Shared decision-making in advanced chronic kidney disease in the elderly

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E.R.C: enfermedad renal crónica." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel Heras Benito, María José Fernández-Reyes Luis" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Manuel" "apellidos" => "Heras Benito" ] 1 => array:2 [ "nombre" => "María José" "apellidos" => "Fernández-Reyes Luis" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S238702061930035X" "doi" => "10.1016/j.medcle.2019.01.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061930035X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775318305165?idApp=UINPBA00004N" "url" => "/00257753/0000015200000005/v1_201902150608/S0025775318305165/v1_201902150608/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020619300361" "issn" => "23870206" "doi" => "10.1016/j.medcle.2018.07.019" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "4618" "copyright" => "Elsevier España, S.L.U." 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"documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2019;152:185-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Editorial article" "titulo" => "Diagnostic role of tumor markers" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "185" "paginaFinal" => "187" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel diagnóstico de los marcadores tumorales" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco Javier Mérida de la Torre, Elvira Eva Moreno Campoy" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Mérida de la Torre" ] 1 => array:2 [ "nombre" => "Elvira Eva" "apellidos" => "Moreno Campoy" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775318306377" "doi" => "10.1016/j.medcli.2018.10.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775318306377?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619300385?idApp=UINPBA00004N" "url" => "/23870206/0000015200000005/v1_201902230639/S2387020619300385/v1_201902230639/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Shared decision-making in advanced chronic kidney disease in the elderly" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "188" "paginaFinal" => "194" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manuel Heras Benito, María José Fernández-Reyes Luis" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Manuel" "apellidos" => "Heras Benito" "email" => array:1 [ 0 => "mherasb@saludcastillayleon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "María José" "apellidos" => "Fernández-Reyes Luis" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital General de Segovia, Segovia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1667 "Ancho" => 2173 "Tamanyo" => 291478 ] ] "descripcion" => array:1 [ "en" => "Multidisciplinary approach in the decision-making process. CKD: chronic kidney disease." ] ] ] "textoCompleto" => "IntroductionChronic kidney disease (CKD) is considered a public health problem.<a class="elsevierStyleCrossRef" href="#bib0285">1</a> The majority of epidemiological studies have shown a high prevalence of CKD in people aged 65 and over.<a class="elsevierStyleCrossRefs" href="#bib0290">2,3</a> The latest 2016 dialysis and transplantation registry report from the Spanish Nephrology Society, states that the incidence rate of patients with CKD at a stage of terminal nephropathy exceeds 400 cases per million people (pmp) in people aged over 65; the maximum incidence rate – 455.2 pmp – occurs in those over 75.<a class="elsevierStyleCrossRef" href="#bib0300">4</a> This trend will probably continue to increase in the coming years as a consequence of our ageing population.However, the development of dialysis techniques, improvement in monitors and dialysis membranes, and its generalisation in most developed countries, has led to the universalisation of renal replacement therapy (RRT). Thus, chronological age by itself does not suppose an absolute contraindication to perform some form of RRT in elderly patients with CKD who reach the stage of terminal nephropathy.<a class="elsevierStyleCrossRefs" href="#bib0305">5,6</a> In Spain, among the prevalent patients with terminal nephropathy, in the 65–74 age range, SDT is distributed approximately in equal proportion between a certain dialysis modality (hemodialysis or peritoneal dialysis) and renal transplantation; however, in patients 75 years or older hemodialysis represents the most frequent form of RRT.<a class="elsevierStyleCrossRef" href="#bib0300">4</a> Another therapeutic modality that can be offered to these patients is renal conservative treatment, i.e. implementing measure that slow renal progression (use of antiproteinuric drugs, avoiding nephrotoxicity, etc.) as well as medical treatment for complications associated with CKD (anaemia, acidosis metabolic, bone-mineral metabolism alterations, etc.), except for the purification of uraemic toxins. This conservative renal treatment is becoming increasingly common in nephrology. Records are unfortunately not yet centralised, so experiences with this modality is on an individual basis for each centre.The possibility of having various therapeutic options to treat terminal stage CKD is, a priori, an advantage for these patients. However, it can generate conflicts when the most appropriate therapeutic modality must be chosen, especially if stage 5 CKD has been reached and no advance care planning has been carried out. To avoid these conflict situations, the patient should be informed about their illness and the different therapeutic options that exists, together with their risks and benefits, so that their preferences when deciding or planning how to treat their illness can be considered (shared decision-making).<a class="elsevierStyleCrossRef" href="#bib0315">7</a> This review will analyse the following: the process of informing elderly patients with advanced CKD (glomerular filtration rate <30ml/min/1.73m2); aspects related to the decision-making process, including the different modalities of terminal CKD treatment options, and, finally, when to initiate or withdraw dialysis in patients who have chosen this modality.Considerations to be taken prior to the decision-making processThe decision-making process in elderly patients with advanced CKD can be complex: in addition to assessing renal parameters, such as the degree of glomerular filtration and uraemic symptoms, other factors that can burden the decision-making process also need to be considered, such as high multimorbidity and geriatric syndromes (fragility, disability, cognitive impairment).<a class="elsevierStyleCrossRefs" href="#bib0320">8,9</a> Other aspects that should be considered in the decision-making process are:First, age affects the CKD prognosis. A study by O’Hare et al.<a class="elsevierStyleCrossRef" href="#bib0330">10</a> analysed more than 200,000 American veterans with CKD stage 3–5, with a follow-up of 3.2 years and described the modulating effect of age on kidney disease: for a comparable glomerular filtration rate level, as age increases, the risk of mortality exceeds that of renal progression to terminal nephropathy. In this study, younger patients with a glomerular filtration rate of lower than 45ml/min/1.73m2 showed a higher risk of progression to renal mortality; conversely, in 85-year-old patients, the risk of mortality exceeded that of renal progression to terminal nephropathy, regardless of their glomerular filtration rate.Second, the CKD progression rate. Some authors have reported that renal deterioration in elderly patients with CKD is slow, especially in those without proteinuria.<a class="elsevierStyleCrossRefs" href="#bib0335">11,12</a> Conversely, its presence, together with frequent episodes of acute renal failure and/or heart failure, are markers of increased renal deterioration.<a class="elsevierStyleCrossRef" href="#bib0345">13</a> These aspects are key to deciding the most appropriate therapeutic modality, and can assist in assessing dialysis preparation, in case of opting for this modality of RRT.<a class="elsevierStyleCrossRef" href="#bib0350">14</a> In addition to professional integrity, where health professionals’ knowledge and experience are valued, it is essential to respect the ethical principles of patient autonomy, beneficence and non-maleficence, as well as the principle of justice, in order to reach a decision together.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Current evidence suggests that the decision to initiate dialysis is frequently indicated by the doctor rather than the result of a shared conversation after the patient has been informed and their preferences have been considered.<a class="elsevierStyleCrossRef" href="#bib0325">9</a> In a study by Davison,<a class="elsevierStyleCrossRef" href="#bib0360">16</a> up to 61% of patients who had initiated dialysis regretted the decision. Therefore, from an ethical perspective, not everything that can technically be done, should be done.<a class="elsevierStyleCrossRef" href="#bib0365">17</a>Key elements in the decision-making process with patients with chronic kidney diseaseChoosing between certain treatment modalities with patients with advanced CKD should be carried in a multidisciplinary manner, and ensure a consensus between medical recommendations and patient preferences; it must also consider patients’ quality of life and other contextual elements,<a class="elsevierStyleCrossRef" href="#bib0320">8</a> as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Medical recommendationsThe benefit derived from applying a specific treatment for each patient is the basis of any medical indication. Before establishing a medical recommendation in elderly patients with advanced CKD, in addition to laboratory parameters and symptoms, a situation diagnosis should be made through a multidimensional assessment (comprehensive geriatric assessment).