Saeed Fahad, Horowitz Robert K, Allen Rebecca J, Auinger Peggy, Epstein Ronald M, Fiscella Kevin A, Veazie Peter J, Duberstein Paul R
Division of Nephrology, Division of Palliative Care, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.
Department of Medicine, Division of Palliative Care, University of Rochester Medical Center, Rochester, NY.
Kidney360. 2025 Feb 1;6(2):236-246. doi: 10.34067/KID.0000000622. Epub 2024 Oct 24.
In non-nephrology settings, specialty palliative care (PC) improves decision making, patient's quality of life (QoL), advance care planning, and certain indicators of the quality of end-of-life (EoL) care. This pilot randomized control trial (RCT) explored the feasibility and acceptability of a PC intervention, CKD-EDU, for adults aged 75 years and older with eGFR ≤25 ml/min and their caregivers.
Participants randomized to the control group received standard nephrology care and routine kidney therapy education, whereas those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss kidney therapy decisions and EoL planning. Patients were assessed at baseline, 4–6, 12–14, and 24–26 weeks. Main outcomes included intervention feasibility and acceptability, decision conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QoL were explored, as were the effects of CKD-EDU on advance care planning, EoL treatment intensity, and 6-month hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure models, mediation analyses, and logistic regression models.
Among the 127 eligible patients screened, 58 (46%) consented: 30 were randomized to CKD-EDU and 28 to the control arm. All patients completed baseline assessments and 89% completed at least 1 intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessment completion rates at 4 (83%, n=45/54), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in Decisional Conflict Scale scores (P = 0.003) at 4–6 weeks and improvements in QoL at 24–26 weeks (P = 0.02). Exploratory analyses were not statistically significant in this pilot study, but all effect sizes were in the predicted direction.
This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.
在非肾脏病学环境中，专科姑息治疗（PC）可改善决策制定、患者生活质量（QoL）、预先护理计划以及某些临终（EoL）护理质量指标。这项试点随机对照试验（RCT）探讨了针对估算肾小球滤过率（eGFR）≤25 ml/min的75岁及以上成年人及其护理人员的PC干预措施CKD-EDU的可行性和可接受性。
随机分配至对照组的参与者接受标准肾脏病护理和常规肾脏治疗教育，而随机分配至CKD-EDU组的参与者接受决策辅助工具，并与PC临床医生会面多达三次，以讨论肾脏治疗决策和临终计划。在基线、4 - 6周、12 - 14周和24 - 26周对患者进行评估。主要结局包括干预措施的可行性和可接受性、决策冲突和患者生活质量。探讨了减少决策冲突对改善生活质量的中介作用，以及CKD-EDU对预先护理计划、临终治疗强度和6个月住院情况的影响。统计分析包括描述性分析、调整后的重复测量模型、中介分析和逻辑回归模型。
在筛选的127名符合条件的患者中，58名（46%）同意参与：30名被随机分配至CKD-EDU组，28名被分配至对照组。所有患者均完成了基线评估，89%的患者完成了至少1次干预疗程（n = 26/29），突出了干预措施的依从性和可行性。同样，在4周（83%，n = 45/54）、12周（93%，n = 42/45）和24周（95%，n = 40/42）时的评估完成率很高。该干预措施在所有问题上的可接受性评分均超过85%。接受CKD-EDU干预的患者在4 - 6周时决策冲突量表得分有显著改善（P = 0.003），在24 - 26周时生活质量有所改善（P = 0.02）。在这项试点研究中，探索性分析无统计学意义，但所有效应大小均呈预期方向。
本研究证明了CKD-EDU的可行性和可接受性。有必要进行更大规模的试验，以评估其在改善对患者和家庭重要的关键结局方面的有效性。
