Does the Evidence Support Conservative Management as an Alternative to Dialysis for Older Patients with Advanced Kidney Disease?

The impact of population ageing on the burden of chronic kidney disease

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

Characterising patients and clinician experiences in comprehensive conservative care for kidney failure in Northern Queensland

BACKGROUND

Comprehensive conservative care (CCC) is an emerging treatment option in kidney failure (KF), but its implementation has been restricted by a limited understanding of KF populations, outcomes and clinician experiences.

AIMS

This pilot study aimed to investigate the characteristics of patients who are opting for (CCC) in North Queensland, Australia. It also aimed to highlight clinician factors impacting treatment discussions.

METHODS

It was an observational study facilitated through an online cross-sectional survey to nephrologists, nephrology advanced trainees and nurse practitioners working across North Queensland.

RESULTS

Study participants disagreed with the statement that patients commencing dialysis are more likely to have cardiac co-morbidities (46.7%), diabetes (40.0%), stroke (60.0%), liver disease (60.0%), chronic lung disease (53.3%), cognitive impairment (60.0%) and use of mobility aids (80.0%) than those commencing CCC. Conversely, they agreed that patients commencing dialysis are more likely to be independent (66.7%) and living in their private residence (40.0%). The median frailty score in patients choosing dialysis was 3.0 (interquartile range (IQR) 2.8-3.3), while that of patients selecting CCC was 4.5 (IQR 3.8-7.0). Our participants were aware of at least one clinical prognostication tool, and the one most frequently used was the 'Surprise Question' (46.2%, n = 6). Overall, our participants demonstrated low confidence (median 8.0%, IQR 6.0-8.0%) in facilitating CCC discussions.

CONCLUSION

Patients who are highly co-morbid and frail and have functional impairment are suitable candidates for CCC. More focus needs to be placed on objective prognostication of patients and the upskilling of clinicians to advocate for, and deliver, CCC.

Dialysis Initiation and All-Cause Mortality Among Incident Adult Patients With Advanced CKD: A Meta-analysis With Bias Analysis

Rationale & Objectives

Due to unmeasured confounding, observational studies have limitations when assessing whether dialysis initiation reduces mortality compared with conservative therapy among adults with advanced chronic kidney disease (CKD). We addressed this issue in this meta-analysis.

Study Design

Meta-analysis with bias analysis for unmeasured confounding.

Setting & Study Population

Adults with stage 4 or 5 CKD who had initiated dialysis or conservative treatment.

Selection Criteria for Studies

Prospective or retrospective cohort studies comparing survival of dialysis versus conservatively managed patients were searched on MEDLINE and Embase from January 2009 to March 20, 2019.

Data Extraction

HRs of all-cause mortality associated with dialysis initiation compared with conservative treatment.

Analytical Approach

We pooled HRs using a random-effects model. We estimated the percentage of effect sizes more protective than HRs of 0.80 and severity of unmeasured confounding that could reduce this percentage to only 10%. Subgroup analysis was performed for studies with only older patients (aged ≥ 65 years).

Results

12 studies were included that involved 16,609 dialysis patients and 3,691 conservatively managed patients. A random-effects model suggested that dialysis initiation was associated with a mean mortality HR of 0.47 (95% CI, 0.34-0.64), in which 92% (95% CI, 50%-100%) of the true effects were more protective than HRs of 0.80. To reduce the percentage of HRs < 0.80 to 10%, unmeasured confounder(s) would need to be associated with both dialysis initiation and mortality by relative risks of 4.05 (95% CI, 2.39-4.15), which is equivalent to shifting each study's estimated HR by 2.31-fold (95% CI, 1.51-2.36). Restricting studies to include only older patients did not modify the results.

Limitations

Limited number of studies and evidence on the absence of publication bias.

Conclusions

Our findings suggest that dialysis initiation considerably reduces mortality among adults with advanced CKD. Future bias-adjusted meta-analyses need to assess outcomes beyond mortality.

Advanced kidney disease: What the nonnephrology NP needs to know

ABSTRACT

Nonnephrology NPs often encounter patients with advanced chronic kidney disease. As patients transition to nephrology care, NPs need to communicate with them about their disease status and treatment. This article describes the treatment approach in patients with advanced kidney disease including medical management, hemodialysis, peritoneal dialysis, and transplantation.

