Clinicians should make a greater effort to engage older patients with chronic kidney disease (CKD) in discussions about the risks they face from COVID-19 and the effect of the illness on treatment options, according to the authors of a new research article in the Clinical Journal of the American Society of Nephrology.
The investigators based that conclusion on interviews with 39 patients aged 70 years or older with advanced CKD, 17 care partners, and 20 clinicians from Boston, Portland, Maine, San Diego, and Chicago from August to December 2020.
“Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement,” Thalia Porteny, PhD, MSc, a postdoctoral scholar at the REACH Lab at Tufts University in Medford, Massachusetts, and colleagues concluded.
The investigators found that many patients “learned about their high vulnerability to COVID-19 from the media, and some expressed that they would have preferred to discuss their heightened risk with clinicians.”
“I think the most surprising finding was that few clinicians directly discussed how COVID reshaped risks for patients with CKD, and patients had unanswered questions about COVID and the impacts on their kidney disease,” study investigator Keren Ladin, PhD, MSc, an associate professor at Tufts and director of the REACH Lab, said in an interview with Renal & Urology News.
She also observed, “The findings illustrate that patients are generally satisfied with treatment decisions and perceive them to be quite safe, irrespective of whether they selected in-center or a home-based treatment. Undoubtedly, this reflects the tremendous efforts of kidney clinicians to adapt to higher precautions in the clinic and dialysis center, and communication with patients about the efforts in place to keep them safe.”
Adapting decision-making and treatment recommendations to reflect new understanding of COVID-19-related risks offers patients the opportunity to better understand and weigh the risks and benefits, Ladin said. “An important area that emerged as a challenge was communication and education when clinic time and in-person education/KRT modality classes are limited owing to the pandemic.”
The interviews also revealed a generally favorable view of telemedicine. “As we think about the future, our findings suggest an openness to telemedicine, as participants perceived this form of care to be convenient; it also gave care partners the ability to participate in clinical encounters when in-person care was restricted,” the authors wrote.
Clinicians are well positioned to discuss challenging new risks with patients, even under conditions of significant uncertainty and emerging information, she noted. Nephrologists can be more open to recommending home-based modalities, especially when risks of in-center modalities increase. “Although this was true for peritoneal dialysis, clinicians were still hesitant to recommend or discuss conservative management. This offers an important opportunity for improvement, as a balanced description of treatment options, including discussion of risks, benefits, and implications for quality of life is critical to shared decision-making,” Dr Ladin said.
Nephrologist Alexander Chang, MD, an assistant professor of clinical research and co-director of the Kidney Health Research Institute at Geisinger Medical Center in Danville, Pennsylvania, said his team has been discussing these issues at length over the past year. “I’ve noticed myself that the pandemic was an effective way to introduce the topic of home dialysis modalities to my patients, with some success in getting them to consider home modalities as the first option if possible,” Dr Chang said.
He said he agrees that the pandemic may have encouraged clinicians and patients to think more about home dialysis modalities, but the true impact remains unclear. “The burnout issue and the ‘great resignation’ with staffing challenges may have also limited the ability of providers in getting patients on home dialysis, as that requires experienced dialysis nurses available to educate and train patients as well as availability of surgeons familiar with peritoneal dialysis and operating room time during the pandemic,” Dr Chang said.
Panduranga Rao, MBBS, Richard D Swartz Collegiate Professor of Nephrology at the University of Michigan in Ann Arbor, said he predicts an increase in the use of home dialysis, perhaps peritoneal dialysis more so than home hemodialysis, in coming years due to a confluence of factors.
“We could be seeing a new era in home dialysis, especially given the innovations in dialysis hardware which would make it more appealing, less intimidating and less burdensome even to the elderly patient,” Dr Rao said.
Porteny T, Gonzales KM, Aufort KE, et al. Treatment decision making for older kidney patients during COVID-19. Published online June 7, 2022. Clin J Am Soc Nephrol. doi:0.2215/CJN.13241021