Evaluating a shared decision-making intervention regarding dialysis modality: development and validation of self-assessment items for patients with chronic kidney disease

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/).

Practical applications of methods to incorporate patient preferences into medical decision models: a scoping review

BACKGROUND

Algorithms and models increasingly support clinical and shared decision-making. However, they may be limited in effectiveness, accuracy, acceptance, and comprehensibility if they fail to consider patient preferences. Addressing this gap requires exploring methods to integrate patient preferences into model-based clinical decision-making.

OBJECTIVES

This scoping review aimed to identify and map applications of computational methods for incorporating patient preferences into individualized medical decision models and to report on the types of models where these methods are applied.

INCLUSION CRITERIA

This review includes articles without restriction on publication date or language, focusing on practical applications. It examines the integration of patient preferences in models for individualized clinical decision-making, drawing on diverse sources, including both white and gray literature, for comprehensive insights.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, a comprehensive search was conducted across databases such as PubMed, Web of Science, ACM Digital Library, IEEE Xplore, Cochrane Library, OpenGrey, National Technical Reports Library, and the first 20 pages of Google Scholar. Keywords related to patient preferences, medical models, decision-making, and software tools guided the search strategy. Data extraction and analysis followed the JBI framework, with an explorative analysis.

RESULTS

From 7074 identified and 7023 screened articles, 45 publications on specific applications were reviewed, revealing significant heterogeneity in incorporating patient preferences into decision-making tools. Clinical applications primarily target neoplasms and circulatory diseases, using methods like Multi-Criteria Decision Analysis (MCDA) and statistical models, often combining approaches. Studies show that incorporating patient preferences can significantly impact treatment decisions, underscoring the need for shared and personalized decision-making.

CONCLUSION

This scoping review highlights a wide range of approaches for integrating patient preferences into medical decision models, underscoring a critical gap in the use of cohesive frameworks that could enhance consistency and clinician acceptance. While the flexibility of current methods supports tailored applications, the limited use of existing frameworks constrains their potential. This gap, coupled with minimal focus on clinician and patient engagement, hinders the real-world utility of these tools. Future research should prioritize co-design with clinicians, real-world testing, and impact evaluation to close this gap and improve patient-centered care.

Management of Elderly Patients with Chronic Kidney Disease

Chronic kidney disease (CKD) is highly prevalent among elderly patients, and as the global population ages, the number of elderly patients with CKD is increasing. Elderly patients require additional considerations beyond those required for their younger counterparts, such as comorbidities, frailty, and geriatric syndromes. In this review, we primarily focus on these additional considerations specific to elderly patients and discuss the assessment of CKD and its management strategies, including blood pressure and glycemic control; dyslipidemia, anemia, and electrolyte and metabolic acidosis management; and medication dosage, among others, as well as polypharmacy and nonpharmacological management. Furthermore, the concept of conservative kidney management and the practical recommendations of the Korean Society of Geriatric Nephrology for elderly patients with end-stage kidney disease requiring dialysis therapy are discussed. In particular, the aging rate in Korea is exceptionally high; therefore, it is crucial to pay more attention to the increase in elderly patients with CKD. A more palliative approach, rather than intensive treatment strategies, may be necessary for these patients. In a world with an abundance of information, shared decision-making with patients is of great importance, and it is essential to keep in mind that this holds true for elderly patients as well.

Effects of shared decision-making on the prognosis of peritoneal dialysis patients

BACKGROUND

Chronic kidney disease (CKD) patients face critical decisions in choosing kidney replacement therapy such as hemodialysis (HD) or peritoneal dialysis (PD), which significantly affect their quality of life and health outcomes. Recent studies highlight the importance of shared decision-making (SDM) in helping patients understand their treatment options and make informed choices. SDM not only improves patient satisfaction and autonomy but also emphasizes the need for comprehensive pre-dialysis education to support optimal treatment selection.

METHODS

Among patients with chronic kidney failure from 8 hospitals in Korea who started dialysis, 256 who participated in a pilot project for home management of PD were included in the present study. A mixed-methods study was conducted using questionnaires and semi-structured interviews. Our study focused on the effects of SDM on patient death, survival rate, HD conversion, emergency room visits, hospitalization days, and outpatient visits.

RESULTS

A significant difference was observed in hospitalization days (P = .0044) between the SDM and non-SDM groups. However, no significant differences were observed in survival rate, rate of conversion to HD, survival rate after conversion to HD, emergency room visit rate, number of hospitalizations per patient, outpatient visit rate, medical cost, hospitalization cost, outpatient cost, and phosphate-binding agent prescription rate.

CONCLUSIONS

This study emphasizes the benefits of SDM in reducing hospitalization days for PD patients, suggesting its potential role as a guide in future decisions regarding PD. PD provides a particularly beneficial home-based treatment alternative for patients facing challenges with hospital visits, supported by advanced technologies. Overseas, various countries are implementing policies and incentives to promote home dialysis, demonstrating the potential for SDM to enhance patient satisfaction and outcomes in dialysis care globally.

