Availability, Accessibility, and Quality of Conservative Kidney Management Worldwide.

BACKGROUND AND OBJECTIVES: People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management. RESULTS: Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery. CONCLUSIONS: Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.

Association of Initiation of Dialysis With Hospital Length of Stay and Intensity of Care in Older Adults With Kidney Failure.

Importance: Comparative outcome data examining the association of dialysis initiation with hospital length of stay and intensity of care in older adults with kidney failure are scarce, and prior studies are limited to patients treated by nephrology teams. Objective: To compare in-hospital days and intensity of care among older adults with kidney failure who were treated vs not treated with maintenance dialysis. Design, Setting, and Participants: This population-based, retrospective cohort study included adults in Alberta, Canada, 65 years or older with kidney failure, defined by at least 2 consecutive outpatient estimated glomerular filtration rate values of less than 10 mL/min/1.73 m2 spanning a period of at least 90 days from May 15, 2002, to March 31, 2014. Data were analyzed from August 1, 2017, to August 29, 2019. Exposures: Time-varying exposure to maintenance dialysis for treatment of kidney failure. Main Outcomes and Measures: The primary outcome was rate of in-hospital days. Secondary outcomes included rates of hospital admissions, intensive care unit admissions, cardiopulmonary resuscitations, inpatient palliative care, and emergency department visits; risk of in-hospital death; and time to admission to long-term care. Results: A total of 968 patients (median age, 78.5 [interquartile range, 72.4-84.7] years; 489 men [50.5%]; median follow-up, 2.0 [interquartile range, 0.8-3.9] years) were included in the analysis. Patients who underwent dialysis spent more adjusted in-hospital days per person-year (36.25 [95% CI, 30.72-41.77] vs 14.65 [95% CI, 12.28-17.02]; incidence rate ratio [IRR], 2.47 [95% CI, 1.99-3.08]). However, the dialysis group did not have a higher rate of hospital admissions (1.18 [95% CI 1.07-1.29] vs 1.32 [95% CI 1.17-1.48] per year; IRR, 0.89 [95% CI, 0.77-1.03]). Patients in the dialysis group had a higher rate of intensive care unit admissions per 1000 hospitalizations (98.37 [95% CI, 81.09-115.65] vs 54.51 [95% CI, 37.76-71.26]; IRR, 1.80 [95% CI, 1.28-2.54]) and lower rates of inpatient palliative care per 1000 in-hospital days (3.92 [95% CI, 3.13-4.72] vs 8.60 [95% CI, 6.3-11.0]; IRR, 0.45 [95% CI, 0.32-0.64]). Conclusions and Relevance: In this cohort study, compared with nondialysis care, patients who received maintenance dialysis spent more time in the hospital and were more likely to be admitted to intensive care units. This finding suggests trade-offs between longer survival and higher intensity of use of health care services as a function of dialysis initiation. Maintenance dialysis may be a proxy for the type of philosophy of care driving increased in-hospital time and intensive care and less use of palliative care.

Preferences for a self-management e-health tool for patients with chronic kidney disease: results of a patient-oriented consensus workshop.

BACKGROUND: Electronic health (e-health) tools may support patients' self-management of chronic kidney disease. We aimed to identify preferences of patients with chronic kidney disease, caregivers and health care providers regarding content and features for an e-health tool to support chronic kidney disease self-management. METHODS: A patient-oriented research approach was taken, with 6 patient partners (5 patients and 1 caregiver) involved in study design, data collection and review of results. Patients, caregivers and clinicians from across Canada participated in a 1-day consensus workshop in June 2018. Using personas (fictional characters) and a cumulative voting technique, they identified preferences for content for 8 predetermined topics (understanding chronic kidney disease, diet, finances, medication, symptoms, travel, mental and physical health, work/school) and features for an e-health tool. RESULTS: There were 24 participants, including 11 patients and 6 caregivers, from across Canada. The following content suggestions were ranked the highest: basic information about kidneys, chronic kidney disease and disease progression; reliable information on diet requirements for chronic kidney disease and comorbidities, renal-friendly foods; affordability of medication, equipment, food, financial resources and planning; common medications, adverse effects, indications, cost and coverage; symptom types and management; travel limitations, insurance, access to health care, travel checklists; screening and supports to address mental health, cultural sensitivity, adjusting to new normal; and support to help integrate at work/school, restrictions. Preferred features included visuals, the ability to enter and track health information and interact with health care providers, "on-the-go" access, links to resources and access to personal health information. INTERPRETATION: A consensus workshop developed around personas was successful for identifying detailed subject matter for 8 predetermined topic areas, as well as preferred features to consider in the codevelopment of a chronic kidney disease self-management e-health tool. The use of personas could be applied to other applications in patient-oriented research exploring patient preferences and needs in order to improve care and relevant outcomes.

A Cost Analysis and Cost-Utility Analysis of a Community Pharmacist-Led Intervention on Reducing Cardiovascular Risk: The Alberta Vascular Risk Reduction Community Pharmacy Project (RxEACH).