<a class="elsevierStyleCrossRefs" href="#bib0320">8,9,18,19</a>ComorbidityThe prevalence of multimorbidity is increasing due to our ageing population. Thus, elderly patients with advanced CKD have high comorbidity and polypharmacy which affects prognosis.<a class="elsevierStyleCrossRef" href="#bib0380">20</a> The Charlson comorbidity index has traditionally been the tool used to establish comorbidity, the higher the patient's score, the worse their prognosis.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>FragilityFragility is a multidimensional clinical entity that is defined as a state of vulnerability to stressors, conditioned by the limitation of compensatory mechanisms which, although dynamic over time and potentially modifiable, place the individual in a situation of high health risk.<a class="elsevierStyleCrossRef" href="#bib0390">22</a> This results in weakness and sarcopenia, and thus the patient has a greater risk of falling and being hospitalised, is more dependent and has a higher mortality.<a class="elsevierStyleCrossRefs" href="#bib0395">23,24</a> Its prevalence increases with age (in patients aged over 85, this rate can be as high as 25%). Furthermore, in renal patients, other factors – such as anaemia, inflammation and oxidative stress, together with malnutrition (diets low in protein that try to preserve renal function, or anorexia) – may contribute to the prevalence of frailty being greater than in the general population.<a class="elsevierStyleCrossRef" href="#bib0395">23</a> For this reason, carrying out fragility screening in patients older than 70, especially in vulnerable patients such as renal patients, is recommended.<a class="elsevierStyleCrossRefs" href="#bib0385">21,23</a> The Fried Frailty Index is often useful for fragility screening, which considers it to be a syndrome based on various criteria – involuntary weight loss, weakness, tiredness, slowness and decreased activity; a fragile patient is one who accumulates ≥3 items.<a class="elsevierStyleCrossRef" href="#bib0405">25</a>However, in people with complex clinical situations where decisions can be difficult, the Rockwood and Mitnitski<a class="elsevierStyleCrossRef" href="#bib0410">26</a> frailty index, which defines fragility by deficit accumulation, is increasingly gaining more importance.<a class="elsevierStyleCrossRef" href="#bib0415">27</a> This new, more dynamic model suggests that as people get older, they tend to accumulate chronic diseases and situations, which in turn imply a dysfunction in their physiological reserve and, therefore, deficits at cognitive, functional or nutritional levels. The quantification of these deficits at a specific moment determines their frailty index (FI), which facilitates stratifying risk in an individualised manner; the higher the patient's FI, the more vulnerable they are; FI values of >0.7 are considered incompatible with life.<a class="elsevierStyleCrossRef" href="#bib0415">27</a> Thus, knowing a patient's level of fragility provides more detailed information about their reserve (‘biological age’) than chronological age does: its clinical measurement is a helpful tool that can assist in designing adequate therapeutic objectives to establish a balance between patients’ clinical situation and their preferences.<a class="elsevierStyleCrossRef" href="#bib0415">27</a>Functional statusFunctional status is understood to be an important clinical marker in kidney disease.<a class="elsevierStyleCrossRef" href="#bib0420">28</a> Functional impairment, or inability to perform basic or instrumental activities in daily life, is common in patients who initiate dialysis, and it continues to deteriorate in patients who continue with dialysis.<a class="elsevierStyleCrossRef" href="#bib0325">9</a> Kurella et al.<a class="elsevierStyleCrossRef" href="#bib0425">29</a> studied the functional status of 3702 elderly people (mean age 73.4) living in residences before and after initiating dialysis. They concluded that initiating dialysis was associated with a significant and sustained decrease in these patients’ functional status, in addition to a mortality rate of 58% at 12 months from the start of dialysis. Similarly, a study by Jassal et al.<a class="elsevierStyleCrossRef" href="#bib0430">30</a> performed in a cohort of octogenarian patients, described the loss of independence after initiating dialysis.Cognitive statusCognitive deterioration has also been associated with the worsening of renal function.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> Guerrero et al.<a class="elsevierStyleCrossRef" href="#bib0440">32</a> showed lower scores on the Mini–Mental State Examination (MMSE) test in elderly patients with glomerular filtration rate MDRD <60ml/min/1.73m2.Disease evolutionCKD (organ failure) is characterised by a chronic deterioration over months or years, with intermittent acute episodes of deterioration, associated with hospitalisation or appearance of new events, whose outcome may be recovery – with a deterioration of previous state – or death. Given these patients’ high multimorbidity, new diseases may appear (neoplasms) and other disease evolutions may overlap, hindering the prediction of its clinical course and its prognosis.<a class="elsevierStyleCrossRef" href="#bib0320">8</a>Survival analysis according to indication of conservative renal treatment versus dialysisSeveral studies comparing conservative renal treatment versus dialysis shows greater survival using dialysis when the cohort is considered globally.<a class="elsevierStyleCrossRefs" href="#bib0445">33–35</a> However, when individual variables are studied separately, such as patients older than 80,<a class="elsevierStyleCrossRef" href="#bib0455">35</a> a greater functional impairment,<a class="elsevierStyleCrossRef" href="#bib0455">35</a> high comorbidity<a class="elsevierStyleCrossRefs" href="#bib0445">33,34</a> or the presence of heart disease,<a class="elsevierStyleCrossRef" href="#bib0445">33</a> the benefits of dialysis in terms of survival are not much better than conservative renal treatment. A study by Wongrakpanich et al.<a class="elsevierStyleCrossRef" href="#bib0460">36</a> carried out a systematic review of 12 studies (prospective and retrospective) that included more than 11,000 patients with stage 5 CKD, and found that the median survival for patients who underwent conservative treatment was 6–30months compared to 8–67months for dialysis, with dialysis patients being younger and with better functional status, and concluded that efforts should focus on promoting patient values and preferences and reaching a shared decision on the most appropriate treatment modality suitable for each patient individually.Shared decision makingOnce the situational diagnosis has been established, the patient's perspective, preferences and/or goals in life, as well as their quality of life, should be measured. Addressing the management of information and verifying to what extent the patient/caregiver has understood the information provided is also important. Support tools can be useful for reaching a consensus in the decision-making process.The main issues that need to be decided with the patient/caregiver are: (1) how information is managed; (2) decisions regarding the different therapeutic options in advanced CKD: choice of conservative treatment versus RRT with dialysis or transplantation, and (3) for patients who decide to be treated with dialysis: initiation and/or removal times.Patient preferences and quality of lifeThe purposes of interviews during the advanced stages of CKD are to provide information and educate the patient in aspects related to their kidney disease and to understand what patients’ objectives, goals, preferences, values and lifestyle choices are, thus respecting the principle of patient autonomy.<a class="elsevierStyleCrossRefs" href="#bib0320">8,37</a>Because any illness or injury that compromises life can affect the patient's quality of life, they are who can best assess their own quality of life.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> In the case of patients with CKD, when deciding whether to undergo conservative treatment or RRT, all the benefits (not only in terms of survival) should be considered, in addition to the quality of life resulting from either modality; and once the decision is taken, the autonomy of the patient should be respected. There are different tools available to assess quality of life, such as the Short Form SF-36 questionnaire, which assesses physical, social and mental aspects, the Hospital Anxiety and Depression Scale and the Satisfaction with Life Scale.<a class="elsevierStyleCrossRef" href="#bib0470">38</a> It may also be helpful to ask short questions to explore quality of life, such as: Has anyone from your family or friends received dialysis treatment? What was seeing them on dialysis like<a class="elsevierStyleCrossRef" href="#bib0320">8</a>? A variety of studies analysing the quality of life of patients undergoing conservative renal treatment or dialysis have found that, although the burden of symptoms at the beginning is significant for patients who choose conservative treatment, with the help of palliative care it is possible to improve the control of symptoms and maintain quality of life.<a class="elsevierStyleCrossRefs" href="#bib0470">38,39</a>Information management and patient educationThrough personal interviews, a study carried out in Spain analysed the information and choice process of the RRT modality in a group of patients with CKD. This study was conclusive and highlighted the lack of information patients receive, as well as the little time dedicated to providing them with information material or responding to their doubts. In addition, 42% of patients who were on hemodialysis indicated that this modality had been imposed on them. Another aspect that should be noted is the lack of understanding about how dialysis techniques work as age increases.