Decisions about Renal Replacement Therapy in Patients with Advanced Kidney Disease in the US Department of Veterans Affairs, 2000–2011

Abstract

In this large United States cohort of patients with advanced CKD, the majority received or were preparing to receive RRT. This was true even among the oldest patients with the highest burden of comorbidity.

Practice Change Is Needed for Dialysis Decision Making with Older Adults with Advanced Kidney Disease

“…The implementation of best clinical practices starts with a baseline assessment of the current state of services. That is what the study by Wong et al (15) in this issue of the Clinical Journal of the American Society of Nephrology provides. They describe the existing practice pattern of dialysis initiation in a distinct cohort from the US Department of Veterans Affairs (VA) and contextualize it with global trends.…”

“…The failure to consider prognosis in dialysis decision making found in the study by Wong et al (15) has been shown before in United States nephrology practice. An interview study of 62 patients on chronic dialysis with high 1-year mortality noted that none of the patients reported a discussion of prognosis with their nephrologist, and in 60% of patients, nephrologists were unable to provide a prognostic estimate (18).…”

“…Wong et al (15) found no difference in the proportion of patients started on or preparing for dialysis when stratified by comorbidity score. These data suggest a decision-making process that is blind to the important role that comorbidity, a known key determinant of prognosis, should play in shared decision making (10).…”

“…For patients who choose not to start dialysis (14.5% in the study by Wong et al [15]), a comprehensive care model that delivers optimal CM needs to be developed in this country. CM models in other countries provide effective symptom management and improve quality of life (22).…”

“…Despite the integration of palliative care into the care of patients with cancer and other chronic diseases (23), a national policy shift toward patient-centered care (12), and recognition by nephrology fellows over a decade ago that more palliative care education is needed in their training (24), Wong et al (15) have shown that nephrology practice in the United States has not kept pace. Nephrology training programs need to include more primary palliative care (25).…”