The views and experiences of older people with conservatively managed renal failure: a qualitative study of communication, information and decision-making

Background

Older people with advanced kidney disease require information and support from clinicians when deciding whether to have dialysis or conservative (non-dialysis) care. There is evidence that communication practices, information provision and treatment rates vary widely across renal units. However, experiences of communicating with clinicians among patients receiving conservative care are poorly understood. This evidence is essential to ensure support is patient-centred and equitable. Our aim was to explore views and experiences of communication, information provision and treatment decision-making among older patients receiving conservative care.

Methods

In-depth qualitative interviews were conducted with patients with stage 5 chronic kidney disease from three UK renal units. Purposive sampling captured variation in age, co-morbidity and functional status. Interviews were analysed thematically.

Results

20 patients were interviewed (11 were men; median age 82 (range 69–95)). Participants described positive experiences of communicating with clinicians and receiving information, but also negative experiences involving insensitivity, rushing or ambiguity. Participants reported clinicians omitting/avoiding conversations regarding diagnosis and prognosis, and described what helped and hindered good communication and support. They wanted information about their treatment options and illness, but expressed ambivalence about knowing details of disease progression. Clinicians’ views and recommendations regarding treatment influenced patients’ decision-making.

Conclusions

Older patients report variable quality in communication with clinicians and gaps in the information received. Uncertainty about the disease trajectory and patients’ ambivalence regarding information makes communication particularly challenging for clinicians. Tailoring information to patient preferences and conveying it clearly and sensitively is critical. Renal clinicians require support and training to ensure decision-making support for older patients is patient-centred. Future research should examine how clinicians’ communication practices influence treatment decision-making.

Characterizing Approaches to Dialysis Decision Making with Older Adults: A Qualitative Study of Nephrologists

BACKGROUND AND OBJECTIVES

Despite guidelines recommending shared decision making, nephrologists vary significantly in their approaches to discussing conservative management for kidney replacement therapy with older patients. Many older patients do not perceive dialysis initiation as a choice or receive sufficient information about conservative management for reasons incompletely understood. We examined how nephrologists' perceptions of key outcomes and successful versus failed treatment discussions shape their approach and characterized different models of decision making, patient engagement, and conservative management discussion.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our qualitative study used semistructured interviews with a sample of purposively sampled nephrologists. Interviews were conducted from June 2016 to May 2017 and continued until thematic saturation. Data were analyzed using typological and thematic analyses.

RESULTS

Among 35 nephrologists from 18 practices, 20% were women, 66% had at least 10 years of nephrology experience, and 80% were from academic medical centers. Four distinct approaches to decision making emerged: paternalist, informative (patient led), interpretive (navigator), and institutionalist. Five themes characterized differences between these approaches, including patient autonomy, engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, and offering explicit treatment recommendation), influence of institutional norms, importance of clinical outcomes (e.g., survival and dialysis initiation), and physician role (educating patients, making decisions, pursuing active therapies, and managing symptoms). Paternalists and institutionalists viewed initiation of dialysis as a measure of success, whereas interpretive and informative nephrologists focused on patient engagement, quality of life, and aligning patient values with treatment. In this sample, only one third of providers presented conservative management to patients, all of whom followed either informative or interpretive approaches. The interpretive model best achieved shared decision making.

CONCLUSIONS

Differences in nephrologists' perceptions of their role, patient autonomy, and successful versus unsuccessful encounters contribute to variation in decision making for patients with kidney disease.

Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists

BACKGROUND

Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community.

STUDY DESIGN

Interview study of nephrologists.

SETTING & PARTICIPANTS

National sample of US nephrologists sampled based on sex, years in practice, practice type, and region.

METHODOLOGY

Qualitative semistructured interviews continued until thematic saturation.

ANALYTICAL APPROACH

Thematic and narrative analysis of recorded and transcribed interviews.

RESULTS

Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress.

LIMITATIONS

Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians.

CONCLUSIONS

Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.

Nephrology Provider Prognostic Perceptions and Care Delivered to Older Adults with Advanced Kidney Disease

BACKGROUND AND OBJECTIVES

Prognostic uncertainty is one barrier that impedes providers in engaging patients with CKD in shared decision making and advance care planning. The surprise question has been shown to identify patients at increased risk of dying.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In our prospective observational study, 488 patients ≥60 years of age with CKD stage 4 or 5 were enrolled. Binary surprise question (i.e., "Would you be surprised if this patient died in the next 12 months?") responses were recorded, and dialysis planning preferences, presence of advance care planning documentation, and care preceding death were abstracted.