<a class="elsevierStyleCrossRef" href="#bib0480">40</a>The process of providing information on CKD and its therapeutic modalities to patients in advanced stages should be initiated early, since the worsening of renal function can be associated with worse cognitive capacity.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> However, the fact that an excess of information can generate uncertainty and be futile, especially in patients with high multimorbidity, who are at risk of dying from other non-renal processes and with preserved renal function, should also be noted. In this sense, when considering the amount of information to provided patients with, both the renal progression rate and the presence of multimorbidity should be borne in mind. Thus, in patients with slow renal deterioration but with high multimorbidity, the amount of information given should be low. Conversely, patients with rapid renal deterioration and little multimorbidity are at risk of reaching terminal nephropathy and might receive some type of RRT, so preparing them by providing exhaustive information is recommended. In the other categories – slow progression/low multimorbidity and rapid progression/high multimorbidity – information management should be personalised.In recent years predictive equations have been developed for progression to ESRD, such as the Kidney Failure Risk Equation,<a class="elsevierStyleCrossRef" href="#bib0485">41</a> and mortality at 5 years, which considers nine variables (age, sex, race, glomerular filtration rate, protein/creatinine ratio, tobacco consumption, diabetes mellitus, stroke and heart failure),<a class="elsevierStyleCrossRef" href="#bib0490">42</a> which can be useful tools when deciding who and how to inform.Ensuring the patient is sufficiently informed must be accompanied by ensuring they have understood the information that has been provided to them, given that decline in comprehension skills is normal in advanced ages.<a class="elsevierStyleCrossRef" href="#bib0480">40</a> In addition, senses such as vision, hearing, as well as other functions (executive, cognitive, orientation in space), can also be affected by normal ageing and hinder understanding and education and, consequently, the decision-making process.<a class="elsevierStyleCrossRef" href="#bib0495">43</a> Likewise, these patients with CKD usually have a high burden of anxiety and depression which can negatively affect their ability to retain information. The participation of a multidisciplinary team, establishing strategies to mitigate these barriers in the elderly (use of glasses, hearing aids, correct lighting, adequate font size), strategies to improve communication (use of direct and concise language) and carrying out anxiety/depression screening, are the key to incorporating patients’ values and preference in the decision-making process.<a class="elsevierStyleCrossRefs" href="#bib0495">43–45</a> Regarding compliance with treatments or indications, adherence can be improved by simplifying instructions, reinforcing behaviours and involving a caregiver.<a class="elsevierStyleCrossRef" href="#bib0495">43</a>Contextual elementsThe patient can be both positively or negatively influenced by other contextual aspects – social, economic, psychological or spiritual – which can affect the decision-making process. Awareness of these aspects, and their resolution should they be conflictive, can also support the decision-making process.<a class="elsevierStyleCrossRef" href="#bib0320">8</a>Tools that support the decision-making processA shared decision (medical recommendations and patients’ preferences) can be reached through carrying out an educational process with a multidisciplinary team (nephrologist, nurse, social worker and psychologist, among others) and the help of decision-making tools.<a class="elsevierStyleCrossRefs" href="#bib0315">7,46</a> Some of these tools include the following guides: “Dialysis: making the decisions that best suit you” (a dialysis decision-making guide, available at www.senefro.org),<a class="elsevierStyleCrossRef" href="#bib0515">47</a> or “Chronic kidney disease: what treatment is best for me?” (a guide prepared by the Junta de Andalucía, Regional Ministry of Health).<a class="elsevierStyleCrossRef" href="#bib0520">48</a> These tools provide information on CKD and explain the risks and benefits of the different treatment modalities as well as the options the patient has according to their profile and lifestyle, so that they can reach a viable conclusion. The implementation of a systematic educational process, together with the aforementioned tools, can ensure a high level of agreement between the chosen and the end modalities.<a class="elsevierStyleCrossRef" href="#bib0510">46</a>No initiation, initiation or withdrawal from dialysisNo initiation of dialysisThe patient, previously informed of the risks and benefits of dialysis and who has the ability to make decisions, can chose not to initiate dialysis when there is a situation of terminal nephropathy and the need for dialysis could arise<a class="elsevierStyleCrossRef" href="#bib0525">49</a>; and should they be unable to express this rejection, it could be requested through an advanced directives document or the patient's legal representative Furthermore, certain medical situations, such as irreversible neurological problems or terminal (non-renal) processes, also contraindicate entry into the RRT programme.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Initiation of dialysisMathematical formulas derived from serum creatinine or Cystatin C facilitates early detection of CKD.<a class="elsevierStyleCrossRef" href="#bib0530">50</a> However, these mathematical formulas are inaccurate and have not yet been validated in the elderly, so could possibly produce errors in diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0530">50,51</a> The glomerular filtration rate value should not be the only parameter to indicate dialysis in patients who have chosen this treatment modality: the analysis of other analytical parameters (potassium, bicarbonate, etc.) together with their symptomatology should also be considered when making this decision.<a class="elsevierStyleCrossRefs" href="#bib0310">6,8</a> The main symptoms that could justify the initiation of dialysis include: oliguria or anuria – which lead to volume overload – refractory to intensive diuretic treatment, severe metabolic acidosis and hyperkalaemia, uraemic pericarditis or significant nutritional deterioration associated with restrictive diets for renal preservation.<a class="elsevierStyleCrossRef" href="#bib0310">6</a>Regarding whether to initiate dialysis early or later, some studies have pointed out that initiating early (with a higher level of glomerular filtration) could be detrimental in the elderly when there is a loss of residual renal function.<a class="elsevierStyleCrossRefs" href="#bib0325">9,52,53</a>On the other hand, in situations of acute renal failure that may occur during the hospitalisation of patients with advanced CKD, the need for ‘acute’ dialysis may be debated. These situations should be debated in initial conversations regarding the therapeutic options available for CKD. Also, in cases of doubt about the treatments, or when patients have acute renal failure, dialysis as a test could be indicated, with marked objectives and for a limited time. This could offer prognostic utility for patients who recover renal function after acute renal failure by providing information on chronic dialysis; it is therefore another tool to support the decision-making process.<a class="elsevierStyleCrossRefs" href="#bib0310">6,49</a>Withdrawal from dialysisA treatment is not indicated if it causes damage or worsens the quality of life. The use of RRT can be called into question if it does not improve patients’ who are terminally ill quality of life, or it causes suffering and a significant burden for the family.<a class="elsevierStyleCrossRefs" href="#bib0355">15,49</a> The appearance of a new serious disease that may affect the short-term vital prognosis (cancer) or the presence of a new morbidity during the dialysis period, such as calciphylaxis, stroke, amputations, dementia or haemodynamic instability during the dialysis technique, may lead to a possible withdrawal from dialysis.<a class="elsevierStyleCrossRef" href="#bib0550">54</a> Generally, if the patient is cognitively able to and states their willingness to withdraw from dialysis or there is an advanced directives document, their decision should be respected, thus preventing conflict.<a class="elsevierStyleCrossRef" href="#bib0525">49</a> However, it is common for patients with advanced CKD or on dialysis to be unaware of their illness and not plan for the end of life.<a class="elsevierStyleCrossRef" href="#bib0525">49</a> In these cases, once the dialysis is initiated there may be conflicts when it comes to withdrawing the dialysis, between the professional (who is aware that without dialysis death may occur within one day or several months, depending on the presence or absence of residual kidney function) and the family or caregivers. For the resolution of these difficult cases of dialysis withdrawal, the help of the an ethics committees can be another tool in the decision-making process.<a class="elsevierStyleCrossRefs" href="#bib0355">15,54</a>Palliative care and advanced chronic kidney diseaseThe application of the principles of palliative care and end-of-life care is essential for a comprehensive and multidisciplinary approach to caring for patients with advanced CKD and terminal nephropathy, and should begin in the initial stages of the disease and continue until the patient's death and the mourning period.<a class="elsevierStyleCrossRefs" href="#bib0320">8,55</a>In addition to the specific symptoms of their disease (anaemia or electrolyte abnormalities), renal patients also usually present other nonspecific symptoms, such as pain, sleep disturbances, digestive disorders or mood disorders (which may worsen before death).