Major Research Findings

End-stage kidney disease (ESKD) is a known risk factor for chronic limb-threatening ischemia (CLTI), as noted in 4 . This study aims to examine variation in the initial treatment location for ESKD patients compared to non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions.

A multicenter, prospective observational cohort study with nested substudies and linked qualitative research (the Elderly Advanced CKD Programme) is being conducted to examine treatment decision-making and care among older adults with kidney failure, as outlined in 10 . This research highlights the limited data available on key outcomes for this population, including survival, quality of life, symptom burden, changes in physical functioning, and experienced burden of healthcare. This lack of information creates significant uncertainty for patients, caregivers, and clinicians when making life-impacting treatment decisions.

Being informed about treatment options for kidney failure and being involved in the related decision-making process can facilitate a smooth transition. However, the initiation of kidney failure replacement therapy is considered a traumatic event for patients with kidney failure, causing physical and emotional distress and disrupting several aspects of their social life, as reported in 1 . To ease the transition, healthcare personnel must ensure patients understand the parameters of each treatment option. It is crucial to increase the knowledge of patients' lived experiences around initiating kidney failure replacement therapy.

A systematic review and meta-analysis of the Chinese experience comparing the clinical efficacy and safety of peritoneal dialysis (PD) and hemodialysis (HD) in treating diabetic kidney failure is presented in 7 . This research reviewed studies on PD and HD for diabetic kidney failure from five databases until August 6, 2022. Fixed-effects or random-effects models were used to calculate the standardized mean difference (SMD) or odds ratio (OR) based on the heterogeneity among studies. Sixteen studies were included. Results showed that patients with diabetic kidney failure treated with PD had lower levels of albumin, total protein, and systolic blood pressure (SBP) and higher levels of urine volume, creatinine, and blood urea nitrogen (BUN), with a significantly lower risk of cardiovascular and bleeding events compared to patients treated with HD (albumin: SMD = -1.22, 95%CI: -1.53, -0.91; total protein: SMD = -0.96, 95%CI: -1.16, -0.77; SBP: SMD = -0.35, 95%CI: -0.64, -0.06; urine volume: SMD = 0.68, 95%CI: 0.40, 0.96; creatinine: SMD = 0.49, 95%CI: 0.27, 0.72; BUN: SMD = 0.55, 95%CI: 0.25, 0.85; cardiovascular events: OR = 0.42, 95%CI: 0.28, 0.62; bleeding: OR = 0.41, 95%CI 0.27, 0.62). The meta-analysis summarized the advantages and disadvantages of PD and HD for treating diabetic kidney failure patients. Compared with HD, PD is more effective in preserving residual kidney function, reducing hemodynamic effects, and lowering the risk of bleeding and cardiovascular events in patients with diabetic kidney failure. However, PD also predisposes to protein-energy malnutrition and increases the risk of infection.

The global burden of type 2 diabetes and related complications has steadily increased over the past few decades, posing a significant global public health threat in the 21st century, as detailed in 8 . Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is a major contributor to cardiovascular morbidity and mortality in this population. Up to one in three patients who receive kidney transplants develop post-transplant diabetes, presenting a significant challenge for clinicians. This review describes the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. It also examines the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or who have received kidney transplants. With the increased availability of novel hypoglycemic agents, the review addresses the potential impacts of these novel agents in patients with diabetes and kidney failure, and in those who have developed post-transplant diabetes.

Kidney failure patients often have reduced cardiovascular reserve. Kidney transplantation (KT) is the optimal treatment for patients with end-stage kidney disease, as it is associated with longer survival and improved quality of life compared to dialysis. A systematic review and meta-analysis of studies using cardiopulmonary exercise testing to examine the cardiorespiratory fitness of patients with kidney failure before and after KT is presented in 2 . The primary outcome was the difference in pre- and post-transplantation values of peak oxygen uptake (VO2peak). The review included six studies from an initial retrieval of 379 records. A marginal, but not significant, improvement was observed in VO2peak after KT compared to pre-transplantation values (SMD: 0.32, 95%CI -0.02; 0.67). Oxygen consumption at the anaerobic threshold was significantly improved after KT (WMD: 2.30 ml/kg/min, 95%CI 0.50; 4.09). Consistent results were shown between preemptive and after-dialysis-initiation transplantation. A trend for improvement in VO2peak was observed at least 3 months post-transplantation, but not earlier. This review suggests that several major indices of cardiorespiratory fitness tend to improve after KT. This finding may represent another modifiable factor contributing to better survival rates of kidney transplant recipients compared to patients undergoing dialysis.

