Dialysis

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines. Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Annual mortality of patients on dialysis exceeds 20%. Withdrawal from dialysis is a common cause of death for dialysis patients worldwide, reflecting their poor health-related quality of life (HRQL), although this may be owing to nonmedical reasons in low-income and lower-middle-income countries. The high level of disability and symptom burden in some patients with advanced CKD is not necessarily improved by dialysis. To improve the quality of care, it is now recognized that palliative care principles need to be integrated into the routine care of these patients. Despite great need, palliative care is under-utilized among patients with advanced CKD compared with other chronic disease populations, even in countries where such care is available. 1,2 Rates of hospitalization, intensive care unit admissions, and other intensive treatments are higher for CKD patients in the last month of life compared with other severe chronic illnesses, including chronic obstructive lung disease, congestive heart failure, and advanced liver disease. 3 Current evidence suggests that end-of-life care practices are not consistent with preferences of patients with advanced CKD (i.e., GFR categories G4 and G5). 4 The majority of dialysis patients die in acute care facilities, receiving high-intensity care that may be unwanted. 1 Health systems and policies that integrate palliative care are urgently required to optimize the care of CKD patients. To achieve international, multidisciplinary, transparent, and unbiased analysis, Kidney http://www.kidney-international.org m e e t i n g r e p o r t

Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.