<a class="elsevierStyleCrossRefs" href="#bib0320">8,55</a> In addition, some symptoms can be difficult to recognise (particularly in professionals with little experience in kidney disease), and their lack of detection can have a negative impact on the patient's quality of life.<a class="elsevierStyleCrossRef" href="#bib0560">56</a> The participation of a palliative care multidisciplinary team would not only facilitate appropriate treatment of the current symptoms, but would also help in identifying them earlier, which can contribute to improving the patient and their family's quality of life. The use of supportive tools such as the Palliative Care Outcome Scale-Symptoms Modified for renal patients (POS-S renal) scale may be useful for addressing these patients’ symptoms.<a class="elsevierStyleCrossRef" href="#bib0560">56</a>Furthermore, these patients present other needs that should also be addressed with palliative care, such as psychosocial and spiritual support and education for both the patient and the family/caregivers.Additionally, establishing an anticipated care plan, that focuses mainly on the patient (rather than the disease) is of interest; it should improve communication between the multidisciplinary team and the patient and/or family, and clearly outline the patient's preferences and wishes for their end of life. This plan should be carried out after honest and realistic information of their status has been given.<a class="elsevierStyleCrossRef" href="#bib0560">56</a> This anticipated care plan should begin from the moment the answer to the following question is ‘no’: “Would you be surprised if this patient died within 6–12months?”<a class="elsevierStyleCrossRef" href="#bib0320">8</a>ConclusionsDecision making in elderly patients with advanced chronic kidney disease is complex: in addition to glomerular filtration and uraemic symptoms, multimorbidity and geriatric syndromes (fragility, cognitive impairment, disability) must also be considered. Care includes the management of information, the choice of treatment modality (conservative or renal replacement therapy) and the time of initiating and/or withdrawal from dialysis. A multidisciplinary approach, within the framework of bioethical principles, can help reach a shared consensus in the decision-making process between medical indication and the patient's preferences.<elsevierMultimedia ident="tb0005"></elsevierMultimedia>Conflict of interestThere are no conflicts of interest or financing." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1154512" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1082264" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1154511" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1082265" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Considerations to be taken prior to the decision-making process" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Key elements in the decision-making process with patients with chronic kidney disease" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Medical recommendations" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Comorbidity" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Fragility" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Functional status" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Cognitive status" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Disease evolution" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Survival analysis according to indication of conservative renal treatment versus dialysis" ] ] ] 1 => array:3 [ "identificador" => "sec0055" "titulo" => "Shared decision making" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Patient preferences and quality of life" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Information management and patient education" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Contextual elements" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Tools that support the decision-making process" ] ] ] ] ] 7 => array:3 [ "identificador" => "sec0080" "titulo" => "No initiation, initiation or withdrawal from dialysis" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "No initiation of dialysis" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Initiation of dialysis" ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Withdrawal from dialysis" ] ] ] 8 => array:2 [ "identificador" => "sec0100" "titulo" => "Palliative care and advanced chronic kidney disease" ] 9 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-12" "fechaAceptado" => "2018-07-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1082264" "palabras" => array:5 [ 0 => "Advanced chronic kidney disease" 1 => "Shared-decision-making" 2 => "Elderly" 3 => "Renal conservative treatment" 4 => "Renal replacement therapy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1082265" "palabras" => array:5 [ 0 => "Enfermedad renal crónica avanzada" 1 => "Toma de decisiones compartida" 2 => "Ancianos" 3 => "Tratamiento conservador renal" 4 => "Tratamiento renal sustitutivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Chronic kidney disease is common in people >65 years of age. The development and improvement of dialysis techniques has allowed its generalisation to the entire population, when there is a situation of terminal nephropathy, without limit of use due to chronological age. Decision making in elderly patients with advanced chronic kidney disease is complex: in addition to renal parameters, both comorbidity and the presence of geriatric syndromes must be considered. This review addresses the management of information, the decision making of different treatment modalities that can be offered to these patients, and the time of initiation and/or withdrawal of dialysis." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La enfermedad renal crónica es frecuente en personas >65 años. El desarrollo y el perfeccionamiento de técnicas de diálisis ha permitido su generalización a toda la población cuando se llega a una situación de nefropatía terminal, sin existir límite de uso por la edad cronológica. La toma de decisiones en ancianos con enfermedad renal crónica avanzada es compleja: además de parámetros renales se debe considerar la comorbilidad, así como la presencia de síndromes geriátricos. En esta revisión se aborda la gestión de la información, la toma de decisión de diferentes modalidades de tratamiento que se pueden ofertar a estos pacientes y el momento de inicio y/o retirada de diálisis." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Heras Benito M, Fernández-Reyes Luis MJ. Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Med Clin (Barc). 2019;152:188–194." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1667 "Ancho" => 2173 "Tamanyo" => 291478 ] ] "descripcion" => array:1 [ "en" => "Multidisciplinary approach in the decision-making process. CKD: chronic kidney disease." ] ] 1 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "Key points<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•In decision making with elderly patients who have advanced chronic kidney disease, the health professional should consider multimorbidity and geriatric syndromes (fragility, cognitive status, etc.) in addition to the glomerular filtration value and uraemic symptoms; establishing a situational diagnosis using an integral geriatric assessment is essential.</li><li class="elsevierStyleListItem" id="lsit0010">•The renal deterioration progression rate and comorbidity, together with prediction equations for terminal nephropathy and/or mortality, are tools that can support the management of information.</li><li class="elsevierStyleListItem" id="lsit0015">•Issues that must be considered during the treatment modality (conservative or renal replacement therapy) decision-making process are: medical indications, patient preferences, quality of life and contextual aspects.</li><li class="elsevierStyleListItem" id="lsit0020">•Overall, renal replacement therapy with dialysis offers advantages in terms of survival compared to conservative renal treatment. These advantages are lost with advanced ages (over 80), in patients with high comorbidity and heart disease, as well as in dependent patients.</li><li class="elsevierStyleListItem" id="lsit0025">•Treatment with dialysis is not indicated if the patient – who has been previously informed of this technique and who has the ability to make decisions – chooses not to perform dialysis, and in certain irreversible situations.</li><li class="elsevierStyleListItem" id="lsit0030">•Dialysis will be initiated when there is uraemic symptomatology. Early initiation (with more glomerular filtration) can be harmful as it causes loss of residual renal function.</li><li class="elsevierStyleListItem" id="lsit0035">•Withdrawal from dialysis can be considered when it no longer provides a benefit to the patient and does not improve their quality of life. Ethics committees can be useful in cases where there is a conflict regarding whether to withdraw dialysis between professionals and the family/caregivers, when the patient does not have the capacity to decide and/or there is also no anticipated directives document or an assigned legal representative.</li></ul>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:56 [ 0 => array:3 [ "identificador" => "bib0285" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic kidney disease as a global public health problem: approaches and initiatives — a position statement from Kidney Disease Improving Global Outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.S. Levey" 1 => "R. Atkins" 2 => "J. Coresh" 3 => "E.P. Cohen" 4 => "A.J. Collins" 5 => "K.-U. 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Shared decision-making in advanced chronic kidney disease in the elderly

Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano

Manuel Heras Benito

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mherasb@saludcastillayleon.es

Corresponding author.

