Advance Care Planning.

Advance care planning should be available to all patients with chronic kidney disease, including end-stage kidney disease on renal replacement therapy. Advance care planning is a process of patient-centred discussion, ideally involving family/significant others, to assist the patient to understand how their illness might affect them, identify their goals and establish how medical treatment might help them to achieve these. An Advance Care Plan is only one useful outcome from the Advance Care Planning process, the education of patient and family around prognosis and treatment options is likely to be beneficial whether or not a plan is written or the individual loses decision making capacity at the end of life. Facilitating Advance Care Planning discussions requires an understanding of their purpose and communication skills which need to be taught. Advance Care Planning needs to be supported by effective systems to enable the discussions and any resulting Plans to be used to aid subsequent decision making.

Cultural considerations when providing care to New Zealand Maori opting for conservative care.

There is significant variation between cultural groups in the way the end of life is discussed and handled (1). This guide does not seek to be an exhaustive resource on Maori cultural practices as they apply to healthcare or the end of life. Dr Stallworthy is a New Zealander of European descent and a renal physician with an interest in renal supportive care and Advance Care Planning. Ms Glavish is from the Ngati Whatua iwi (Maori tribe) and is Chief Advisor-Tikanga (Maori protocol) for Auckland and Waitemata District Health Boards in New Zealand. Where statements in this section are based on Ms Glavish's expert opinion this is noted by '(NG)' following the statement.

Do echocardiographic parameters predict mortality in patients with end-stage renal disease?

BACKGROUND: Left ventricular function predicts cardiovascular mortality both in the general population and those with end-stage renal disease. Echocardiography is commonly undertaken as a screening test before kidney transplantation; however, there are little data on its predictive power. METHODS: This was a retrospective review of patients assessed for renal transplantation from 2000 to 2009. A survival analysis using demographic and echocardiographic variables was undertaken using the Cox proportional hazards regression model. RESULTS: Of 862 patients assessed for transplantation, 739 had an echocardiogram and 217 of 739 (29%) died during a mean follow-up of 4.2 years. In a multivariate survival analysis, increased age (P<0.0001), diabetes (P<0.0001), transplant listing status (P<0.0001), severely impaired left ventricular function (P<0.01), pulmonary hypertension and/or right ventricular dysfunction (P=0.01), and regional wall motion abnormalities (P<0.01) were associated with all-cause mortality. Combined in a score where one point was given for the presence of each of the parameters above, these factors were strongly predictive of increased mortality with a hazard ratio of 3.57, 6.80, and 44.47 for the presence of one, two, or more factors, respectively, compared with the absence of any of these factors. CONCLUSIONS: In patients with end-stage renal disease, multiple easily determined echocardiographic parameters, including regional wall motion abnormalities and pulmonary hypertension and/or right ventricular dysfunction, were independently associated with all-cause and cardiovascular mortality. Combining these factors in a simple score may further assist in risk stratifying patients being considered for renal transplantation.