The Centers for Medicare & Medicaid Services designed a mandatory payment model, the End-Stage Renal Disease Treatment Choices (ETC), to incentivize the use of home dialysis. Outpatient dialysis facilities and healthcare professionals providing nephrology services were randomly assigned to ETC participation at the hospital referral region level, as noted in 9 . This study examined the association of the ETC with home dialysis use at the onset of kidney failure from 2016 to 2022.

The COVID-19 pandemic has presented challenges for healthcare systems worldwide, placing hospitals and healthcare providers (HCPs) at the center of a global crisis, as described in 11 . Disruptions to hospital priorities and limitations on the mobility of societies have contributed to changes in how HCPs and patients view and access dialysis for kidney failure, including their preference for specific dialysis modalities.

Kidney services vary in how they involve individuals with kidney failure (PwKF) in treatment decisions as management needs change. Decision-science applications can proactively support PwKF to make informed decisions between treatment options with kidney professionals, as discussed in 6 . This review presents a schema representing different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together. Adjustments at micro, meso, and macro levels support integration in practice. Innovating services to meet clinical guidelines on enhancing shared decision-making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service, and organizational levels.

Indigenous leadership is crucial for reducing inequities in the treatment of kidney failure, as highlighted in .

Traditional paternalistic medicine in nephrology has been modified to a shared decision-making model that clearly benefits patients with kidney disease. Understanding kidney disease is a cornerstone of shared treatment decision-making for patients with kidney failure. However, kidney disease is often silent until advanced stages and has a complex pathophysiology that is not well understood by the general population. Health literacy (HL) plays a critical role in the care of patients with kidney disease and shared treatment decisions. Limited HL is associated with inefficient use of health services, medication non-compliance, worse quality of life, and increased mortality. This review addresses the importance of low HL in nephrology in terms of diagnosis, measurement, its effects on shared decision-making, and how to increase it in people with kidney disease. 5 .

Nephropathic Cystinosis (NC), a rare disease characterized by the intra-lysosomal accumulation of cystine, results in progressive kidney failure (KF). Compliance with lifelong oral cysteamine treatment, the only therapy, is often compromised. The relationship between compliance and the costs of NC has not been formally assessed previously. This study evaluates the impact of compliance on the lifetime (direct) costs of treating KF in NC patients in the United Kingdom. 3

Treatment Summary

A study examining the variation in initial treatment location for ESKD patients compared to non-ESKD patients undergoing peripheral vascular intervention for CLTI was conducted in 4 . This research also aimed to identify preoperative risk factors for tibial interventions.

The Elderly Advanced CKD Programme, described in 10 , is a multicenter, prospective observational cohort study with nested substudies and linked qualitative research that examines treatment decision-making and care among older adults with kidney failure. This research highlights the limited data available on key outcomes for this population, including survival, quality of life, symptom burden, changes in physical functioning, and experienced burden of healthcare. This lack of information creates significant uncertainty for patients, caregivers, and clinicians when making life-impacting treatment decisions.

1 examines the experience of transitioning into life-sustaining treatment for patients with kidney failure. This study emphasizes the importance of informing patients about treatment options and involving them in the decision-making process for a smooth transition. However, the initiation of kidney failure replacement therapy can be a traumatic experience for patients with kidney failure, causing physical and emotional distress and disrupting several aspects of their social life.

