Conservative care for end-stage kidney disease: joint medical conference with the Renal Association, British Geriatrics Society and Association for Palliative Medicine

Alston, Helen

doi:10.7861/clinmedicine.13-4-383

Cited by 14 publications

(15 citation statements)

References 8 publications

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“…Their data were, however, published in 2005 and in 2006, and since then CKM has been established as a treatment option in many UK renal units. CKM is one of the fastest-changing areas of renal medicine, 58 and there is a need to understand how it is delivered nationally.…”

Section: Discussionmentioning

confidence: 99%

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Roderick

Rayner

Tonkin‐Crine

et al. 2015

Health Services and Delivery Research

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BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Discussionmentioning

confidence: 99%

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Roderick

Rayner

Tonkin‐Crine

et al. 2015

Health Services and Delivery Research

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“…Conservative care for ESRD is evolving in the UK (19), and information on how it is practiced is limited to individual units. In 2005, Gunda et al (20) reported significant variation in the provision of palliative care for ESRD across the UK.…”

Section: Introductionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age $75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR,. CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

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“…Bei schlechten Erfolgsaussichten sollte im Vordergrund stehen, den Patienten vor weiterem Schaden zu bewahren. Hinweise für eine strukturierte Evaluation der mit dem ANV verknüpf-tem Problem einer gemeinsamen Entscheidungsfindung liegen vor [12,36,37]. Für Patienten, die nicht entscheidungsfähig sind und bei denen keine Willensäußerung vorliegt und eine gesetzliche Betreuung angeregt wurde, gelten besondere Rechte bezüglich der Entscheidungsfindung [38].…”

Section: Therapeutische üBerlegungenunclassified

“…den "konservativen" Therapieansatzes fortzusetzen, muss in Erwägung gezogen werden. Dieser Aspekt gewinnt mit der Alterung der Gesellschaft zunehmend an Bedeutung[36]. decision making | Die Lebenserwartung älterer Dialysepatienten ist begrenzt und Folgeerkrankungen sowie die chronische Dialysebehandlung beeinträchtigen die Lebensqualität.…”

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Das akute Nierenversagen bei älteren Patienten – entscheidend für die Gesamtmortalität?

Pommer¹

2015

Dtsch med Wochenschr

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Acute kidney injury (AKI) in the elderly is associated with high risks of chronic kidney disease (CKD), hospital- and all-cause mortality. Based on the decreased renal function in older age groups and age-specific co-morbidity as hypertension, cardiovascular complications, and diabetes mellitus, the risk for AKI is increased. In outpatients inadequate pharmacotherapy and self-medication contribute to increased risk of AKI while in hospital settings severe infection, cardiovascular interventions with contrast media and major surgery may result in higher rates of AKI. Every fourth case is on risk for recurrent AKI followed by advanced CKD and renal replacement therapy. In the oldest old with high co-morbidity condition indication of renal replacement in AKI should be processed by shared-decision making. In many cases palliative care in this setting may be appropriate.

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Conservative care for end-stage kidney disease: joint medical conference with the Renal Association, British Geriatrics Society and Association for Palliative Medicine

Cited by 14 publications

References 8 publications

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Conservative Care for ESRD in the United Kingdom

Das akute Nierenversagen bei älteren Patienten – entscheidend für die Gesamtmortalität?

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