Embedding frailty assessment and management into advanced kidney care services across London
Abstract
Background
Frailty is highly prevalent amongst people living with kidney disease, and is set to increase as the population ages. In those aged over 80, or over 65 living with frailty, there is limited evidence of a survival benefit from renal replacement therapy (RRT) and clear evidence of poorer perceived quality of life. Despite this, shared decision making around alternatives to RRT is often not explored meaningfully.
Methods
Consultant geriatricians were embedded within the renal services of three London renal units. Referral criteria were patients within advanced kidney care clinics who were aged ≥60 with a Clinical Frailty Scale (CFS) score ≥5, aged ≥80 regardless of CFS, had ≥3 admissions in the last year, or otherwise based on clinical judgement.
Geriatricians undertook comprehensive geriatric assessment resulting in new diagnoses, identification of unmet functional need, and exploration of values and priorities, ultimately leading to personalised shared decision making and advance care planning (ACP).
Results
374 patients were seen. 189 patients who had previously planned for RRT or been undecided chose conservative kidney management (CKM) after geriatrician input. In the 12 months prior to death, patients in conservative kidney management had fewer hospital admissions (CKM 1.3; HD 2.6) and spent fewer days in hospital (CKM 11.2; HD 31.5) than patients on haemodialysis (HD). Several new diagnoses were made including previously unrecognised cognitive impairment (23 in one centre), postural instability, higher-level gait and movement disorders. Rates of ACP completion were high: of 13 patients dying at one centre, 12 patients had involvement from a palliative care team, with seven dying at home.
Conclusion
Geriatrician involvement in advanced kidney care supports informed decision making, identifies frailty syndromes, and is associated with high rates of advance care planning. Geriatricians now contribute to five of seven London renal units. This collaborative approach is replicable nationally.