A systematic review and meta-analysis of the Chinese experience comparing the clinical efficacy and safety of peritoneal dialysis (PD) and hemodialysis (HD) in treating diabetic kidney failure is presented in 7 . This research reviewed studies on PD and HD for diabetic kidney failure from five databases until August 6, 2022. Fixed-effects or random-effects models were used to calculate the standardized mean difference (SMD) or odds ratio (OR) based on the heterogeneity among studies. Sixteen studies were included. Results showed that patients with diabetic kidney failure treated with PD had lower levels of albumin, total protein, and systolic blood pressure (SBP) and higher levels of urine volume, creatinine, and blood urea nitrogen (BUN), with a significantly lower risk of cardiovascular and bleeding events compared to patients treated with HD (albumin: SMD = -1.22, 95%CI: -1.53, -0.91; total protein: SMD = -0.96, 95%CI: -1.16, -0.77; SBP: SMD = -0.35, 95%CI: -0.64, -0.06; urine volume: SMD = 0.68, 95%CI: 0.40, 0.96; creatinine: SMD = 0.49, 95%CI: 0.27, 0.72; BUN: SMD = 0.55, 95%CI: 0.25, 0.85; cardiovascular events: OR = 0.42, 95%CI: 0.28, 0.62; bleeding: OR = 0.41, 95%CI 0.27, 0.62). The meta-analysis summarized the advantages and disadvantages of PD and HD for treating diabetic kidney failure patients. Compared with HD, PD is more effective in preserving residual kidney function, reducing hemodynamic effects, and lowering the risk of bleeding and cardiovascular events in patients with diabetic kidney failure. However, PD also predisposes to protein-energy malnutrition and increases the risk of infection.

The global burden of type 2 diabetes and related complications has steadily increased over the past few decades, posing a significant global public health threat in the 21st century, as detailed in 8 . Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is a major contributor to cardiovascular morbidity and mortality in this population. Up to one in three patients who receive kidney transplants develop post-transplant diabetes, presenting a significant challenge for clinicians. This review describes the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. It also examines the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or who have received kidney transplants. With the increased availability of novel hypoglycemic agents, the review addresses the potential impacts of these novel agents in patients with diabetes and kidney failure, and in those who have developed post-transplant diabetes.

Kidney failure patients often have reduced cardiovascular reserve. Kidney transplantation (KT) is the optimal treatment for patients with end-stage kidney disease, as it is associated with longer survival and improved quality of life compared to dialysis. A systematic review and meta-analysis of studies using cardiopulmonary exercise testing to examine the cardiorespiratory fitness of patients with kidney failure before and after KT is presented in 2 . The primary outcome was the difference in pre- and post-transplantation values of peak oxygen uptake (VO2peak). The review included six studies from an initial retrieval of 379 records. A marginal, but not significant, improvement was observed in VO2peak after KT compared to pre-transplantation values (SMD: 0.32, 95%CI -0.02; 0.67). Oxygen consumption at the anaerobic threshold was significantly improved after KT (WMD: 2.30 ml/kg/min, 95%CI 0.50; 4.09). Consistent results were shown between preemptive and after-dialysis-initiation transplantation. A trend for improvement in VO2peak was observed at least 3 months post-transplantation, but not earlier. This review suggests that several major indices of cardiorespiratory fitness tend to improve after KT. This finding may represent another modifiable factor contributing to better survival rates of kidney transplant recipients compared to patients undergoing dialysis.

The Centers for Medicare & Medicaid Services designed a mandatory payment model, the End-Stage Renal Disease Treatment Choices (ETC), to incentivize the use of home dialysis. Outpatient dialysis facilities and healthcare professionals providing nephrology services were randomly assigned to ETC participation at the hospital referral region level, as noted in 9 . This study examined the association of the ETC with home dialysis use at the onset of kidney failure from 2016 to 2022.

The COVID-19 pandemic has presented challenges for healthcare systems worldwide, placing hospitals and healthcare providers (HCPs) at the center of a global crisis, as described in 11 . Disruptions to hospital priorities and limitations on the mobility of societies have contributed to changes in how HCPs and patients view and access dialysis for kidney failure, including their preference for specific dialysis modalities.

Kidney services vary in how they involve individuals with kidney failure (PwKF) in treatment decisions as management needs change. Decision-science applications can proactively support PwKF to make informed decisions between treatment options with kidney professionals, as discussed in 6 . This review presents a schema representing different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together. Adjustments at micro, meso, and macro levels support integration in practice. Innovating services to meet clinical guidelines on enhancing shared decision-making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service, and organizational levels.

Indigenous leadership is crucial for reducing inequities in the treatment of kidney failure, as highlighted in .