, María José Fernández-Reyes Luis

Servicio de Nefrología, Hospital General de Segovia, Segovia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic kidney disease &#40;CKD&#41; is considered a public health problem&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">1</span></a> The majority of epidemiological studies have shown a high prevalence of CKD in people aged 65 and over&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">2&#44;3</span></a> The latest 2016 dialysis and transplantation registry report from the Spanish Nephrology Society&#44; states that the incidence rate of patients with CKD at a stage of terminal nephropathy exceeds 400 cases per million people &#40;pmp&#41; in people aged over 65&#59; the maximum incidence rate &#8211; 455&#46;2 pmp &#8211; occurs in those over 75&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">4</span></a> This trend will probably continue to increase in the coming years as a consequence of our ageing population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; the development of dialysis techniques&#44; improvement in monitors and dialysis membranes&#44; and its generalisation in most developed countries&#44; has led to the universalisation of renal replacement therapy &#40;RRT&#41;&#46; Thus&#44; chronological age by itself does not suppose an absolute contraindication to perform some form of RRT in elderly patients with CKD who reach the stage of terminal nephropathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">5&#44;6</span></a> In Spain&#44; among the prevalent patients with terminal nephropathy&#44; in the 65&#8211;74 age range&#44; SDT is distributed approximately in equal proportion between a certain dialysis modality &#40;hemodialysis or peritoneal dialysis&#41; and renal transplantation&#59; however&#44; in patients 75 years or older hemodialysis represents the most frequent form of RRT&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">4</span></a> Another therapeutic modality that can be offered to these patients is renal conservative treatment&#44; i&#46;e&#46; implementing measure that slow renal progression &#40;use of antiproteinuric drugs&#44; avoiding nephrotoxicity&#44; etc&#46;&#41; as well as medical treatment for complications associated with CKD &#40;anaemia&#44; acidosis metabolic&#44; bone-mineral metabolism alterations&#44; etc&#46;&#41;&#44; except for the purification of uraemic toxins&#46; This conservative renal treatment is becoming increasingly common in nephrology&#46; Records are unfortunately not yet centralised&#44; so experiences with this modality is on an individual basis for each centre&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The possibility of having various therapeutic options to treat terminal stage CKD is&#44; a priori&#44; an advantage for these patients&#46; However&#44; it can generate conflicts when the most appropriate therapeutic modality must be chosen&#44; especially if stage 5 CKD has been reached and no advance care planning has been carried out&#46; To avoid these conflict situations&#44; the patient should be informed about their illness and the different therapeutic options that exists&#44; together with their risks and benefits&#44; so that their preferences when deciding or planning how to treat their illness can be considered &#40;shared decision-making&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">7</span></a> This review will analyse the following&#58; the process of informing elderly patients with advanced CKD &#40;glomerular filtration rate <span class="elsevierStyleMonospace">&#60;</span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#59; aspects related to the decision-making process&#44; including the different modalities of terminal CKD treatment options&#44; and&#44; finally&#44; when to initiate or withdraw dialysis in patients who have chosen this modality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Considerations to be taken prior to the decision-making process</span><p id="par0020" class="elsevierStylePara elsevierViewall">The decision-making process in elderly patients with advanced CKD can be complex&#58; in addition to assessing renal parameters&#44; such as the degree of glomerular filtration and uraemic symptoms&#44; other factors that can burden the decision-making process also need to be considered&#44; such as high multimorbidity and geriatric syndromes &#40;fragility&#44; disability&#44; cognitive impairment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;9</span></a> Other aspects that should be considered in the decision-making process are&#58;</p><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; <span class="elsevierStyleItalic">age affects the CKD prognosis&#46;</span> A study by O&#8217;Hare et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">10</span></a> analysed more than 200&#44;000 American veterans with CKD stage 3&#8211;5&#44; with a follow-up of 3&#46;2 years and described the <span class="elsevierStyleItalic">modulating effect of age</span> on kidney disease&#58; for a comparable glomerular filtration rate level&#44; as age increases&#44; the risk of mortality exceeds that of renal progression to terminal nephropathy&#46; In this study&#44; younger patients with a glomerular filtration rate of lower than 45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> showed a higher risk of progression to renal mortality&#59; conversely&#44; in 85-year-old patients&#44; the risk of mortality exceeded that of renal progression to terminal nephropathy&#44; regardless of their glomerular filtration rate&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Second&#44; <span class="elsevierStyleItalic">the CKD progression rate&#46;</span> Some authors have reported that renal deterioration in elderly patients with CKD is slow&#44; especially in those without proteinuria&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">11&#44;12</span></a> Conversely&#44; its presence&#44; together with frequent episodes of acute renal failure and&#47;or heart failure&#44; are markers of increased renal deterioration&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a> These aspects are key to deciding the most appropriate therapeutic modality&#44; and can assist in assessing dialysis preparation&#44; in case of opting for this modality of RRT&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">14</span></a> In addition to professional integrity&#44; where health professionals&#8217; knowledge and experience are valued&#44; it is essential to respect the ethical principles of patient autonomy&#44; beneficence and non-maleficence&#44; as well as the principle of justice&#44; in order to reach a decision together&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Current evidence suggests that the decision to initiate dialysis is frequently indicated by the doctor rather than the result of a shared conversation after the patient has been informed and their preferences have been considered&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> In a study by Davison&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">16</span></a> up to 61&#37; of patients who had initiated dialysis regretted the decision&#46; Therefore&#44; from an ethical perspective&#44; not everything that can technically be done&#44; should be done&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Key elements in the decision-making process with patients with chronic kidney disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">Choosing between certain treatment modalities with patients with advanced CKD should be carried in a multidisciplinary manner&#44; and ensure a consensus between medical recommendations and patient preferences&#59; it must also consider patients&#8217; quality of life and other contextual elements&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a> as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Medical recommendations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The benefit derived from applying a specific treatment for each patient is the basis of any medical indication&#46; Before establishing a medical recommendation in elderly patients with advanced CKD&#44; in addition to laboratory parameters and symptoms&#44; a situation diagnosis should be made through a multidimensional assessment &#40;comprehensive geriatric assessment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;9&#44;18&#44;19</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Comorbidity</span><p id="par0050" class="elsevierStylePara elsevierViewall">The prevalence of multimorbidity is increasing due to our ageing population&#46; Thus&#44; elderly patients with advanced CKD have high comorbidity and polypharmacy which affects prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">20</span></a> The Charlson comorbidity index has traditionally been the tool used to establish comorbidity&#44; the higher the patient&#39;s score&#44; the worse their prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fragility</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fragility is a multidimensional clinical entity that is defined as a state of vulnerability to stressors&#44; conditioned by the limitation of compensatory mechanisms which&#44; although dynamic over time and potentially modifiable&#44; place the individual in a situation of high health risk&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">22</span></a> This results in weakness and sarcopenia&#44; and thus the patient has a greater risk of falling and being hospitalised&#44; is more dependent and has a higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">23&#44;24</span></a> Its prevalence increases with age &#40;in patients aged over 85&#44; this rate can be as high as 25&#37;&#41;&#46; Furthermore&#44; in renal patients&#44; other factors &#8211; such as anaemia&#44; inflammation and oxidative stress&#44; together with malnutrition &#40;diets low in protein that try to preserve renal function&#44; or anorexia&#41; &#8211; may contribute to the prevalence of frailty being greater than in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">23</span></a> For this reason&#44; carrying out fragility screening in patients older than 70&#44; especially in vulnerable patients such as renal patients&#44; is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;23</span></a> The Fried Frailty Index is often useful for fragility screening&#44; which considers it to be a syndrome based on various criteria &#8211; involuntary weight loss&#44; weakness&#44; tiredness&#44; slowness and decreased activity&#59; a fragile patient is one who accumulates &#8805;3 items&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">However&#44; in people with complex clinical situations where decisions can be difficult&#44; the Rockwood and Mitnitski<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">26</span></a> frailty index&#44; which defines fragility by deficit accumulation&#44; is increasingly gaining more importance&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">27</span></a> This