A Study of CKM-EMPOWER: Empowering Medical Professionals on CKM With Educational Resources
Phase: NA
Conditions: Kidney Disease, Chronic
Sponsor: University of Washington

 
 
 
 
 
 
 
 
 
A Study of CKM-EMPOWER:  
Empowering Medical Professionals on CKM with Educational Resources 
Funding Agency: Doris Duke Charitable Foundation 
Award: Clinical Scientist Development Award 
Principal Investigator: Susan P.Y. Wong, MD 
Protocol 
6/7/2024 
 
 

 
Page 2 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
 
Abstract 
Objective(s) and Hypotheses: 
Conservative kidney management (CKM) is an important therapeutic alternative for patients 
who do not wish to pursue dialysis for their advanced chronic kidney disease (CKD). Despite 
a growing body of evidence and clinical services to support patients who do not wish to 
pursue dialysis, nephrologists receive very limited training in CKM. This study aims to test the 
efficacy of a series of just-in-time educational videos on topics related to CKM (CKM-
EMPOWER) in improving nephrology providers ability to provide CKM. The investigators 
hypothesize that the CKM-EMPOWER will improve nephrology fellows’ knowledge and 
confidence with delivering key elements of CKM.  
 
Research Design: 
This is a randomized trial of nephrology fellows that utilizes surveys to assess their change in 
knowledge, confidence and practice of providing CKM with receipt of CKM-EMPOWER.  
 
Methodology 
126 nephrology fellows will be recruited from around US fellowship programs and randomize 
participants in a 1:1 fashion to either receipt of the CKM-EMPOWER or non-receipt. 
Participants will complete web-based surverys to assess knowledge and confidence with 
providing CKM between groups. 
 
Relevance 
 
 
 
 
 
 
 
 
           
An important step to towards helping patients receive treatment for kidney failure that is right 
for them is expanding access to a range of positive therapeutic options. The proposed study 
has the potential to lead to improved access and delivery of CKM and ensuring that patients 
who prefer CKM are able to receive the care that they desire.  
 

 
Page 3 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
List of Abbreviations 
 
CKD: chronic kidney disease 
Conservative Kidney Management: CKM 
UW: University of Washington, Seattle WA 
KRI: Kidney Research Institute, University of Washington, Seattle WA 

 
Page 4 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
 
Table of Contents 
PROTOCOL TITLE: A STUDY OF CKM-EMPOWER .................................................................................... 5 
1.0 
STUDY PERSONNEL .................................................................................................................. 5 
2.0 
INTRODUCTION ....................................................................................................................... 5 
3.0 
OBJECTIVES ............................................................................................................................. 6 
4.0 
STUDY SITES ............................................................................................................................ 6 
5.0  
STUDY DESIGN ........................................................................................................................ 6 
5.1 STUDY ARMS ......................................................................................................................................... 6 
5.2 POTENTIAL RISKS AND BENEFITS ................................................................................................................ 7 
5.3 RECRUITMENT METHODS ......................................................................................................................... 7 
5.3 INFORMED CONSENT PROCEDURES ............................................................................................................ 8 
5.4 INCLUSION/EXCLUSION CRITERIA .............................................................................................................. 8 
5.5 STUDY EVALUATIONS .............................................................................................................................. 8 
5.6 DATA ANALYSIS ..................................................................................................................................... 9 
5.7 WITHDRAWAL OF SUBJECTS ...................................................................................................................... 9 
5.0 
REPORTING ............................................................................................................................. 9 
6.0 
PRIVACY AND CONFIDENTIALITY ............................................................................................ 10 
7.0 
COMMUNICATION PLAN ......................................................................................................... 10 
10.0 
REFERENCES ......................................................................................................................... 10 
 
 
 

 
Page 5 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
Protocol Title: A Study of CKM-EMPOWER 
 
1.0 
Study Personnel 
 
Principal Investigator:  
Susan P. Y. Wong, M.D.  
Associate Professor of Medicine, University of Washington (UW) 
1660 S. Columbian Way, Renal Dialysis Unit 5B-113, Seattle WA 98108 
Email: spywong@uw.edu 
Phone: 206-277-3012 
Fax: 206-764-2022 
 
Co-investigators: 
Daniel Lam, MD 
Associate Professor of Medicine, University of Washington (UW) 
 
Stephanie Wheeler, MD 
Associate Professor of Medicine, University of Washington (UW) 
 
Research Personnel 
Julie Chotivatanapong, BA 
Research Coordinator, KRI 
 
Taryn Oestreich, M.P.H. 
Research Coordinator, KRI  
 
Rachel Smith, B.A. 
Study Coordinator, KRI  
 
David Prince, Ph.D. 
Biostatistician, KRI  
2.0 
Introduction 
 
Chronic kidney disease (CKD) afflicts 1 in 7 Americans. Although dialysis is commonly regarded 
as a life-prolonging therapy for advanced CKD, there is growing recognition that dialysis is not 
always beneficial. Decisions about dialysis often involve difficult trade-offs between the potential 
gains in longevity and symptom management and the burdens of treatment including the 
substantial time spent on dialysis, complications related to treatment, frequent interaction with 
the healthcare system and loss of independence.  
 