BACKGROUND: A randomized trial (the Alberta Vascular Risk Reduction Community Pharmacy Project) showed that a community pharmacist-led intervention was efficacious for reducing cardiovascular (CV) risk. However, the cost of this strategy is unknown. OBJECTIVES: We examined the short- and long-term cost of a pharmacist-led intervention to reduce CV risk compared to usual care. METHODS: We conducted a trial-based cost analysis from the perspective of a publicly funded healthcare system. Over 3 and 12 months of follow-up, we examined specific intervention costs (pharmacy claims), related intervention costs (laboratory tests and medications), and ongoing healthcare costs (physician claims, emergency department visits, and hospital admissions). We also used the validated CV Disease Policy Model-Canada to estimate the long-term effects. RESULTS: A total of 684 participants (mean age 62, 57% male) were included. Overall, there were no significant differences in healthcare costs at 3 or 12 months between the usual care and intervention groups (P = .127). The CV disease-related healthcare cost of managing a patient over a lifetime was estimated to be Can$45 530 (95% uncertainty interval [UI], 45 460-45 580) and Can$40 750 (95% UI, 37 780-43 620) in usual care and intervention groups, respectively, an incremental cost savings of Can$4770 per patient (95% UI, 1900-7760). The intervention dominated usual care (better outcomes and lower costs) across 3-year, 5-year, 10-year, and lifetime horizons. CONCLUSION: This economic analysis suggests that a clinical pathway-driven pharmacist-led intervention (previously shown to reduce CV risk) was associated with similar measured healthcare costs over 1 year, and lower extrapolated healthcare costs over a patient lifetime. This strategy could be broadly implemented to realize its benefits.

Understanding Adults With Chronic Kidney Disease and Their Caregivers' Self-Management Experiences: A Qualitative Study Using the Theoretical Domains Framework.

BACKGROUND: Self-management support interventions are widely accepted in chronic kidney disease (CKD) care; however, interventions rarely consider individual behaviors by incorporating a behavioral theoretical framework. The Theoretical Domains Framework (TDF) can be used to facilitate an understanding of patients and their caregivers' behaviors to successfully self-manage CKD. OBJECTIVES: (1) To understand behaviors of patients with CKD and their caregivers and identify potential intervention approaches to support CKD self-management and (2) to explore relationships between the 14 TDF domains and CKD self-management. DESIGN: Qualitative descriptive study using both content and thematic analysis. SETTING: Purposive criterion was used to recruit participants from across Canada. PATIENTS: Canadian patients with CKD and their caregivers. MEASUREMENTS: Focus groups and telephone interviews using a semistructured interview guide. METHODS: We conducted a secondary analysis of qualitative data collected from focus groups and telephone interviews from July 2017 to January 2018. Two research team members coded the transcribed data to the 14 TDF domains using a modified approach of the Framework Method. We linked the common TDF domains to relevant intervention functions from the Behaviour Change Wheel (BCW) to identify potential intervention approaches. We also identified and mapped relationships between the relevant TDF domains to report emerging themes. RESULTS: Six focus groups (37 participants) and 11 telephone interview transcripts were analyzed. Five TDF domains that influenced CKD self-management behavior were identified: environmental context and resources, knowledge, beliefs about capabilities, beliefs about consequences, and social influences. Four BCW intervention functions were identified: education, modeling, persuasion, and environmental restructuring. Four emergent themes, shaped by the populated 14 TDF domains, were identified: What does this mean for me? Help me help myself, How does this make me feel? and Who am I? LIMITATIONS: The TDF was not used to design the interview guide; therefore, there may be underrepresentation of some TDF domains relevant for self-management. CONCLUSION: Our findings highlight 5 TDF domains that can influence CKD self-management behavior and 4 possible intervention approaches to influence behavior change in patients with CKD and their caregivers. Emergent themes highlight participants' interpretation of being diagnosed with CKD, their motivations, feelings, values, and altered identity. This work will inform the codesign of a behavior change intervention to enhance patient self-management of CKD.

CONTEXTE: Les interventions visant à soutenir l'autogestion en santé sont largement acceptées dans le traitement de l'insuffisance rénale chronique (IRC). Cependant, ces interventions tiennent rarement compte des comportements individuels en intégrant un cadre comportemental théorique. Le Theoretical Domains Framework (TDF) pourrait être employé pour faciliter la compréhension des comportements des patients et de leurs fournisseurs de soins en vue d'une autogestion efficace de l'IRC. OBJECTIF: 1. Comprendre les comportements des patients atteints d'IRC, de même que ceux de leurs fournisseurs de soins, et proposer des approches interventionnelles visant à soutenir l'autogestion de l'IRC.2. Explorer la relation entre les 14 domaines du TDF et l'autogestion de l'IRC. TYPE D'ÉTUDE: Une étude qualificative et descriptive utilisant à la fois l'analyse de contenu et l'analyse thématique. CADRE: Un critère fondé sur l'objectif a été utilisé pour recruter des participants partout au Canada. SUJETS: Des Canadiens atteints d'IRC et leurs fournisseurs de soins. MESURES: Des groupes de discussion et des entretiens téléphoniques menés à l'aide d'un guide d'interview semi-structurée. MÉTHODOLOGIE: Nous avons procédé à une analyze secondaire des données qualitatives provenant des groupes de discussion et des entretiens téléphoniques entre juillet 2017 et janvier 2018. Deux chercheurs membres de l'équipe ont codé les données transcrites selon les 14 domaines du TDF à l'aide d'une approche modifiée de The Framework Method. Nous avons relié les domaines courants du TDF aux fonctions d'intervention appropriées du Behaviour Change Wheel (BCW) pour cerner de potentielles approches interventionnelles. Enfin, nous avons établi et cartographié les relations entre les domaines pertinents du TDF pour en dégager les thèmes émergents. RÉSULTATS: L'analyse porte sur six groupes de discussion (37 participants) et 11 entretiens téléphoniques. Il en est ressorti cinq domaines du TDF ayant influencé l'autogestion de l'IRC (les ressources et le contexte environnemental, les connaissances, les croyances relatives aux capacités, les croyances relatives aux conséquences et les influences sociales) et quatre fonctions d'intervention du BCW (l'éducation, le modelage, la persuasion et le réaménagement du milieu). De plus, quatre thèmes émergents, influencés par les 14 domaines du TDF, ont été mis en lumière: Qu'est-ce que cela signifie pour moi? Aidez-moi à m'aider moi-même., Qu'est-ce que cela me fait ressentir? Qui suis-je? LIMITES: Certains domaines du TDF pertinents pour l'autogestion pourraient être sous-représentés puisque le TDF n'a pas été utilisé pour l'élaboration du guide d'interview. CONCLUSION: Nos résultats mettent en lumière cinq domaines du TDF susceptibles d'influencer les comportements en autogestion de l'IRC et quatre approches interventionnelles qui pourraient entraîner des changements de comportement chez les patients atteints d'IRC et leurs fournisseurs de soins. Les thèmes émergents mettent l'accent sur l'interprétation qu'ont les patients du diagnostic de l'IRC, de même que sur leurs motivations, leurs sentiments, leurs valeurs et leur identité modifiée. Ces travaux éclaireront la co-conception d'une intervention facilitant les changements de comportements, en vue d'améliorer l'autogestion de l'IRC par les patients.

