Dr. Kelly Li is a dual-trained nephrologist and palliative care physician from St George Hospital in Sydney, Australia, and the University of New South Wales. Her academic interests include kidney supportive care, bioethics, advance care planning, and communication skills in the healthcare setting.
Jeffrey Ha @_jeffreyha
Dr. Jeffrey Ha is a nephrology fellow at St George Hospital, Sydney. He attended medical school at University of Sydney and completed his nephrology training in the East Coast Renal Network in Sydney. He is currently undertaking a PhD through The George Institute for Global Health, to better understand and manage the high burden of cardiovascular disease in patients with chronic kidney disease (CKD). His research interests are in epidemiology, clinical trials, and expertise in anticoagulation and the treatment of cardiovascular disease in CKD. He is passionate about teaching and quality improvement
Competitors for the Transitions of Care Region
Kidney supportive care: supporting all transitions in kidney disease
Transitions of care, like major transitions in life, involve decisions that are daunting, uncomfortable, and difficult to navigate. How we assist patients transition into a different phase of illness and treatment can have profound impacts on how they live their life. We are cheering on the transition to kidney supportive care, because as nephrologists, we believe this is core business, and we all need the skills and institutional support to do it well.
Dialysis is not always the answer
Like it or not, our patients with chronic kidney disease (CKD) are part of an ageing population, as people live longer with chronic diseases. Mortality on dialysis remains high, even more so for those who are older, reside in a nursing home, or with high co-morbidity burden. For some, survival may not be longer with dialysis. Further, dialysis doesn’t alleviate the common and distressing symptoms of kidney failure. So it shouldn’t come as a surprise that dialysis is unsuitable or undesirable for many of our older patients. What happens when a patient chooses to forego dialysis?
Kidney supportive care
We work in a well-established kidney supportive care program in an Australian nephrology unit. We started this program because many patients were troubled by distressing symptoms, despite our unit performing above benchmarks in traditional key performance indicators (KPIs). To foster a successful service, we took a page out of the palliative care rulebook. According to the World Health Organisation, palliative care is an approach that improves quality of life of patients with life-limiting illnesses, addressing suffering which can be physical, psychosocial or spiritual. Kidney failure is life-limiting, and associated with high symptom burden and reduced quality of life. Effort and commitment to relieve suffering in this population is long overdue.
A main aspect of kidney supportive care is conservative kidney management – active symptom management and holistic, psychosocial, multidisciplinary support, alongside interventions to delay CKD progression. It is an important alternative to dialysis, one that foregoes sophisticated machines and cocktails of dialysate, instead prioritising individual values, quality of life, and time spent outside of the healthcare setting. Doing this well requires dedication from a whole team of medical, nursing, and allied health providers, and a commitment to not abandon our patients at all stages of illness.
Patients in our program with median age 84 years managed conservatively, lived 15 months (median survival) from eGFR <15ml/min/1.73m2, and 6 months from eGFR <10ml/min/1.73m2. They also had less hospitalized days than younger, less co-morbid patients who opted for dialysis, and their symptoms improved over time with active management, despite worsening GFR. All were co-managed by nephrologists and kidney supportive care. We think it’s time patients in every nephrology unit have access to and the opportunity for such a program, and clinicians and institutions need to facilitate it.
Kidney supportive care can be integrated across a spectrum of kidney diseases, through many complex and life-changing transitions, not just conservative management. Older dialysis patients need proactive symptom management and advance care planning. Patients with a failing graft may not wish to return to life on dialysis. Those faced with the difficult decision to withdraw from dialysis – whatever the reason – need the support of their nephrology team. Dialysis or transplant patients diagnosed with advanced malignancies need palliative care input integrated with their existing nephrology care. Kidney supportive care can look after patients through each of these stages within their nephrology unit, where their nephrologist continues to guide and support them. This holistic care is what our patients need and value, and is what makes kidney-supportive care a strong contender for this year’s NephMadness competition.
– Guest Post written by Kelli Li and Jeffrey Ha @_jeffreyha
As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.