Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these patients at risk of further functional decline, nursing home placement, and missed opportunities for timely goals of care conversations. Routine geriatric assessment could be a useful tool for identifying older CKD patients who are at increased risk of functional decline and provide contextual information to guide clinical decision-making. We implemented two innovative programs in the Veterans Health Administration that incorporate geriatric assessment performed concurrently with a nephrology visit. In one program, standardized geriatric assessment tools were performed on CKD patients ≥ 70 years by a geriatrician embedded in a nephrology clinic (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic employed comprehensive appointments for patients ≥ 75 years to conduct both geriatric assessments and CKD care (Renal Silver). We report data on 68 Veterans who had geriatric assessments through these programs between November 2013 and May 2015. In CGA-4-CKD, difficulty with one or more ADLs, history of falls, and cognitive impairment were each found in 27.3% of patients. ADL difficulty, falls and cognitive impairment were found in 65.7%, 28.6%, and 51.6% of patients in Renal Silver. Geriatric assessment guided care processes in 45.4% (n=15) and 37.1% (n=13) of Veterans in the CGA-4-CKD and Renal Silver programs, respectively. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.

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SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...