Identifying Needs for Self-management Interventions for Adults With CKD and Their Caregivers: A Qualitative Study.

RATIONALE & OBJECTIVE: Fostering the ability of patients to self-manage their chronic kidney disease (CKD), with support from caregivers and providers, may slow disease progression and improve health outcomes. However, little is known about such patients' needs for self-management interventions. We aimed to identify and describe the needs of adults with CKD and informal caregivers for CKD self-management support. STUDY DESIGN: Descriptive qualitative study using semi-structured interviews and focus groups. SETTING & PARTICIPANTS: 6 focus groups (37 participants) and 11 telephone interviews with adults with CKD (stages 1-5, not on renal replacement therapy) and informal caregivers from across Canada. ANALYTIC APPROACH: Thematic analysis. RESULTS: 3 major themes were identified: (1) empowerment through knowledge (awareness and understanding of CKD, diet challenges, medication and alternative treatments, attuning to the body, financial implications, mental and physical health consequences, travel and transportation restrictions, and maintaining work and education), (2) activation through information sharing (access, meaningful and relevant, timing, and amount), and (3) tangible supports for the health journey (family, community, and professionals). LIMITATIONS: Participants were primarily white, educated, married, and English speaking, which limits generalizability. CONCLUSIONS: There are opportunities to enhance CKD self-management support by addressing knowledge pertinent to living well with CKD and priority areas for sharing information and providing tangible support. Future efforts may consider the development of innovative CKD self-management support interventions based on the diverse patient and caregiver needs identified in this study.

Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study.

BACKGROUND: Guidelines recommend nephrology referral for people with advanced non-dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease. METHODS: We linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m2 for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered "unexposed." Participants who saw a nephrologist during follow-up were considered "unexposed" before the first outpatient nephrology visit and "exposed" thereafter. The primary outcome was all-cause mortality. RESULTS: Of the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82-0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65-0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88-1.25). INTERPRETATION: The survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.

Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study.

BACKGROUND: The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD). METHODS: The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients' and providers' perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys. RESULTS: Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses "Always" and "Often" together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers' job satisfaction following KFRE implementation. CONCLUSIONS: Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.

Change in Proteinuria or Albuminuria as a Surrogate for Cardiovascular and Other Major Clinical Outcomes: A Systematic Review and Meta-analysis.

BACKGROUND: There is ongoing controversy around the surrogacy of proteinuria or albuminuria, particularly for cardiovascular (CV) outcomes, which remain the leading cause of morbidity and mortality among patients with chronic kidney disease. We performed a systematic review and meta-analysis of the literature to assess the surrogacy of changing proteinuria or albuminuria for CV events, end-stage renal disease (ESRD), and all-cause mortality. METHODS: CENTRAL, EMBASE, and MEDLINE were searched (from inception to October 2017). All randomized controlled trials in adults that reported change in proteinuria or albuminuria and ≥ 10 CV, ESRD, or all-cause mortality events were included. We calculated treatment effect ratios (TERs), defined as the ratio of the treatment effect on a clinical outcome and the effect on the change in the surrogate outcome. TERs close to 1 indicate greater agreement between the clinical outcome and changing proteinuria or albuminuria. RESULTS: Thirty-six trials were included in the meta-analysis. We observed inconsistent treatment effects for proteinuria and CV events (20 trials; TER 1.11 [95% confidence interval (CI), 1.01-1.22]) with moderate heterogeneity (I2 = 51%, P = 0.005). Treatment effects on proteinuria or albuminuria were also inconsistent with the effects on all-cause mortality (21 trials; TER 1.17 [95% CI, 1.07-1.28]; I2 = 35%, P for heterogeneity = 0.06), although they were similar with the effects on ESRD (23 trials; TER 0.99 [95% CI, 0.88-1.13]; I2 = 9%, P for heterogeneity = 0.337). CONCLUSIONS: Change in proteinuria or albuminuria might be a suitable surrogate outcome for ESRD. However, overall treatment effects on these potential surrogates are inconsistent and overestimate the treatment effects on CV events and all-cause mortality.

Identification and Prioritization of Quality Indicators for Conservative Kidney Management.