RESULTS

The median patient age was 71 (65-77) years old. Providers responded no and yes to the surprise question for 171 (35%) and 317 (65%) patients, respectively. Median follow-up was 1.9 (1.5-2.1) years, during which 18% of patients died (33% of surprise question no, 10% of surprise question yes; P<0.001). In patients with a known RRT preference (58%), 13% of surprise question no participants had a preference for conservative management (versus 2% of yes counterparts; P<0.001). A medical order (i.e., physician order for life-sustaining treatment) was documented in 13% of surprise question no patients versus 5% of yes patients (P=0.004). Among surprise question no decedents, 41% died at home or hospice, 38% used hospice services, and 54% were hospitalized in the month before death. In surprise question yes decedents, 39% died at home or hospice (P=0.90 versus no), 26% used hospice services (P=0.50 versus no), and 67% were hospitalized in the month before death (P=0.40 versus surprise question no).

CONCLUSIONS

Nephrologists' prognostic perceptions were associated with modest changes in care, highlighting a critical gap in conservative management discussions, advance care planning, and end of life care among older adults with CKD stages 4 and 5 and high-risk clinical characteristics.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_09_18_CJASNPodcast_17_11.mp3.

Mesenchymal Stem Cell-based Therapy as a New Horizon for Kidney Injuries

Today, the prevalence of kidney diseases is increasing around the world, but there has still been no effective medical treatment. The therapeutic choices are confined to supportive cares and preventive strategies. Currently, mesenchymal stem cells (MSCs)-based cell therapy was proposed for the treatment of kidney injuries. However, after the transplantation of MSCs, they are exposed to masses of cytotoxic factors involving an inflammatory cytokine storm, a nutritionally-poor hypoxic environment and oxidative stresses that finally lead to minimize the efficacy of MSCs based cell therapy. Therefore, several innovative strategies were developed in order to potentiate MSCs to withstand the unfavorable microenvironments of the injured kidney tissues and improve their therapeutic potentials. This review aims to introduce MSCs as a new modality in the treatment of renal failure. Here, we discuss the clinical trials of MSCs-based therapy in kidney diseases as well as the in vivo studies dealing with MSCs application in kidney injuries mainly from the proliferation, differentiation, migration and survival points of view. The obstacles and challenges of this new modality in kidney injuries are also discussed.

Characteristics and Outcomes of In-Hospital Palliative Care Consultation among Patients with Renal Disease Versus Other Serious Illnesses

BACKGROUND AND OBJECTIVES

Despite significant morbidity and mortality associated with ESRD, these patients receive palliative care services much less often than patients with other serious illnesses, perhaps because they are perceived as having less need for such services. We compared characteristics and outcomes of hospitalized patients in the United States who had a palliative care consultation for renal disease versus other serious illnesses.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this observational study, we used data collected by the Palliative Care Quality Network, a national palliative care quality improvement collaborative. The 23-item Palliative Care Quality Network core dataset includes demographics, processes of care, and clinical outcomes of all hospitalized patients who received a palliative care consultation between December of 2012 and March of 2016.

RESULTS

The cohort included 33,183 patients, of whom 1057 (3.2%) had renal disease as the primary reason for palliative care consultation. Mean age was 71.9 (SD=16.8) or 72.8 (SD=15.2) years old for those with renal disease or other illnesses, respectively. At the time of consultation, patients with renal disease or other illnesses had similarly low mean Palliative Performance Scale scores (36.0% versus 34.9%, respectively; P=0.08) and reported similar moderate to severe anxiety (14.9% versus 15.3%, respectively; P=0.90) and nausea (5.9% versus 5.9%, respectively; P>0.99). Symptoms improved similarly after consultation regardless of diagnosis (P≥0.50), except anxiety, which improved more often among those with renal disease (92.0% versus 66.0%, respectively; P=0.002). Although change in code status was similar among patients with renal disease versus other illnesses, from over 60% full code initially to 30% full code after palliative care consultation, fewer patients with renal disease were referred to hospice than those with other illnesses (30.7% versus 37.6%, respectively; P<0.001).

CONCLUSIONS

Hospitalized patients with renal disease referred for palliative care consultation had similar palliative care needs, improved symptom management, and clarification of goals of care as those with other serious illnesses.