new&#44; more dynamic model suggests that as people get older&#44; they tend to accumulate chronic diseases and situations&#44; which in turn imply a dysfunction in their physiological reserve and&#44; therefore&#44; deficits at cognitive&#44; functional or nutritional levels&#46; The quantification of these deficits at a specific moment determines their <span class="elsevierStyleItalic">frailty index</span> &#40;FI&#41;&#44; which facilitates stratifying risk in an individualised manner&#59; the higher the patient&#39;s FI&#44; the more vulnerable they are&#59; FI values of &#62;0&#46;7 are considered incompatible with life&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">27</span></a> Thus&#44; knowing a patient&#39;s level of fragility provides more detailed information about their reserve &#40;&#8216;biological age&#8217;&#41; than chronological age does&#58; its clinical measurement is a helpful tool that can assist in designing adequate therapeutic objectives to establish a balance between patients&#8217; clinical situation and their preferences&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Functional status</span><p id="par0065" class="elsevierStylePara elsevierViewall">Functional status is understood to be an important clinical marker in kidney disease&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">28</span></a> Functional impairment&#44; or inability to perform basic or instrumental activities in daily life&#44; is common in patients who initiate dialysis&#44; and it continues to deteriorate in patients who continue with dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> Kurella et al&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">29</span></a> studied the functional status of 3702 elderly people &#40;mean age 73&#46;4&#41; living in residences before and after initiating dialysis&#46; They concluded that initiating dialysis was associated with a significant and sustained decrease in these patients&#8217; functional status&#44; in addition to a mortality rate of 58&#37; at 12 months from the start of dialysis&#46; Similarly&#44; a study by Jassal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">30</span></a> performed in a cohort of octogenarian patients&#44; described the loss of independence after initiating dialysis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Cognitive status</span><p id="par0070" class="elsevierStylePara elsevierViewall">Cognitive deterioration has also been associated with the worsening of renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> Guerrero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a> showed lower scores on the Mini&#8211;Mental State Examination &#40;MMSE&#41; test in elderly patients with glomerular filtration rate MDRD &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Disease evolution</span><p id="par0075" class="elsevierStylePara elsevierViewall">CKD &#40;organ failure&#41; is characterised by a chronic deterioration over months or years&#44; with intermittent acute episodes of deterioration&#44; associated with hospitalisation or appearance of new events&#44; whose outcome may be recovery &#8211; with a deterioration of previous state &#8211; or death&#46; Given these patients&#8217; high multimorbidity&#44; new diseases may appear &#40;neoplasms&#41; and other disease evolutions may overlap&#44; hindering the prediction of its clinical course and its prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Survival analysis according to indication of conservative renal treatment versus dialysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Several studies comparing conservative renal treatment versus dialysis shows greater survival using dialysis when the cohort is considered globally&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">33&#8211;35</span></a> However&#44; when individual variables are studied separately&#44; such as patients older than 80&#44;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">35</span></a> a greater functional impairment&#44;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">35</span></a> high comorbidity<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">33&#44;34</span></a> or the presence of heart disease&#44;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">33</span></a> the benefits of dialysis in terms of survival are not much better than conservative renal treatment&#46; A study by Wongrakpanich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a> carried out a systematic review of 12 studies &#40;prospective and retrospective&#41; that included more than 11&#44;000 patients with stage 5 CKD&#44; and found that the median survival for patients who underwent conservative treatment was 6&#8211;30<span class="elsevierStyleHsp" style=""></span>months compared to 8&#8211;67<span class="elsevierStyleHsp" style=""></span>months for dialysis&#44; with dialysis patients being younger and with better functional status&#44; and concluded that efforts should focus on promoting patient values and preferences and reaching a shared decision on the most appropriate treatment modality suitable for each patient individually&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Shared decision making</span><p id="par0085" class="elsevierStylePara elsevierViewall">Once the situational diagnosis has been established&#44; the patient&#39;s perspective&#44; preferences and&#47;or goals in life&#44; as well as their quality of life&#44; should be measured&#46; Addressing the management of information and verifying to what extent the patient&#47;caregiver has understood the information provided is also important&#46; Support tools can be useful for reaching a consensus in the decision-making process&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The main issues that need to be decided with the patient&#47;caregiver are&#58; &#40;1&#41; how information is managed&#59; &#40;2&#41; decisions regarding the different therapeutic options in advanced CKD&#58; choice of conservative treatment versus RRT with dialysis or transplantation&#44; and &#40;3&#41; for patients who decide to be treated with dialysis&#58; initiation and&#47;or removal times&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient preferences and quality of life</span><p id="par0095" class="elsevierStylePara elsevierViewall">The purposes of interviews during the advanced stages of CKD are to provide information and educate the patient in aspects related to their kidney disease and to understand what patients&#8217; objectives&#44; goals&#44; preferences&#44; values and lifestyle choices are&#44; thus respecting the principle of patient autonomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;37</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Because any illness or injury that compromises life can affect the patient&#39;s quality of life&#44; they are who can best assess their own quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> In the case of patients with CKD&#44; when deciding whether to undergo conservative treatment or RRT&#44; all the benefits &#40;not only in terms of survival&#41; should be considered&#44; in addition to the quality of life resulting from either modality&#59; and once the decision is taken&#44; the autonomy of the patient should be respected&#46; There are different tools available to assess quality of life&#44; such as the <span class="elsevierStyleItalic">Short Form</span> SF-36 questionnaire&#44; which assesses physical&#44; social and mental aspects&#44; the <span class="elsevierStyleItalic">Hospital Anxiety and Depression Scale</span> and the <span class="elsevierStyleItalic">Satisfaction with Life Scale</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">38</span></a> It may also be helpful to ask short questions to explore quality of life&#44; such as&#58; Has anyone from your family or friends received dialysis treatment&#63; What was seeing them on dialysis like<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a>&#63; A variety of studies analysing the quality of life of patients undergoing conservative renal treatment or dialysis have found that&#44; although the burden of symptoms at the beginning is significant for patients who choose conservative treatment&#44; with the help of palliative care it is possible to improve the control of symptoms and maintain quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">38&#44;39</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Information management and patient education</span><p id="par0105" class="elsevierStylePara elsevierViewall">Through personal interviews&#44; a study carried out in Spain analysed the information and choice process of the RRT modality in a group of patients with CKD&#46; This study was conclusive and highlighted the lack of information patients receive&#44; as well as the little time dedicated to providing them with information material or responding to their doubts&#46; In addition&#44; 42&#37; of patients who were on hemodialysis indicated that this modality had been imposed on them&#46; Another aspect that should be noted is the lack of understanding about how dialysis techniques work as age increases&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">40</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The process of providing information on CKD and its therapeutic modalities to patients in advanced stages should be initiated early&#44; since the worsening of renal function can be associated with worse cognitive capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> However&#44; the fact that an excess of information can generate uncertainty and be futile&#44; especially in patients with high multimorbidity&#44; who are at risk of dying from other non-renal processes and with preserved renal function&#44; should also be noted&#46; In this sense&#44; when considering the amount of information to provided patients with&#44; both the renal progression rate and the presence of multimorbidity should be borne in mind&#46; Thus&#44; in patients with slow renal deterioration but with high multimorbidity&#44; the amount of information given should be low&#46; Conversely&#44; patients with rapid renal deterioration and little multimorbidity are at risk of reaching terminal nephropathy and might receive some type of RRT&#44; so preparing them by providing exhaustive information is recommended&#46; In the other categories &#8211; slow progression&#47;low multimorbidity and rapid progression&#47;high multimorbidity &#8211; information management should be personalised&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In recent years predictive equations have been developed for progression to ESRD&#44; such as the <span class="elsevierStyleItalic">Kidney Failure Risk Equation</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">41</span></a> and mortality at 5 years&#44; which considers nine variables &#40;age&#44; sex&#44; race&#44; glomerular filtration rate&#44; protein&#47;creatinine ratio&#44; tobacco consumption&#44; diabetes mellitus&#44; stroke and heart