RATIONALE & OBJECTIVE: Conservative kidney management is holistic patient-centered care for patients with kidney failure that focuses on delaying the progression of kidney disease and symptom management, without the provision of renal replacement therapy. Currently there is no consensus as to what constitutes high-quality conservative kidney management. We aimed to develop a set of quality indicators for the conservative management of kidney failure. STUDY DESIGN: Nominal group technique and Delphi survey process. SETTING & PARTICIPANTS: 16 patients and caregivers from Calgary, Canada, participated in 2 nominal group meetings. 91 multidisciplinary health care professionals from 10 countries took part in a Delphi process. ANALYTICAL APPROACH: Nominal group technique study of patients and caregivers was used to identify and prioritize a list of quality indicators. A 4-round Delphi process with health care professionals was used to rate the quality indicators until consensus was reached (defined as a mean rating on the Likert scale ≥7.0 and percent agreement >75%). Quality indicators that met criteria for consensus inclusion in the Delphi survey were ranked, and comparisons were made with nominal group priorities. RESULTS: 99 quality indicators met consensus criteria for inclusion. The most highly rated quality indicator in the Delphi process was the "percentage of patients that die in the place they desire." There was significant discordance between priorities of the nominal groups with that of the Delphi survey, with only 1 quality indicator being shared on each groups' top 10 list of quality indicators. LIMITATIONS: Participants were largely from high-income English-speaking countries, and most already had structured conservative kidney management programs in place, all potentially limiting generalizability. CONCLUSIONS: Quality of conservative kidney management care is important to patients, caregivers, and health care professionals. However, discordant quality indicator priorities between groups suggested that care providers delivering conservative kidney management may not prioritize what is most important to those receiving this care. Conservative kidney management programs and health care providers can improve the applicability of this consensus-based quality indicator list to their program by further developing and evaluating it for use in their program.

Survival among older adults with kidney failure is better in the first three years with chronic dialysis treatment than not.

Comparisons of survival between dialysis and nondialysis care for older adults with kidney failure have been limited to those managed by nephrologists, and are vulnerable to lead and immortal time biases. So we compared time to all-cause mortality among older adults with kidney failure treated vs. not treated with chronic dialysis. Our retrospective cohort study used linked administrative and laboratory data to identify adults aged 65 or more years of age in Alberta, Canada, with kidney failure (2002-2012), defined by two or more consecutive outpatient estimated glomerular filtration rates less than 10 mL/min/1.73m2, spanning 90 or more days. We used marginal structural Cox models to assess the association between receipt of dialysis and all-cause mortality by allowing control for both time-varying and baseline confounders. Overall, 838 patients met inclusion criteria (mean age 79.1; 48.6% male; mean estimated glomerular filtration rate 7.8 mL/min/1.73m2). Dialysis treatment (vs. no dialysis) was associated with a significantly lower risk of death for the first three years of follow-up (hazard ratio 0.59 [95% confidence interval 0.46-0.77]), but not thereafter (1.22 [0.69-2.17]). However, dialysis was associated with a significantly higher risk of hospitalization (1.40 [1.16-1.69]). Thus, among older adults with kidney failure, treatment with dialysis was associated with longer survival up to three years after reaching kidney failure, though with a higher risk of hospital admissions. These findings may assist shared decision-making about treatment of kidney failure.

Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study.

BACKGROUND: The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care. OBJECTIVE: We aimed to describe patient, family, and health care provider's perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input. METHODS: We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey. RESULTS: Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants' feedback. CONCLUSIONS: We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.

CONTEXTE: La Kidney Failure Risk equation (KFRE), l'équation qui mesure le risque d'évolution vers la défaillance rénale, est susceptible d'orienter les soins prodigués en néphrologie. OBJECTIFS DE L'ÉTUDE: Nous souhaitions savoir comment les patients, leurs proches et leurs fournisseurs de soins percevaient le recours à une approche de prédiction du risque pour répartir les patients atteints d'insuffisance rénale chronique (IRC) dans le système de soins. Plus précisément, nous nous sommes intéressés aux avantages et aux défis perçus face à une telle approche, et les commentaires recueillis se destinaient à en raffiner la mise en œuvre. MÉTHODOLOGIE: Nous avons utilisé une méthodologie qualitative pour étudier les avantages et les défis perçus de la KFRE comme outil d'évaluation de l'admissibilité de patients sud-albertains atteints d'IRC à la prise en charge par une équipe multidisciplinaire. Les perceptions des patients et de leurs proches ont été recueillies lors de groupes de discussion; les fournisseurs de soins ont quant à eux donné leur avis au moyen d'entrevues et d'un sondage en ligne à questions ouvertes. Au total, douze patients et membres de leurs familles ont participé aux groupes de discussion, 16 fournisseurs des soins ont été interviewés et 40 ont répondu au sondage en ligne. RÉSULTATS: Dans l'ensemble, les participants étaient d'avis que la KFRE avait le potentiel d'améliorer l'efficience des cliniques en néphrologie en canalisant les soins vers les patients à risque élevé de défaillance rénale. Les participants se sont toutefois dits préoccupés par les éventuelles conséquences d'une perte de services pour les patients à moindre risque. Ils appréhendaient également une capacité insuffisante du milieu communautaire à prendre en charge les patients atteints d'IRC. Nous avons modifié notre stratégie de mise en œuvre suivant les commentaires recueillis. CONCLUSION: Cette étude nous a permis de recenser les avantages et les défis perçus face à l'application d'une approche fondée sur la KFRE pour prodiguer des soins aux patients atteints d'IRC à un stade avancé. À la lumière des résultats, la stratégie de mise en œuvre a été modifiée. Nous avons notamment supprimé la catégorie de renvoi automatique aux seuls soins primaires pour faire en sorte que, dans le cas de patients à faible risque, le mode de prise en charge soit conjointement déterminé par le néphrologue et le patient.

