Background Older adults with advanced CKD have significant pain, other symptoms, and disability. To help ensure that care is consistent with patients' values, nephrology providers should understand their patients' priorities when they make clinical recommendations.Methods Patients aged $60 years with advanced (stage 4 or 5) non-dialysis-dependent CKD receiving care at a CKD clinic completed a validated health outcome prioritization tool to ascertain their health outcome priorities. For each patient, the nephrology provider completed the same health outcome prioritization tool. Patients also answered questions to self-rate their health and completed an end-of-life scenarios instrument. We examined the associations between priorities and self-reported health status and between priorities and acceptance of common end-of-life scenarios, and also measured concordance between patients' priorities and providers' perceptions of priorities.Results Among 271 patients (median age 71 years), the top health outcome priority was maintaining independence (49%), followed by staying alive (35%), reducing pain (9%), and reducing other symptoms (6%). Nearly half of patients ranked staying alive as their third or fourth priority. There was no relationship between patients' self-rated health status and top priority, but acceptance of some end-of-life scenarios differed significantly between groups with different top priorities. Providers' perceptions about patients' top health outcome priorities were correct only 35% of the time. Patient-provider concordance for any individual health outcome ranking was similarly poor.Conclusions Nearly half of older adults with advanced CKD ranked maintaining independence as their top heath outcome priority. Almost as many ranked being alive as their last or second-to-last priority. Nephrology providers demonstrated limited knowledge of their patients' priorities.

Background Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question (“Would you be surprised if this patient died in the next 12 months?”) is a tool to assist in prognostication. However, it has not been studied in non–dialysis-dependent CKD and its reliability is unknown. Study Design Observational study Setting & Participants 388 patients at least 60 years of age, with non–dialysis-dependent CKD stages 4–5, who were seen at an outpatient nephrology clinic. Predictor Trinary (i.e., ‘Yes’, ‘Neutral’, ‘No’) and binary (‘Yes’, ‘No’) surprise question response. Outcomes Mortality, test-retest reliability, and blinded inter-rater reliability Measurements Baseline comorbidities, Charlson comorbidity index, cause of CKD, and baseline laboratory values (i.e., serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). Results The median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded ‘Yes’, ‘Neutral’, and ‘No’ for 202 (52%), 80 (21%), 106 (27%) patients, respectively. About 5%, 15%, and 27% of ‘Yes’, ‘Neutral’, and ‘No’ patients died, respectively (p<0.001). The trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42–0.72) and the test-retest reliability was 0.63 (95% CI, 0.54–0.72). The trinary surprise question ‘No’ response had a sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had a sensitivity of 66% (95% CI, 49%-80%; p=0.3 vs trinary) but a lower specificity of 68% (95% CI, 63%-73%; p=0.02 vs trinary). Limitations Single center, small number of deaths. Conclusions The surprise question associates with mortality in CKD stages 4–5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non–dialysis-dependent CKD.

Objective Sarcopenic obesity (SO), a combination of low muscle mass and high fat mass, is considered as risk factor for mortality in general population. It is unclear if SO affects mortality in maintenance hemodialysis (MHD) patients. In this study, we aimed to determine whether body composition as assessed by currently available SO definitions are related to all-cause mortality in MHD subjects. We also examined the impact of applying different definitions on the prevalence of SO in our MHD database. Design Retrospective analysis Subjects and Settings Adult patients on MHD for at least 3 months with no acute illness studied in the clinical research center between 2003 and 2011. Intervention Assessment of body composition was performed using dual energy x-ray absorptiometry (DEXA). SO (Appendicular Skeletal Mass (ASM): arm lean mass + leg lean mass and fat mass) was defined according to Baumgartner definition, Janssen Criteria 1 and Janssen Criteria 2. Main Outcome Measure All-cause mortality and prevalence of SO. Patient deaths were ascertained from medical records and United States social security death index. Results Of 122 participants, 62% were male; mean age was 46 (interquartile range [IQR] 40, 54) in men and 50 (44, 61) in women. Prevalence of SO ranged from 12% to 62% in men and 2% to 74% in female according to different definitions. SO prevalence was lowest using the Baumgartner criteria (all: 8%, men 12%, women: 2%), and highest according to the Janssen Criteria 2 (all: 57%, men 46%, women 74%). There were 45 deaths during a median follow-up period of 44 (20, 76) months. SO by any definition was not statistically significantly associated with mortality during follow up. Conclusions The current SO definitions are not applicable to predict increased risk of death in MHD patients. We found high degree of variation in the rates of SO when using different definitions. Future studies should focus on establishing MHD population-specific thresholds of muscle mass and adiposity for accurate prognostication.

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