Letter to the Editor
Reply to «Shared decision-making in advanced chronic kidney disease in the elderly. Follow the example»
Réplica a «Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir»
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Follow the example»" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "33" "paginaFinal" => "34" ] ] "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 => "manuhebe@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María José" "apellidos" => "Fernández-Reyes Luis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General de Segovia, Segovia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Réplica a «Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We appreciate the reflections given by Drs Torrente Jiménez et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on the extrapolation of the approach we outlined in the review ‘Shared decision-making in advanced chronic kidney disease in the elderly’<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to other medical specialties that treat multimorbidity. Technological advances in medicine and in society in general, have led to a change in the profile of the chronic patient (an increasingly ageing population with pluripatology). To manage this, we need a change of mentality among the healthcare professionals who serve these patients, who should give a relevant (active) role to the patient when weighing the different therapeutic options that they have, and which can have an impact on daily living.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Because a situational diagnosis must be made –prior to decision-making– other key support elements are essential. One of these elements that we indicated in our review was <span class="elsevierStyleItalic">comorbidity</span>. We indicated that the Charlson index was a classic tool to help establish comorbidity. Torrente Jimenez et al. pointed out that the PROFUND index would be a better prognostic tool, compared to the Charlson index. Undoubtedly, the more tools (and, above all, the more accurate) we have, the more support for the decision-making process. We would also like to highlight the existence of other indices (Walter, Desai, Levine…), perhaps less well known, that have both advantages and disadvantages, but which are proof of interest that the measurement of pluripatology has aroused in recent years. Another element that we included in the review, having limited it to ‘elderly people with advanced chronic kidney disease’, was that of <span class="elsevierStyleItalic">fragility</span>, a common syndrome in the elderly, and an aspect that professionals dealing with the elderly patient are familiar with. We agree, for what it represents (‘measurement of the degree of biological reserve’), that it should be included in the decision-making process. In any case, both Fried’s physical fragility model (‘static’) and the Rockwood deficit accumulation model (dynamic) provide more value than the objective data of chronological age. For this reason, we believe that all professionals dealing with pluripatological patients should familiarise themselves with fragility and its measurement, for a better stratification of this type of patients. In the review, we decided to include only the definition of fragility that had been established consensually, being a multidimensional entity with a complex aetiology.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the specific issue of the review –chronic kidney disease and its evolution– a variety of issues can modulate its trajectory (sepsis, drugs, surgeries, etc.) and, therefore, we agree with Torrente Jiménez et al. on the importance of establishing a plan for early care with the patient as soon as possible, to address the various scenarios that may present throughout the disease’s evolution. And with regard to the contribution on renal palliative care, in the review we indicated that they should be initiated early, and maintained until the end of life and grief; we appreciate the clarification of Drs Torrente Jiménez et al., regarding palliative primary care, as due to these patients’ peculiarities and pluripatology, they will most probably present many associated symptoms, which should be corrected, whether through active treatment such as renal replacement therapy or through conservative renal management.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, when addressing the complexity of the renal patient, we indicated the convenience of a multidisciplinary participation, but without making an express mention of the role played by primary care in the management of these pluripatological patients. We agree with Drs Torrente Jimenez et al. on the fundamental value of primary care doctors, not only in guaranteeing continuity of care when the patient is no longer hospitalised, but also in other actions associated with the multimorbidity (avoiding duplication of drugs, home care, set priorities according to patient preferences, etc.).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We are aware of the interest that this new healthcare model (patient-focused needs) and the search for specific support tools in primary care (such as the Ariadne principles) has aroused in primary care professionals; they will facilitate the management of this increasingly common problem in primary care doctors’ consultations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In short, involving the patient with advanced chronic kidney disease in the decision-making process –as we described, and applicable to different medical specialties–; a multidisciplinary approach to the disease; other additional key elements and using support tools, should be the new healthcare model that challenges multimorbidity in these patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Heras Benito M, Fernández-Reyes Luis MJ. Réplica a «Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir». Med Clin (Barc). 2020;154:33–34.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Torrente Jiménez" 1 => "S. Herranz Martínez" 2 => "M. 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