Implementation and Evaluation of a Risk-Based Approach to Guide Chronic Kidney Disease Care: Protocol for a Multiphase Mixed-Methods Study.

BACKGROUND: Risk prediction tools are used in a variety of clinical settings to guide patient care, although their use in chronic kidney disease (CKD) care is limited. OBJECTIVES: To assess the association of a risk-based model of CKD care on patient care, satisfaction, outcomes, and cost. DESIGN: Mixed-methods with a pre-post design. SETTING: We will use mixed-methods and a pre-post design to evaluate use of the Kidney Failure Risk Equation (KFRE) to guide CKD care. The KFRE will be applied to patients currently followed in nephrology multidisciplinary CKD clinics in Alberta, as well as to new patients being considered for multidisciplinary care. PATIENTS: Patients with a 2-year risk of kidney failure ≥10% or estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m2 will be recommended care by a multidisciplinary team coordinated by a nurse clinician and nephrologist, with access to other multidisciplinary resources including dietitians, pharmacists, and social workers as required. MEASUREMENTS/METHODS: Focus groups and interviews will be conducted to qualitatively describe patient and provider perspectives of potential barriers and facilitators to implementation of the risk-based approach to CKD care. Patient and provider surveys will also be used to quantify patient and provider satisfaction before and after the intervention. Finally, administrative data will be used to evaluate the association between the risk-based approach to care and outcomes including health care resource use, frequency of testing, modality choice, and death. CONCLUSIONS: Use of a risk-based model of care has the potential to increase use of optimal treatments such as the use of home dialysis and preemptive kidney transplantation, while reducing costs and poor outcomes related to processes of care such as unnecessary laboratory testing; however, there is also potential for unintended consequences. Our mixed-methods approach will integrate perceptions and needs from key stakeholders (including patients with CKD, their families, and their providers) to guide implementation and ensure appropriate modifications.

CONTEXTE: Les outils de prévision des risques sont employés dans différents contextes cliniques pour orienter les soins prodigués aux patients. Néanmoins, leur usage dans le contexte de l'insuffisance rénale chronique (IRC) demeure limité. OBJECTIF: Évaluer, dans le contexte de l'IRC, l'influence qu'un modèle de soins intégrant la prévision des risques pourrait avoir sur les soins prodigués aux patients, sur leur satisfaction, sur l'évolution de la maladie et sur les coûts de santé. TYPE D'ÉTUDE: Méthode mixte avec évaluation avant et après l'intervention. CADRE DE L'ÉTUDE: À l'aide d'une méthode mixte et d'une évaluation avant et après l'intervention, nous mesurerons l'emploi de l'équation prédictive du risque d'évolution vers l'insuffisance rénale, la Kidney Failure Risk Equation (KFRE), comme guide de soins en IRC. La KFRE sera appliquée aux patients suivis actuellement dans les cliniques multidisciplinaires de néphrologie en Alberta, de même qu'à tous les nouveaux patients qui seront aiguillés vers les soins multidisciplinaires. PATIENTS: Deux groupes de patients seront aiguillés vers une équipe de soins multidisciplinaire coordonnée par une infirmière clinicienne et un néphrologue, soit les patients présentant un risque égal ou supérieur à 10 % de progresser vers l'insuffisance rénale d'ici deux ans, et ceux dont le débit de filtration glomérulaire estimé (DFGe) est de 15 ml/min/1,73 m2 ou moins. Ces patients auront également accès aux autres ressources de la clinique si nécessaire, notamment des nutritionnistes, des pharmaciens et des travailleurs sociaux. MÉTHODOLOGIE: Des groupes de discussion seront formés et des entretiens individuels seront menés pour sonder le point de vue des patients et des fournisseurs de soins sur les possibles obstacles et facilitateurs à l'adoption d'une approche de soins axée sur la prévision du risque. Ces sondages serviront également à évaluer la satisfaction des participants avant et après l'intervention. Les données administratives seront employées pour évaluer l'association entre une approche de soins axée sur la prévision du risque et les issues en lien avec l'intervention, notamment l'utilisation des ressources en santé, la fréquence des tests, le choix de modalité et le décès. CONCLUSION: L'emploi d'un modèle de soins intégrant la prévision du risque a le potentiel d'accroître le recours aux traitements optimaux tels que la dialyse à domicile et la greffe rénale préventive. Il permettra également de réduire les coûts de santé et les issues défavorables comme les tests de laboratoires inutiles. Par contre, ce modèle comporte aussi un risque de conséquences imprévues. Notre approche par méthodes mixtes intègrera les avis et les besoins des personnes impliquées (les patients atteints d'IRC, leurs familles et le personnel soignant) afin d'orienter la mise en œuvre et pour s'assurer d'apporter les modifications appropriées.

A Description of Advanced Chronic Kidney Disease Patients in a Major Urban Center Receiving Conservative Care.