Traditional paternalistic medicine in nephrology has been modified to a shared decision-making model that clearly benefits patients with kidney disease. Understanding kidney disease is a cornerstone of shared treatment decision-making for patients with kidney failure. However, kidney disease is often silent until advanced stages and has a complex pathophysiology that is not well understood by the general population. Health literacy (HL) plays a critical role in the care of patients with kidney disease and shared treatment decisions. Limited HL is associated with inefficient use of health services, medication non-compliance, worse quality of life, and increased mortality. This review addresses the importance of low HL in nephrology in terms of diagnosis, measurement, its effects on shared decision-making, and how to increase it in people with kidney disease. 5 .

Nephropathic Cystinosis (NC), a rare disease characterized by the intra-lysosomal accumulation of cystine, results in progressive kidney failure (KF). Compliance with lifelong oral cysteamine treatment, the only therapy, is often compromised. The relationship between compliance and the costs of NC has not been formally assessed previously. This study evaluates the impact of compliance on the lifetime (direct) costs of treating KF in NC patients in the United Kingdom. 3

Benefits and Risks

Benefits Summary

Kidney transplantation for kidney failure patients offers a significant benefit compared to dialysis, resulting in longer survival and improved quality of life. 2

Peritoneal dialysis (PD) may be more effective than hemodialysis (HD) in preserving residual kidney function, reducing hemodynamic effects, and lowering the risk of bleeding and cardiovascular events in diabetic kidney failure patients. 7

Risks Summary

PD can increase the risk of protein-energy malnutrition and infection. 7

Informing patients about treatment options and involving them in the decision-making process can facilitate a smooth transition into life-sustaining treatment. However, the initiation of kidney failure replacement therapy can be a traumatic experience for patients with kidney failure, causing physical and emotional distress and disrupting several aspects of their social life. 1

Research Comparisons

Commonalities in Research

Multiple studies examine the effectiveness and safety of various treatment options for patients with kidney failure. These studies focus on important outcomes like quality of life, survival duration, and the occurrence of complications.

Differences in Research

Research studies vary in their focus on different populations of kidney failure patients, treatment options, and outcome measurement methods. For example, 7 focuses on patients with diabetic kidney failure, while 2 examines the cardiorespiratory fitness of patients who have received kidney transplants.

Consistency and Inconsistencies in Results

Multiple studies suggest that kidney transplantation provides longer survival and improved quality of life for kidney failure patients compared to dialysis. However, achieving these benefits depends on patient compliance and proper management after transplantation. Concerning the comparison between PD and HD, PD may be more effective in preserving residual kidney function, reducing hemodynamic effects, and lowering the risk of bleeding and cardiovascular events. However, PD can increase the risk of protein-energy malnutrition and infection.

Application in Real Life: Considerations

The findings of these studies provide valuable insights into the care of patients with kidney failure. However, applying these findings to individual patients requires careful consideration because each patient's needs, risks, and preferences are unique. Clinicians and patients should discuss the available treatment options and select the most appropriate course of treatment for the patient's specific situation.

Limitations of Current Research

These studies have limitations, including their often single-center focus on specific treatment options, which may limit the generalizability of their findings to other populations. Additionally, the short follow-up duration in many studies prevents the evaluation of long-term effects.

Future Research Directions

Future research should address several critical issues related to the treatment of patients with kidney failure. These include investigating the long-term effects of various treatment options, examining the association between patient compliance and outcomes, and developing new treatment approaches. Furthermore, understanding the variation in treatment outcomes across different populations, empowering patients in the decision-making process, and developing interventions to improve patient quality of life are crucial areas for future research.

Conclusion

Kidney failure is a serious health problem that is increasing worldwide. These studies investigate the effectiveness and safety of various treatment options for patients with kidney failure. While the findings can help clinicians select the most appropriate treatment for their patients, careful consideration is necessary when applying these findings to individual patients due to unique needs, risks, and preferences. Future research is essential to continue improving the care of patients with kidney failure.

We can make a difference in the lives of those with kidney failure through advancements in knowledge, patient empowerment, and commitment to healthcare equity. Prioritize your health and your family's health by adopting healthy lifestyle practices to maintain kidney health.

Treatment List

Kidney transplantation, hemodialysis, peritoneal dialysis, oral cysteamine, peripheral vascular intervention