failure&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">42</span></a> which can be useful tools when deciding who and how to inform&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Ensuring the patient is sufficiently informed must be accompanied by ensuring they have understood the information that has been provided to them&#44; given that decline in comprehension skills is normal in advanced ages&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">40</span></a> In addition&#44; senses such as vision&#44; hearing&#44; as well as other functions &#40;executive&#44; cognitive&#44; orientation in space&#41;&#44; can also be affected by normal ageing and hinder understanding and education and&#44; consequently&#44; the decision-making process&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">43</span></a> Likewise&#44; these patients with CKD usually have a high burden of anxiety and depression which can negatively affect their ability to retain information&#46; The participation of a multidisciplinary team&#44; establishing strategies to mitigate these barriers in the elderly &#40;use of glasses&#44; hearing aids&#44; correct lighting&#44; adequate font size&#41;&#44; strategies to improve communication &#40;use of direct and concise language&#41; and carrying out anxiety&#47;depression screening&#44; are the key to incorporating patients&#8217; values and preference in the decision-making process&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">43&#8211;45</span></a> Regarding compliance with treatments or indications&#44; adherence can be improved by simplifying instructions&#44; reinforcing behaviours and involving a caregiver&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Contextual elements</span><p id="par0125" class="elsevierStylePara elsevierViewall">The patient can be both positively or negatively influenced by other contextual aspects &#8211; social&#44; economic&#44; psychological or spiritual &#8211; which can affect the decision-making process&#46; Awareness of these aspects&#44; and their resolution should they be conflictive&#44; can also support the decision-making process&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Tools that support the decision-making process</span><p id="par0130" class="elsevierStylePara elsevierViewall">A shared decision &#40;medical recommendations and patients&#8217; preferences&#41; can be reached through carrying out an educational process with a multidisciplinary team &#40;nephrologist&#44; nurse&#44; social worker and psychologist&#44; among others&#41; and the help of decision-making tools&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">7&#44;46</span></a> Some of these tools include the following guides&#58; &#8220;Dialysis&#58; making the decisions that best suit you&#8221; &#40;a dialysis decision-making guide&#44; available at www&#46;senefro&#46;org&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">47</span></a> or &#8220;Chronic kidney disease&#58; what treatment is best for me&#63;&#8221; &#40;a guide prepared by the Junta de Andaluc&#237;a&#44; Regional Ministry of Health&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">48</span></a> These tools provide information on CKD and explain the risks and benefits of the different treatment modalities as well as the options the patient has according to their profile and lifestyle&#44; so that they can reach a viable conclusion&#46; The implementation of a systematic educational process&#44; together with the aforementioned tools&#44; can ensure a high level of agreement between the chosen and the end modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">46</span></a></p></span></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">No initiation&#44; initiation or withdrawal from dialysis</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">No initiation of dialysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">The patient&#44; previously informed of the risks and benefits of dialysis and who has the ability to make decisions&#44; can chose not to initiate dialysis when there is a situation of terminal nephropathy and the need for dialysis could arise<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">49</span></a>&#59; and should they be unable to express this rejection&#44; it could be requested through an advanced directives document or the patient&#39;s legal representative Furthermore&#44; certain medical situations&#44; such as irreversible neurological problems or terminal &#40;non-renal&#41; processes&#44; also contraindicate entry into the RRT programme&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Initiation of dialysis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Mathematical formulas derived from serum creatinine or Cystatin <span class="elsevierStyleSmallCaps">C</span> facilitates early detection of CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">50</span></a> However&#44; these mathematical formulas are inaccurate and have not yet been validated in the elderly&#44; so could possibly produce errors in diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">50&#44;51</span></a> The glomerular filtration rate value should not be the only parameter to indicate dialysis in patients who have chosen this treatment modality&#58; the analysis of other analytical parameters &#40;potassium&#44; bicarbonate&#44; etc&#46;&#41; together with their symptomatology should also be considered when making this decision&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">6&#44;8</span></a> The main symptoms that could justify the initiation of dialysis include&#58; oliguria or anuria &#8211; which lead to volume overload &#8211; refractory to intensive diuretic treatment&#44; severe metabolic acidosis and hyperkalaemia&#44; uraemic pericarditis or significant nutritional deterioration associated with restrictive diets for renal preservation&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">6</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding whether to initiate dialysis early or later&#44; some studies have pointed out that initiating early &#40;with a higher level of glomerular filtration&#41; could be detrimental in the elderly when there is a loss of residual renal function&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">9&#44;52&#44;53</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">On the other hand&#44; in situations of acute renal failure that may occur during the hospitalisation of patients with advanced CKD&#44; the need for &#8216;acute&#8217; dialysis may be debated&#46; These situations should be debated in initial conversations regarding the therapeutic options available for CKD&#46; Also&#44; in cases of doubt about the treatments&#44; or when patients have acute renal failure&#44; <span class="elsevierStyleItalic">dialysis as a test</span> could be indicated&#44; with marked objectives and for a limited time&#46; This could offer prognostic utility for patients who recover renal function after acute renal failure by providing information on chronic dialysis&#59; it is therefore another tool to support the decision-making process&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">6&#44;49</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Withdrawal from dialysis</span><p id="par0155" class="elsevierStylePara elsevierViewall">A treatment is not indicated if it causes damage or worsens the quality of life&#46; The use of RRT can be called into question if it does not improve patients&#8217; who are terminally ill quality of life&#44; or it causes suffering and a significant burden for the family&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">15&#44;49</span></a> The appearance of a new serious disease that may affect the short-term vital prognosis &#40;cancer&#41; or the presence of a new morbidity during the dialysis period&#44; such as calciphylaxis&#44; stroke&#44; amputations&#44; dementia or haemodynamic instability during the dialysis technique&#44; may lead to a possible withdrawal from dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">54</span></a> Generally&#44; if the patient is cognitively able to and states their willingness to withdraw from dialysis or there is an advanced directives document&#44; their decision should be respected&#44; thus preventing conflict&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">49</span></a> However&#44; it is common for patients with advanced CKD or on dialysis to be unaware of their illness and not plan for the end of life&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">49</span></a> In these cases&#44; once the dialysis is initiated there may be conflicts when it comes to withdrawing the dialysis&#44; between the professional &#40;who is aware that without dialysis death may occur within one day or several months&#44; depending on the presence or absence of residual kidney function&#41; and the family or caregivers&#46; For the resolution of these difficult cases of dialysis withdrawal&#44; the help of the an ethics committees can be another tool in the decision-making process&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">15&#44;54</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Palliative care and advanced chronic kidney disease</span><p id="par0160" class="elsevierStylePara elsevierViewall">The application of the principles of palliative care and end-of-life care is essential for a comprehensive and multidisciplinary approach to caring for patients with advanced CKD and terminal nephropathy&#44; and should begin in the initial stages of the disease and continue until the patient&#39;s death and the mourning period&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;55</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In addition to the specific symptoms of their disease &#40;anaemia or electrolyte abnormalities&#41;&#44; renal patients also usually present other nonspecific symptoms&#44; such as pain&#44; sleep disturbances&#44; digestive disorders or mood disorders &#40;which may worsen before death&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;55</span></a> In addition&#44; some symptoms can be difficult to recognise &#40;particularly in professionals with little experience in kidney disease&#41;&#44; and their lack of detection can have a negative impact on the patient&#39;s quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">56</span></a> The participation of a palliative care multidisciplinary team would not only facilitate appropriate treatment of the current symptoms&#44; but would also help in identifying them earlier&#44; which can contribute to improving the patient and their family&#39;s quality of life&#46; The use of supportive tools such as the <span class="elsevierStyleItalic">Palliative Care Outcome Scale-Symptoms Modified for renal patients</span> &#40;POS-S renal&#41; scale may be useful for addressing these patients&#8217; symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">56</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Furthermore&#44; these patients present