Conservative kidney management (CKM) is an important option for patients who choose not to 
pursue dialysis that focuses on slowing the decline in renal function, active symptom 
management, advance care planning and the provision of appropriate palliative care. 
Conservatively managed patients can survive several years after their decision to pursue CKM 

 
Page 6 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
and experience sustained quality of life until late in the course of illness.1 For adults aged ≥75 
years with significant comorbidity and functional impairment, dialysis might not improve survival2-
7 and quality of life8-10 beyond what can be achieved with a more conservative approach for 
advanced CKD. Conservatively managed patients also spend less time in the hospital,6,11-13 less 
often experience burdensome procedures,6,13 and less often die in the hospital setting than 
patients treated with dialysis.3,13-16 
 
Despite a growing body of evidence and clinical services to support patients who do not wish to 
pursue dialysis,17,18 nephrology providers receive very limited training in CKM. Thus, it is not 
suprising that many providers find it difficult or are reluctant to discuss conservative options for 
advanced CKD.19,20 Qualitative interviews with providers indicate that many feel ill- equipped to 
provide CKM or worry that to not pursue dialysis might be perceived as “no care” or “giving 
up.”17,19  
 
The current application is to support a randomized controlled trial to test the efficacy of a series 
of just-in-time educational videos on CKM (CKM-EMPOWER) with nephrology fellows that was 
created by a research team led by the principal investigator (PI, Wong). CKM-EMPOWER has 
the potential to be a cost-effective, time-saving and scalable intervention to improve provider 
education on CKM and delivery of CKM to patients with advanced CKD.  
3.0 
Objectives 
The investigators aim to conduct a randomized controlled trial to test the efficacy of CKM-
EMPOWER in improving nephrology fellows’ knowledge of CKM, and explore preliminary 
outcomes, including confidence in managing health concerns of patients opting for CKM, 
challenges in caring for patients who opt for CKM, and changes in practice with caring for 
patients who opt for CKM. The investigators hypothesize that CKM-EMPOWER will improve 
nephrology fellows’ knowledge of CKM.  
4.0 
Study sites 
 
Nephrology fellows will be recruited from US fellowship programs. Fellowship programs will be 
purposively sampled to reflect of range of geographic locations, academic and community 
teaching sites, and size. All recruitment, data collection and data analyses will occur at UW.  
5.0  Study Design 
 
The investigators will conduct a randomized controlled trial to test the efficacy of CKM-
EMPOWER among nephrology fellows. 
  
5.1 Study arms 
 
Participants will be randomized in a 1:1 fashion using REDCap auto-randomizer to either 1 of 2 
groups, receipt of CKM-EMPOWER (intervention group) or non-receipt of CKM-EMPOWER 
(control group).  
 

 
Page 7 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
CKM-EMPOWER (intervention group) 
CKM-EMPOWER is a series of 11 just-in-time educational videos on topics related to caring for 
patients who opt for CKM: CKM overview, dysgeusia, fatigue, restless leg syndrome, uremic 
pruiritis, cramping, pain, volume overload, electrolyte abnormalities, anticipatory grief, and 
actively dying patient. Videos are approximately 5-10 minutes in length and intended to provide 
learners with a brief overiew on the definition of each issue, impact of the issue on a patient, 
assessment of the issue, and approaches to addressing the issue. Videos conclude with 
references to additional resources on each topic for more in-depth self-study. CKM-EMPOWER 
was created by a team comprised of a health educator, the principal investigator (nephrologist), a 
geriatrician and a physician dually trained in nephrology and palliative care and with feedback 
from a geriatric pharmacist and members of a national professional interest workgroup in kidney 
palliative care. CKM-EMPOWER videos will be made available on an unlisted Youtube channel. 
 
Control group  
Participants randomized to the control group will not receive CKM-EMPOWER until after the 
study is completed. 
5.2 Potential Risks and Benefits 
 
Anticipated risks:  
The principal risk posed to patients is the potential loss of confidentiality. The proposed work 
requires the collection of personal information to identify and recruit eligible subjects and contact 
and maintain follow up. To minimize this risk, investigators have outlined steps below to 
safeguard confidentiality. These include restricting data analyses to only de-identified data files, 
keeping separate a crosswalk file linking study ID with personal identifiers and data analysis files, 
storage of data on password-protected secure servers accessible to only study team members 
who have completed training in the protection of human subjects, and the aggregation of study 
data for presentations and publications in order to conceal the subjects’ identities. 
 
Potential Benefits:  
Subjects may benefit from this research directly and indirectly. This study will provide education 
to subjects on a topic that they may know little about, potentially improving their knowledge and 
ability to care for patients opting for CKM.  
 