BACKGROUND: Conservative/palliative (nondialysis) management is an option for some individuals for treatment of stage 5 chronic kidney disease (CKD). Little is known about these individuals treated with conservative care in the Canadian setting. OBJECTIVE: To describe the characteristics of patients treated with conservative care for category G5 non-dialysis CKD in a Canadian context. DESIGN: Retrospective chart review. SETTING: Urban nephrology center. PATIENTS: Patients with G5 non-dialysis CKD (estimated glomerular filtration rate <15 mL/min/1.73 m2). MEASUREMENTS: Baseline patient demographic and clinical characteristics of conservative care follow-up, advanced care planning, and death. METHODS: We undertook a descriptive analysis of individuals enrolled in a conservative care program between January 1, 2009, and June 30, 2015. RESULTS: One hundred fifty-four patients were enrolled in the conservative care program. The mean age and standard deviation was 81.4 ± 9.0 years. The mean modified Charlson Comorbidity Index score was 3.4 ± 2.8. The median duration of conservative care participation was 11.5 months (interquartile range: 4-25). Six (3.9%) patients changed their modality to dialysis. One hundred three (66.9%) patients died during the study period. Within the deceased cohort, most (88.2%) patients completed at least some advanced care planning before death, and most (81.7%) of them died at their preferred place. Twenty-seven (26.7%) individuals died in hospital. LIMITATIONS: Single-center study with biases inherent to a retrospective study. Generalizability to non-Canadian settings may be limited. CONCLUSIONS: We found that individuals who chose conservative care were very old and did not have high levels of comorbidity. Few individuals who chose conservative care changed modality and accepted dialysis. The proportions of engagement in advanced care planning and of death in place of choice were high in this population. Death in hospital was uncommon in this population.

CONTEXTE: Les traitements conservateurs ou soins palliatifs (sans dialyse) constituent une option thérapeutique pour certaines personnes atteintes 'd'insuffisance rénale chronique non-dialyse de catégorie 5 (IRC-ND). Toutefois, nous en savons peu au sujet des personnes inscrites à un programme de traitement conservateur dans le contexte canadien. OBJECTIF DE L'ÉTUDE: Faire le portrait des patients atteints d'IRC-ND G5, sous traitement conservateur dans un contexte canadien. TYPE D'ÉTUDE: Examen rétrospectif des dossiers médicaux. CADRE DE L'ÉTUDE: Un centre de néphrologie en milieu urbain. PATIENTS: Des patients atteints d'IRC-ND G5 (débit de filtration glomérulaire estimé à moins de 15 ml/min/1,73 m2). MESURES: Les données démographiques initiales des patients, de même que les données cliniques de suivi du traitement conservateur, de planification des soins avancés et du décès. MÉTHODOLOGIE: Nous avons entrepris l'analyse descriptive des individus inscrits à un programme de traitement conservateur pour la période s'échelonnant du 1er janvier 2009 au 30 juin 2015. RÉSULTATS: Au total, 154 patients ont été inscrits dans un programme de traitement conservateur au cours de la période étudiée. L'âge moyen des patients était de 81,4 ans avec un écart-type de ± 9,0 ans. Le score moyen à l'index de comorbidité de Charlson modifié était de 3,4 ± 2,8 et la durée médiane de participation à un programme de traitement conservateur était de 11,5 mois (écart interquartile de 4,25). Au cours de la période étudiée, six patients (3,9%) sont passés du traitement conservateur à la dialyse et 103 patients (66,9%) sont décédés. Au sein de la cohorte de patients décédés, la grande majorité (88,2%) avait complété une partie des soins avancés planifiés avant le décès. De cette même cohorte, la plupart (81,7%) sont décédés où ils l'avaient choisi alors que 27 personnes (26,7%) sont décédées à l'hôpital. LIMITES DE L'ÉTUDE: L'étude s'est tenue au sein d'un seul centre hospitalier et comporte des biais inhérents attribuables à son modèle rétrospectif. De plus, la généralisation des résultats à des paramètres non canadiens peut être limitée. CONCLUSIONS: Nous avons constaté que les personnes qui avaient opté pour un traitement conservateur étaient très âgées et présentaient peu de comorbidités. Au cours de la période étudiée, quelques patients qui avaient choisi un traitement conservateur ont changé de modalité et accepté de passer à la dialyse. Nous avons également observé que l'engagement dans la planification des soins avancés et dans le choix de l'endroit où mourir était élevé au sein de cette population, alors que le décès à l'hôpital a été plutôt rare.

Multimorbidity, dementia and health care in older people:a population-based cohort study.

BACKGROUND: Little is known about how multimorbidity, dementia and increasing age combine to influence health outcomes or utilization. Our objective was to examine the joint associations between age, dementia and burden of morbidity with mortality and other clinical outcomes. METHODS: We did a retrospective population-based cohort study of all adults aged 65 years and older residing in Alberta, Canada, between 2002 and 2013. We used validated algorithms applied to administrative and laboratory data from the provincial health ministry to assess the presence/absence of dementia and 29 other morbidities, and their associations with mortality (our primary outcome), other clinical outcomes (emergency department visits, all-cause hospital admissions) and a proxy for loss of independent living (discharge to long-term care). Cox and Poisson models were adjusted for year-varying covariates. A 3-way interaction was modelled for dementia, the number of comorbidities, and age. RESULTS: There were 610 457 adults aged 65 years and older living in Alberta over the study period. Over median follow-up of 6.8 years, 153 125 (25.1%) participants died and 5569 (0.9%) were discharged to long-term care. The prevalence of people with at least 3 morbidities was 33.7% in 2003 and 50.2% in 2012. The prevalence of dementia rose from 6.2% in fiscal year 2003 to 8.3% in fiscal year 2012, representing a net increase of approximately 13 700 people. The likelihood of all 4 outcomes increased with age and with greater burden of morbidity; the presence of dementia further increased these risks. For example, the risk of mortality increased by 1.54 to 6.38 in the presence of dementia, depending on age and morbidity burden. The risk associated with dementia was attenuated by increasing comorbidity. INTERPRETATION: Older age, multimorbidity and dementia are all strongly correlated with adverse health outcomes as well as a proxy for loss of independent living. The increasing prevalences of dementia and multimorbidity over time suggest the need for coordinated national strategies aimed at mitigating the health challenges associated with the aging of the population.

