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Chronic kidney disease patients should be given more treatment options, new Rutgers study says

Some elderly patients with chronic kidney disease (CKD) may choose not to begin dialysis treatments because they value their quality of life over how many years they have left. – Photo by Matt Bennett / Unsplash

A recent Rutgers study includes a proposal that could fundamentally change the way chronic kidney disease (CKD) is approached, according to a press release.

Lead author Fahad Saeed, an assistant professor of medicine and public health in the divisions of nephrology and palliative care at the University of Rochester, said that the study discusses the benefits of the “Deciding Not to Decide” (DND) method, which suggests that some patients may benefit from being able to exercise greater control over their treatment plan for CKD.

Specifically, older adults who are not candidates for kidney transplants may experience better care if physicians take more time to consider different treatment options instead of starting dialysis straight away, according to the release.

Alvin Moss, a professor of medicine at West Virginia School of Medicine, said that the current treatment for patients with end-stage kidney disease is renal replacement therapy (RRT), which is designed to support crucial kidney functions through dialysis methods and kidney transplants if necessary.

Rather than dismiss the current approach of treating kidney disease, the proposal intends to address an issue plaguing many CKD patients today, which is that they face a lot of pressure to begin treatment, Saeed said.

Moss said that patients may feel apprehensive about RRT due to its time-consuming and inconvenient nature.

“In-center hemodialysis is the most frequent form of therapy for over 80 percent of patients,” he said. “It involves going to a dialysis center three times a week for usually four hours to receive a dialysis treatment.”

As a result of this pressure to start RRT, patients may not receive relevant information pertaining to their health and treatment options, Saeed said. The study proposes that instead of patients just being given the option of dialysis, they should be presented with more information regarding treatment options. 

“If a patient has a good kidney prognosis, despite their relatively low function and they are elderly, probably they’ll never need dialysis,” he said. “In those cases, we’re proposing that the patient should have an option of deciding not to decide.”

Moss said that mental health risks should also be considered when making treatment decisions, specifically because approximately 20 percent of patients with advanced kidney disease also face depression.

Paul Duberstein, a professor in the Department of Health Behavior, Society and Policy in the School of Public Health at Rutgers University—New Brunswick and co-author of the study, said that suicide prevention is an important factor to consider. 

“In the United States and many other countries worldwide, suicide rates increase across the lifespan and are highest in older men,” he said. “Individuals with serious life-limiting conditions such as chronic kidney disease are at elevated risk.”

Moss said that though most CKD patients do not become suicidal, suicide within dialysis patients occurs at a higher rate than within the general population. This could be due to the strict schedule of treatments, medication and diet that such patients have to follow, he said.

Patients in dialysis may also suffer from anxiety and feel ambivalent about upcoming dialysis treatments, but the DND option could alleviate the pressure for patients to receive surgery and thus lessen the effects of such mental health conditions, Moss said. 

He said that since the DND proposal is a patient-centered approach, being permitted to “decide not to decide” could be in the best interest of the patient, who may value their quality of life more than the number of years they have left, especially in the cases where chronically ill patients want to avoid extended suffering.

Only approximately 20 percent of CKD patients would choose DND, with only approximately 3 percent of those patients expected to start dialysis after changing their minds, he said. This means that the risk of hospital overcrowding from an influx in patients seeking emergency dialysis initiations is low. 

Overall, the study is important in that if DND is accepted by nephrologists, individuals who face advanced kidney disease will be provided with more options for treatment instead of the traditional disease-oriented approach, Moss said.

Saeed said that the study was primarily exploratory and thus much about kidney disease remains unknown, so researchers could possibly explore more in the future.

Moss and Saeed both said that ultimately, treatment should be decided from informed consent and patient preference, and the fact that patients with CKD face pressure to begin dialysis weakens this process.

“DND counters the powerful default in the care of patients with kidney disease,” Moss said. “Powerful defaults elsewhere in medicine also should be reevaluated and steps taken to mitigate them."

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