A National Survey of Conservative Kidney Management Practices for Patients who Forgo Kidney Replacement Therapy.

BACKGROUND: Clinical practice guidelines advocate for conservative kidney management (CKM), a planned, holistic, patient-centered approach to caring for patients who forgo initiation of kidney replacement therapy (KRT). Little is known about the extent to which current care practices meet these expectations.

METHODS: We conducted a cross-sectional survey of a national sample of nephrology providers recruited through US professional societies between March-July 2022 and inquired about their experiences with caring for patients who forgo KRT and their capacity to provide CKM.

RESULTS: Overall, 203 nephrology providers (age 47±12years, 53.2% white, 66.0% female), of which 49.8% were nephrologists and 50.2% advanced practice providers, completed the survey. Most (70.3%) reported that <10% of their practice comprised patients who had forgone KRT. Most indicated that they "always" or "often" provided symptom management (81.8%), multidisciplinary care (68.0%), tools to support shared decision-making about treatment of advanced kidney disease (66.3%), and psychological support (52.2%) to patients who forgo KRT, while less than half reported that they "always" or "often" provided staff training on the care of these patients (47.8%) and spiritual support (41.4%). Most providers reported "always" or "often" working with primary care (72.9%), palliative medicine (68.8%), hospice (62.6%), social work (58.1%) and dietitian (50.7%) services to support these patients, while only a minority indicated that they "always" or "often" offered chaplaincy (23.2%), physical and/or occupational therapy (22.8%), psychology or psychiatry (31.5%), and geriatric medicine (28.1%).

CONCLUSIONS: Many nephrology providers have limited experience with caring for patients who forgo KRT. Our findings highlight opportunities to optimize comprehensive CKM care for these patients.