Developing Consensus-Based Priority Outcome Domains for Trials in Kidney Transplantation: A Multinational Delphi Survey With Patients, Caregivers, and Health Professionals.

BACKGROUND: Inconsistencies in outcome reporting and frequent omission of patient-centered outcomes can diminish the value of trials in treatment decision making. We identified critically important outcome domains in kidney transplantation based on the shared priorities of patients/caregivers and health professionals. METHODS: In a 3-round Delphi survey, patients/caregivers and health professionals rated the importance of outcome domains for trials in kidney transplantation on a 9-point Likert scale and provided comments. During rounds 2 and 3, participants rerated the outcomes after reviewing their own score, the distribution of the respondents' scores, and comments. We calculated the median, mean, and proportion rating 7 to 9 (critically important), and analyzed comments thematically. RESULTS: One thousand eighteen participants (461 [45%] patients/caregivers and 557 [55%] health professionals) from 79 countries completed round 1, and 779 (77%) completed round 3. The top 8 outcomes that met the consensus criteria in round 3 (mean, ≥7.5; median, ≥8; proportion, >85%) in both groups were graft loss, graft function, chronic rejection, acute rejection, mortality, infection, cancer (excluding skin), and cardiovascular disease. Compared with health professionals, patients/caregivers gave higher priority to 6 outcomes (mean difference of 0.5 or more): skin cancer, surgical complications, cognition, blood pressure, depression, and ability to work. We identified 5 themes: capacity to control and inevitability, personal relevance, debilitating repercussions, gaining awareness of risks, and addressing knowledge gaps. CONCLUSIONS: Graft complications and severe comorbidities were critically important for both stakeholder groups. These stakeholder-prioritized outcomes will inform the core outcome set to improve the consistency and relevance of trials in kidney transplantation.

Trends in the Management of Patients With Kidney Failure in Alberta, Canada (2004-2013).

BACKGROUND: Based on clinical practice guidelines, specific quality indicators are examined to assess the performance of a health care system for patients with end-stage renal disease (ESRD). We examined trends in the proportion of patients with ESRD referred late to nephrology, timing of dialysis initiation in those with chronic kidney disease, and proportion of patients with ESRD treated with pre-emptive kidney transplantation or peritoneal dialysis (PD). Design:: This was a retrospective cohort study. Setting:: The study was conducted in Alberta, Canada. Patients:: Alberta residents aged 18 years or older with incident ESRD requiring renal replacement therapy between 2004 and 2013 were included. Measurements:: Descriptive statistics, and log binomial and linear regression models were used for analysis. Methods:: We determined the proportion of patients with ESRD who did not see a nephrologist within 90 days prior to starting dialysis (late referrals) and those who were receiving PD 90 days after dialysis initiation. Among those who had been seen by a nephrologist for at least 90 days, we also assessed the proportion who initiated dialysis with estimated glomerular filtration rate (eGFR) higher than or equal to 10.5 mL/min/1.73 m2, and underwent a pre-emptive transplant. Results:: Our cohort included 5343 patients (mean age 61.8 years, 61.2% male). Over a 10-year period, there was a decrease in the proportion of late referrals (26.4% to 21.1%, P = .001). We also noted a decrease in the proportion of dialysis initiation with eGFR higher than or equal to 10.5 mL/min/1.73 m2 (21.2% to 14.7%, P < .001), with a significant increase in the proportion of patients initiating dialysis as an inpatient (38.8% to 45.2%, P = .001). There was a non-significant decrease in both the proportion of patients treated with a pre-emptive transplant and PD at 90 days over the 10-year period. Limitations:: The use of administrative data restricted the availability of clinical data regarding underlying circumstances of each quality indicator, including patient symptoms, indications for dialysis initiation, and PD eligibility. CONCLUSIONS: We noted improvement in late referrals and early dialysis initiation over time. However, we also noted low and stable use of pre-emptive kidney transplantation and PD at 90 days, which warrants further exploration. These findings support the need for quality improvement initiatives designed to address these gaps in care and improve outcomes for patients with kidney failure.