Shared Decision Making for Choosing renAl Replacement Therapy in Chronic Kidney Disease Patients (SDM-ART trial): study protocol for randomized clinical trial

BACKGROUND

Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients.

METHODS

This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence.

DISCUSSION

The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.

The experience of shared decision-making for patients with end-stage kidney disease undergoing haemodialysis and their families-A scoping review

AIM

To identify the experiences of shared decision-making (SDM) for adults with end-stage kidney disease undergoing haemodialysis (HD) and their family members.

DESIGN

A scoping literature review.

METHOD

A scoping literature review, using Joanna Briggs Institute guidelines.

DATA SOURCES

Medline (OVID), EMBASE, CINAHL, Psych Info, ProQuest, Web of Science, Open grey and grey literature were searched covering years from January 2015 to July 2022. Empirical studies, unpublished thesis and studies in English were included. The scoping review was conducted using the Preferred Reporting Items for Systematic Meta analysis-scoping review extension (PRISMA-Scr).

RESULTS

Thirteen studies were included in the final review. While SDM is welcomed by people undergoing HD, their experience is often limited to treatment decisions, with little opportunity to revisit decisions previously made. The role of the family/caregivers as active participants in SDM requires recognition.

CONCLUSION

People with end-stage kidney disease undergoing HD do and want to participate in the process of SDM, on a wide range of topics, in addition to treatment. A strategy is needed to ensure that SDM interventions are successful in achieving patient-driven outcomes and enhancing their quality of life.

IMPLICATIONS FOR CLINICAL PRACTICE

This review highlights the experiences of people undergoing HD and their family/caregivers. There is a wide variety of clinical decisions requiring consideration for people undergoing HD, including considering the importance who should be involved in the decision-making processes and when decisions should occur. Further study to ensure nurses understand the importance, and influence of including family members in conversations on both SDM processes and outcomes is needed. There is a need for research from both patient and healthcare professional (HCP) perspectives to ensure that people feel supported and have their needs met in the SDM process.

PATIENT AND PUBLIC CONTRIBUTION

No patient or public contribution.

Therapeutic roles of thiazides and loop diuretics in blood pressure control and renal protection against chronic kidney disease

Fluid overload secondary to loss of functional nephron mass can elevate blood pressure, which is characteristic of hypertension shown in chronic kidney disease (CKD). Therefore, it is logical to use diuretics at appropriate dose to lower blood pressure in patients with CKD and hypertension. Despite the theoretical background on the use of diuretics in CKD, there have been no definitive data on the effectiveness or safety of diuretics as first-line therapy for the management of hypertension in patients with CKD. Results from some clinical trials have demonstrated that diuretics would not lower blood pressure. They could even worsen electrolyte imbalance and kidney function when they are administered in patients with CKD. Major clinical practice guidelines on management of blood pressure or CKD have stated that evidence for benefits of thiazide diuretics is not conclusive yet in patients with advanced CKD, although loop diuretics are often effective for volume control at lower glomerular filtration rate. Recently, evidence for diuretics as effective blood pressure lowering agents in patients with advanced CKD is increasing. Renoprotective effect of thiazide or loop diuretics might represent a consequence of their influence on blood pressure or their ability to potentiate the effect of renin-angiotensin system blockade by making intraglomerular pressure more renin-angiotensin system-dependent, although their direct benefit on renal function remains controversial. This review summarizes recent data on the possible role of diuretics in lowering blood pressure, slowing the progression of kidney disease, and reducing cardiovascular risk in CKD patients.

Shared decision-making intervention regarding dialysis modality in patients with CKD stage 5

BACKGROUND

Patients with kidney failure must make complicated decisions about the dialysis modalities used either at home or in-hospital. Different options have varying levels of impact on patients' physical and psychological conditions and their social life. The purpose of this study was to evaluate the implementation of an intervention designed to achieve shared decision making (SDM) in patients' options for dialysis.

METHODS

SDM was performed after consent was written for stage 5 chronic kidney disease patients before dialysis, and 435 cases were performed in 408 patients from December 16, 2019 to June 30, 2021. Among these, 101 patients were compared by SDM measurement scale, patient satisfaction, disease recognition scale survey, and dialysis method.

RESULTS

The average age of participants was 56 years, with a gender composition of 55 males (54.5%) and 46 females (45.5%). Following SDM, the final dialysis methods decided upon by patients and clinicians were peritoneal dialysis (67 patients, 66.3%), hemodialysis (22 patients, 21.8%), and kidney transplantation (1 patient, 1.0%).

CONCLUSIONS

Among participating patients, SDM was effective when used to decide on dialysis treatment, and patients were satisfied with the dialysis method decision process. On the disease awareness scale, those who participated in this project had relatively high positive and low negative perceptions, so it can be concluded that SDM was relatively effective. The implementation of SDM was helpful in selecting patients' best dialysis methods, and SDM scale results were higher in the peritoneal dialysis group than in the hemodialysis group.

The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea

Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37-0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52-0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.