communicate in German, as well as underage patients, cannot participate. For the primary end point, the proportion of patients who have had a conversation about their treatment options after graft loss is compared at 12 months after randomization. Additionally, 2 different assessment tools for SDM, the CollaboRATE mean score and the Control Preference Scale, are compared between the 2 groups at 12 months and 24 months after randomization. Furthermore, recordings of patient-physician conversations, as well as semistructured interviews with patients, support persons, and physicians, are performed to support the quantitative results.

RESULTS

The enrollment for the study is ongoing. The first results are expected to be submitted for publication in 2025.

CONCLUSIONS

This is the first study to examine the influence of AI-based risk prediction on physician-patient interaction in the context of kidney transplantation. We use a mixed methods approach by combining a randomized design with a simple quantitative end point (frequency of conversations), different quantitative measurements for SDM, and several qualitative research methods (eg, records of physician-patient conversations and semistructured interviews) to examine the implementation of AI-based risk prediction in the clinic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06056518; https://clinicaltrials.gov/study/NCT06056518.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54857.

The Impact of Physical Exercise on microRNAs in Hemodialysis Patients: A Review and a Protocol for an Ancillary Study

Physical inactivity is considered a significant risk factor for mortality and morbidity among chronic hemodialysis (HD) patients. Therefore, physical exercise is recommended in the treatment of HD patients. Although the beneficial effects of physical exercise in HD patients are well-described in the literature, the underlying physiological mechanisms still need to be fully understood. Recently, microRNAs (miRNAs) have emerged as potential mediators of the therapeutic effects of physical exercise in healthy individuals. miRNAs are short, single-stranded, noncoding RNAs involved in gene expression regulation. Specifically, upon forming the RNA-induced silencing complex, miRNAs selectively bind to specific miRNAs within cells, reducing gene expression. miRNAs can be secreted by cells in an accessible form or enclosed within exosomes or extracellular vesicles. They can be detected in various body fluids, including serum (circulating miRNAs), facilitating the study of their diverse expression. Currently, there is no available data regarding the impact of physical exercise on the expression of miRNAs involved in osteogenic differentiation, a fundamental mechanism in the development of vascular calcification, for HD patients. Therefore, we have designed an observational and longitudinal case-control study to evaluate the expression of miR-9 and miR-30b in HD patients participating in a 3-month interdialytic physical exercise program. This paper aims to present the study protocol and review the expression of circulating miRNAs in HD patients and their modulation through physical exercise.