ABSTRACT
A 32-year-old male presented with hypertensive emergency and features of thrombotic microangiopathy. He underwent a kidney biopsy after renal dysfunction persisted despite clinical improvement otherwise. The kidney biopsy was performed with direct ultrasound guidance. The procedure was complicated by hematoma formation and persistent turbulent flow on color Doppler concerning for ongoing bleeding. Serial point of care ultrasounds of the kidney with color flow Doppler were used to monitor the size of the hematoma and determine if there was evidence of ongoing bleeding. These serial ultrasounds showed stable hematoma size, resolution of biopsy-associated Doppler signal and prevented further invasive interventions.
ABSTRACT
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.
