Barriers and Facilitators to Active Medical Management without Dialysis.

Multiple studies document there are patients for whom hemodialysis can be predicted not to offer a survival advantage. The medical evidence also includes reports of strong, active medical management without dialysis programs in Australia, Canada, and the United Kingdom, yet the nephrology community in the United States has yet to provide to patients with end stage kidney disease an active medical management without dialysis option available throughout the country. This article reviews barriers and facilitators to starting such a program and offers recommendations for the components that have enabled international programs to be successful.

Effecting Palliative Care for Patients with Chronic Kidney Disease by Increasing Provider Knowledge.

This evidence-based quality initiative project was designed to increase advance care planning and palliative care referrals, thus improving quality of life for patients with chronic kidney disease by increasing nephrology providers' knowledge of the Renal Physicians Association guidelines on "Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis." Thirteen nephrology providers and nurses received the educational intervention. Post-intervention outcomes included four renal palliative care referrals and 21 advance care plans over four months from a baseline of zero/unknown. The supportive benefits to nursing and society are vast, minimizing nursing, health system, and caregiver burden.

Show Me CKDintercept Initiative: A Collective Impact Approach to Improve Population Health in Missouri.

Ninety percent of people with chronic kidney disease (CKD) remain undiagnosed, most people at risk do not receive guideline-concordant testing, and disparities of care and outcomes exist across all stages of the disease. To improve CKD diagnosis and management across primary care, the National Kidney Foundation launched a collective impact (CI) initiative known as Show Me CKDintercept. The initiative was implemented in Missouri, USA from January 2021 to June 2022, using a data strategy, stakeholder engagement and relationship mapping, learning in action working groups (LAWG), and a virtual leadership summit. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to evaluate success. The initiative united 159 stakeholders from 81 organizations (Reach) to create an urgency for change and engage new CKD champions (Effectiveness). The adoption resulted in 53% of participants committed to advancing the roadmap (Adoption). Short-term results reported success in laying a foundation for CI across Missouri. The long-term success of the CI initiative in addressing the public health burden of kidney disease remains to be determined. The project reported the potential use of a CI initiative to build leadership consensus to drive measurable public health improvements nationwide.

Palliative Care for Nephrology Patients in the Intensive Care Unit.

Both nephrologists and palliative care specialists are frequently consulted on patients admitted to the intensive care unit suffering from both acute kidney injury and end-stage kidney disease. Dialysis continues to be the predominant treatment recommendation for kidney failure despite the aging population and increased incidence of comorbid conditions. Research shows patients request prognostic information and dialysis survival rates before initiating treatment; however, many patients initiate dialysis naive of their increased morbidity and mortality. Palliative care, in collaboration with nephrology, can help improve communication and a focus on shared decision making.