other needs that should also be addressed with palliative care&#44; such as psychosocial and spiritual support and education for both the patient and the family&#47;caregivers&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Additionally&#44; establishing an anticipated care plan&#44; that focuses mainly on the patient &#40;rather than the disease&#41; is of interest&#59; it should improve communication between the multidisciplinary team and the patient and&#47;or family&#44; and clearly outline the patient&#39;s preferences and wishes for their end of life&#46; This plan should be carried out after honest and realistic information of their status has been given&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">56</span></a> This anticipated care plan should begin from the moment the answer to the following question is &#8216;no&#8217;&#58; &#8220;Would you be surprised if this patient died within 6&#8211;12<span class="elsevierStyleHsp" style=""></span>months&#63;&#8221;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Decision making in elderly patients with advanced chronic kidney disease is complex&#58; in addition to glomerular filtration and uraemic symptoms&#44; multimorbidity and geriatric syndromes &#40;fragility&#44; cognitive impairment&#44; disability&#41; must also be considered&#46; Care includes the management of information&#44; the choice of treatment modality &#40;conservative or renal replacement therapy&#41; and the time of initiating and&#47;or withdrawal from dialysis&#46; A multidisciplinary approach&#44; within the framework of bioethical principles&#44; can help reach a shared consensus in the decision-making process between medical indication and the patient&#39;s preferences&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">There are no conflicts of interest or financing&#46;</p></span></span>"
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            4 => "Tratamiento renal sustitutivo"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic kidney disease is common in people &#62;65 years of age&#46; The development and improvement of dialysis techniques has allowed its generalisation to the entire population&#44; when there is a situation of terminal nephropathy&#44; without limit of use due to chronological age&#46; Decision making in elderly patients with advanced chronic kidney disease is complex&#58; in addition to renal parameters&#44; both comorbidity and the presence of geriatric syndromes must be considered&#46; This review addresses the management of information&#44; the decision making of different treatment modalities that can be offered to these patients&#44; and the time of initiation and&#47;or withdrawal of dialysis&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad renal cr&#243;nica es frecuente en personas &#62;65 a&#241;os&#46; El desarrollo y el perfeccionamiento de t&#233;cnicas de di&#225;lisis ha permitido su generalizaci&#243;n a toda la poblaci&#243;n cuando se llega a una situaci&#243;n de nefropat&#237;a terminal&#44; sin existir l&#237;mite de uso por la edad cronol&#243;gica&#46; La toma de decisiones en ancianos con enfermedad renal cr&#243;nica avanzada es compleja&#58; adem&#225;s de par&#225;metros renales se debe considerar la comorbilidad&#44; as&#237; como la presencia de s&#237;ndromes geri&#225;tricos&#46; En esta revisi&#243;n se aborda la gesti&#243;n de la informaci&#243;n&#44; la toma de decisi&#243;n de diferentes modalidades de tratamiento que se pueden ofertar a estos pacientes y el momento de inicio y&#47;o retirada de di&#225;lisis&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Heras Benito M&#44; Fern&#225;ndez-Reyes Luis MJ&#46; Toma de decisiones compartida en la enfermedad renal cr&#243;nica avanzada del anciano&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;152&#58;188&#8211;194&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary approach in the decision-making process&#46; CKD&#58; chronic kidney disease&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Key points</span><p id="par0185" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">In decision making with elderly patients who have advanced chronic kidney disease&#44; the health professional should consider multimorbidity and geriatric syndromes &#40;fragility&#44; cognitive status&#44; etc&#46;&#41; in addition to the glomerular filtration value and uraemic symptoms&#59; establishing a situational diagnosis using an integral geriatric assessment is essential&#46;</p></li><li class="elsevierStyleListItem" id="lsit0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The renal deterioration progression rate and comorbidity&#44; together with prediction equations for terminal nephropathy and&#47;or mortality&#44; are tools that can support the management of information&#46;</p></li><li class="elsevierStyleListItem" id="lsit0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Issues that must be considered during the treatment modality &#40;conservative or renal replacement therapy&#41; decision-making process are&#58; medical indications&#44; patient preferences&#44; quality of life and contextual aspects&#46;</p></li><li class="elsevierStyleListItem" id="lsit0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Overall&#44; renal replacement therapy with dialysis offers advantages in terms of survival compared to conservative renal treatment&#46; These advantages are lost with advanced ages &#40;over 80&#41;&#44; in patients with high comorbidity and heart disease&#44; as well as in dependent patients&#46;</p></li><li class="elsevierStyleListItem" id="lsit0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Treatment with dialysis is not indicated if the patient &#8211; who has been previously informed of this technique and who has the ability to make decisions &#8211; chooses not to perform dialysis&#44; and in certain irreversible situations&#46;</p></li><li class="elsevierStyleListItem" id="lsit0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Dialysis will be initiated when there is uraemic symptomatology&#46; Early initiation &#40;with more glomerular filtration&#41; can be harmful as it causes loss of residual renal function&#46;</p></li><li class="elsevierStyleListItem" id="lsit0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Withdrawal from dialysis can be considered when it no longer provides a benefit to the patient and does not improve their quality of life&#46; Ethics committees can be useful in cases where there is a conflict regarding whether to withdraw dialysis between professionals and the family&#47;caregivers&#44; when the patient does not have the capacity to decide and&#47;or there is also no anticipated directives document or an assigned legal representative&#46;</p></li></ul></p></span></span>"
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    "bibliografia" => array:2 [
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      "seccion" => array:1 [
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                      "titulo" => "Competing-risk analysis of death and dialysis initiation among elderly &#40;&#8805;80 years&#41; newly referred to nephrologists&#58; a French prospective study"
                      "autores" => array:1 [
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                          "etal" => false
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                            0 => "B&#46; Faller"
                            1 => "J&#46;B&#46; Beuscart"
                            2 => "L&#46; Frimat"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-2369-14-103"
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                        "link" => array:1 [
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                      "titulo" => "Treatment decisions for older adults with advanced chronic kidney disease"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;J&#46; Rosansky"
                            1 => "J&#46; Schell"
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                0 => array:1 [
                  "referenciaCompleta" => "Coulter A&#44; Collins A&#46; Making shared decision-making a reality&#46; No decision about me&#44; without me&#59; 2011&#58;1&#8211;45&#46; Available in&#58; <a id="intr0010" class="elsevierStyleInterRef" href="https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf">https&#58;&#47;&#47;www&#46;kingsfund&#46;org&#46;uk&#47;sites&#47;default&#47;files&#47;Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011&#95;0&#46;pdf</a>"
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            ]
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                  ]
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                          ]
                        ]
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                  "contribucion" => array:1 [
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                      "titulo" => "Age affects outcomes in chronic kidney disease"
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                          "etal" => true
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                            0 => "A&#46;M&#46; O&#8217;Hare"
                            1 => "A&#46;I&#46; Choi"
                            2 => "D&#46; Bertenthal"
                            3 => "P&#46; Bacchetti"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                      "titulo" => "Progression of kidney dysfunction in the community-dwelling elderly"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            5 => "W&#46;A&#46; Ghali"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        ]
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                  ]
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                      "titulo" => "Ancianos con enfermedad renal cr&#243;nica&#58; &#191;qu&#233; ocurre a los cinco a&#241;os de seguimiento&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46; Heras"
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                            2 => "R&#46; S&#225;nchez"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
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                        "volumen" => "32"
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                          ]
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                      "autores" => array:1 [
                        0 => array:2 [
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                          ]
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                    ]
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                        ]
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                  ]
                ]
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            ]
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "N&#46; Demoulin"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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