MISE EN CONTEXTE: Les indicateurs de la qualité, lorsqu'ils s'appuient sur des preuves solides, permettent d'évaluer efficacement la performance d'un système de soins de santé, y compris les soins dispensés aux patients atteints d'insuffisance rénale terminale (IRT). Nous avons examiné les tendances en matière d'indicateurs de la qualité, y compris la proportion de patients orientés tardivement en néphrologie, ainsi que la proportion de patients traités par dialyse péritonéale (DP) ou au moyen d'une greffe de rein comme modalité initiale de remplacement de la fonction rénale. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective. CADRE: L'étude a été menée en Alberta, au Canada. PATIENTS: Il s'agit de patients albertains adultes nouvellement atteints d'IRT et nécessitant une thérapie continue de remplacement rénal. MESURES: Nous avons mesuré la proportion de patients qui n'avait pas vu un néphrologue dans les 90 jours précédant l'amorce de la dialyse (orientation tardive) ; la proportion de patients chez qui on avait amorcé la dialyse à la suite d'une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 et la proportion de patients qui avaient subi une greffe comme modalité initiale de thérapie de remplacement de la fonction rénale et la proportion de ceux qui étaient traités par DP à 90 jours. MÉTHODOLOGIE: Nous avons utilisé des statistiques descriptives, un modèle logarithmique binomial ainsi que des modèles de régression linéaire pour évaluer les tendances des indicateurs de la qualité mentionnés ci-dessus. RÉSULTATS: Notre cohorte était formée de 5343 patients (61,2 % d'hommes) dont l'âge moyen se situait à 61.8 ans. Sur une période de 10 ans, nous avons observé que la proportion d'orientations tardives est passée de 26.4% à 21.1% (P = .001). Nous avons aussi noté une diminution de la proportion de patients chez qui on avait amorcé la dialyse avec une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 (21.2% à 14.7%, P < .001). Toutefois, nous avons constaté une augmentation significative de la proportion de patients chez qui la dialyse avait été amorcée lors d'une hospitalisation (38.8% à 45.2%, P = .001). Enfin, nous avons noté une diminution non significative dans la proportion de patients traités par une greffe comme modalité initiale de remplacement de la fonction rénale ainsi que dans la proportion des patients traités par DP à 90 jours au cours de la même période. LIMITES DE L'ÉTUDE: L'utilisation de données administratives a limité la disponibilité des données cliniques en ce qui concerne les circonstances sous-jacentes à chaque indicateur de la qualité, incluant les symptômes du patient, les indications pour l'initiation de la dialyse et l'admissibilité à la dialyse péritonéale. CONCLUSIONS: Nous avons constaté une amélioration en ce qui concerne les orientations tardives et l'initiation d'une dialyse précoce au fil du temps. Cependant, nous avons remarqué, de façon constante dans le temps, un faible recours à la transplantation rénale comme modalité initiale et à la DP à 90 jours, ce qui devrait faire l'objet d'une étude plus poussée. Ces constatations constituent la première étape d'une proposition pour l'amélioration de la qualité conçue pour réduire les écarts observés au niveau des soins, et visant à améliorer les résultats pour les patients atteints d'insuffisance rénale.

A Population-Based Analysis of Quality Indicators in CKD.

BACKGROUND AND OBJECTIVES: Awareness of CKD remains low in comparison with other chronic diseases, such as diabetes, leading to low use of preventive medications and appropriate testing. The objective of this study was to evaluate the quality of care provided to people with and at risk of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a population-based analysis of all Albertans with eGFR=15-59 ml/min per 1.73 m2 between April 1, 2011 and March 31, 2012 as well as patients with diabetes (as of March 31, 2012). We assessed multiple quality indicators in people with eGFR=15-59 ml/min per 1.73 m2, including appropriate risk stratification with albuminuria testing and preventive medication use and screened people with diabetes using urine albumin-to-creatinine ratio and serum creatinine measurements. RESULTS: Among 96,480 adults with eGFR=15-59 ml/min per 1.73 m2, we found that 17.0% of those without diabetes were appropriately risk stratified with a measure of albuminuria compared with 64.2% of those with diabetes (P<0.001). Of those with eGFR=15-59 ml/min per 1.73 m2 and moderate or severe albuminuria, 63.2% of those without diabetes received an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker compared with 82.1% in those with diabetes (P<0.001). Statin use was also significantly lower in patients with eGFR=15-59 ml/min per 1.73 m2 without diabetes (39.2%) compared with those with diabetes (64.6%; P<0.001). Among 235,649 adults with diabetes, only 41.8% received a urine albumin-to-creatinine ratio and 73.2% received a serum creatinine measurement over 1 year. CONCLUSIONS: We identified large gaps in care, especially in those with CKD but no diabetes. The largest gap was in the prescription of guideline-concordant medication in those with CKD as well as appropriate screening for albuminuria in those with diabetes. Our work illustrates the importance of measuring health system performance as the first step in a quality improvement process to improve care and outcomes in CKD.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research.

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Developing a Set of Core Outcomes for Trials in Hemodialysis: An International Delphi Survey.

BACKGROUND: Survival and quality of life for patients on hemodialysis therapy remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. The aim of this project was to generate a consensus-based prioritized list of core outcomes for trials in hemodialysis. STUDY DESIGN: In a Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale in round 1 and then re-rated outcomes in rounds 2 and 3 after reviewing other respondents' scores. For each outcome, the median, mean, and proportion rating as 7 to 9 (critically important) were calculated. SETTING & PARTICIPANTS: 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed round 1, with 838 (71%) completing round 3. OUTCOMES & MEASUREMENTS: Outcomes included in the potential core outcome set met the following criteria for both patients/caregivers and health professionals: median score ≥ 8, mean score ≥ 7.5, proportion rating the outcome as critically important ≥ 75%, and median score in the forced ranking question < 10. RESULTS: Patients/caregivers rated 4 outcomes higher than health professionals: ability to travel, dialysis-free time, dialysis adequacy, and washed out after dialysis (mean differences of 0.9, 0.5, 0.3, and 0.2, respectively). Health professionals gave a higher rating for mortality, hospitalization, decrease in blood pressure, vascular access complications, depression, cardiovascular disease, target weight, infection, and potassium (mean differences of 1.0, 1.0, 1.0, 0.9, 0.9, 0.8, 0.7, 0.4, and 0.4, respectively). LIMITATIONS: The Delphi survey was conducted online in English and excludes participants without access to a computer and internet connection. CONCLUSIONS: Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. The prioritized outcomes for both groups were vascular access problems, dialysis adequacy, fatigue, cardiovascular disease, and mortality. This process will inform a core outcome set that in turn will improve the relevance, efficiency, and comparability of trial evidence to facilitate treatment decisions.