Factors influencing the decision to start renal replacement therapy: results of a survey among European nephrologists

Background: Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT. Study Design: European web-based survey. Predictors: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors. Setting & Participants: Nephrologists from 11 European countries. Outcomes & Measurements: We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT. Results: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m(2). Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from high-versus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m(2)) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m(2)). Limitations: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists. Conclusions: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making. Am J Kidney Dis. 60(6): 940-948. (C) 2012 by the National Kidney Foundation, In

Conservative care in Europe: nephrologists' experience with the decision not to start renal replacement therapy

BACKGROUND: For some patients with end-stage renal disease (ESRD), providing conservative care until death may be an acceptable alternative for renal replacement therapy (RRT). We aimed to estimate the occurrence of conservative care in Europe and evaluated opinions about which factors nephrologists consider important in their decision not to offer RRT. METHODS: With a web-based survey sent to nephrologists in 11 European countries, we inquired how often RRT was not started in 2009 and how specific factors would influence the nephrologists' decision to provide conservative care. We compared subgroups by nephrologist and facility characteristics using chi-square tests and Mann-Whitney U tests. RESULTS: We received 433 responses. Nephrologists decided to offer conservative care in 10% of their patients [interquartile range (IQR) 5-20%]. An additional 5% (IQR 2-10%) of the patients chose conservative care as they refused when nephrologists intended to start RRT. Patient preference (93%), severe clinical conditions (93%), vascular dementia (84%) and low physical functional status (75%) were considered extremely or quite important in the nephrologists' decision to provide conservative care. Nephrologists from countries with a low incidence of RRT, not-for-profit centres and public centres more often scored these factors as extremely or quite important than their counterparts from high-incidence countries, for-profit centres and private centres. CONCLUSIONS: Nephrologists estimated conservative care was provided to up to 15% of their patients in 2009. The presence of severe clinical conditions, vascular dementia and a low physical functional status are important factors in the decision-making not to start RRT. Patient preference was considered as a very important factor, confirming the importance of extensive patient education and shared decision-making