With the measures outlined, investigators believe that the potential risks associated with the 
proposed work will be mitigated and will not outweigh the potential benefit to study subjects and 
the greater CKD population.  
5.3 Recruitment Methods 
 
Investigators aim to enroll 126 nephrology fellows. Using email, investigators will contact the 
program directors of nephrology fellowship programs from around the US to request their 
permission to disseminate an email invitation to circulate among their program fellows to 
participate in the study. Fellowship programs will be purposively sampled to represent a diverse 
range of geographic regions and academic and non-academic settings. Investigators will send no 
more than 2 follow-up emails to program directors requesting their assistance to circulate our 
email invitation.  
 
 

 
Page 8 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
5.3 Informed Consent Procedures 
 
Embedded in the email invitation will be a hyperlink to an online consent form hosted on 
REDCap (https://redcap.link/CKM-EMPOWER). The consent form describes the study 
procedures, risks, and benefits, and information on what to do and expect if they decide not to 
participate. A copy of the consent form can also be downloaded from the webpage.  
 
Fellows will be informed that participation is fully voluntary and that their decision regarding 
participation will be kept confidential from their fellowship program and program directors. 
5.4 Inclusion/Exclusion Criteria 
 
Inclusion  
• 
Matriculated in a US nephrology program 
 
Exclusion 
• 
None 
 
5.5 Study Evaluations 
 
The date of study enrollment will be the date that a subject’s consent is obtained.  
 
Participants will complete the following surveys at enrollment. Participants randomized to the 
control group will have 2 weeks to complete the surveys Participants randomized to the 
intervention will have 2 weeks to review CKM-EMPOWER videos and complete the surveys. All 
surveys will be administered through REDCap. Each survey will take approximately of 15 to 30 
minutes to complete. Investigators will send up to 3 reminder emails to participants around the 
time of each study visit to complete the surveys. Investigators will give participants a $5 e-gift 
card to participants randomized to the control group and $10 e-gift card to participants 
randomized to the intervention group due to the additional time spent reviewing videos.  
 
Demographic questions: Participants will be asked their gender, age, race, ethnicity, whether 
they are a US or international medical school graduate, years since graduating medical degree, 
current year in nephrology fellowship, and whether they have completed fellowship in a 
subspecialty other than nephrology. 
 
Experience with CKM: Participants will be asked the total number of clinic patients with CKD 
stage 4-5 who have chosen to forgo dialysis whom they have cared for. 
 
Comfort with providing CKM:  Participants will be asked to rate their level of comfort with 
managing patients who have chosen CKM; dysgeusia, fatigue, restless leg syndrome, uremic 
pruiritis, cramping, pain, volume overload, electrolyte abnormalities, and anticipatory grief in 
patients who have chosen CKM; and, patients who have chosen CKM and are actively dying. 
 
Knowledge of CKM: Participants will be asked 11 multiple choice questions about managing 
patients who have chosen CKM; dysgeusia, fatigue, restless leg syndrome, uremic pruiritis, 
cramping, pain, volume overload, electrolyte abnormalities, and anticipatory grief in patients who 

 
Page 9 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
have chosen CKM; and, patients who have chosen CKM and are actively dying. Each knowledge 
questions has 4 answers of which more than one can be correct.  
 
Challenges with CKM: Participants who are randomized to the control group will be asked what 
they find more challenging with managing patients who have chosen CKM; dysgeusia, fatigue, 
restless leg syndrome, uremic pruiritis, cramping, pain, volume overload, electrolyte 
abnormalities, and anticipatory grief in patients who have chosen CKM; and, patients who have 
chosen CKM and are actively dying.  
 
Change in CKM practice: Participants who are randomized to the intervention group will be 
asked what they have learned from the intervention that they intend to apply in their practice in 
managing patients who have chosen CKM; dysgeusia, fatigue, restless leg syndrome, uremic 
pruiritis, cramping, pain, volume overload, electrolyte abnormalities, and anticipatory grief in 
patients who have chosen CKM; and, patients who have chosen CKM and are actively dying. 
 
5.6 Data Analysis 
Change in CKM knowledge: As the primary analysis, investigators will compare the mean 
number of knowledge questions (total 44) answered correctly between arms using a two-sample 
t-test. The target sample size (n=126) is estimated to provide 80% power (two tailed, a=0.05) to 
detect an absolute difference of 27 or more questions answered correctly between the 
intervention and control groups assuming a baseline knowledge rate of 22/44 and standard 
deviation of 10. In case of drop-out, investigators will continue to recruit participants until the 
target sample size who have completed both study visits has been achieved. 
 
As a pre-specified analysis, investigators will compare the mean number of questions in 
each category (total 11) answered correctly between study arm groups. Differences for which 
p<0.005 will be considered statistically significant (Bonferonni correction).   
 
Confidence with CKM: As a secondary outcome, investigators will compare confidence scores 
between study arms for each topic using two-tailed t-tests. 
 
Exploratory outcomes: Using thematic analysis, investigators will assess self-reported challenges 
with each topic among participants randomized to the control arm and self-reported change in 
CKM practice with each topic among participants randomized to the intervention arm. 
5.7 Withdrawal of Subjects 
 
There are no anticipated circumstances under which subjects will be withdrawn from the 
research without their consent. There are no anticipated consequences of a subject's decision to 
withdraw from the research. 
5.0 
Reporting 
Investigators do not anticipate any adverse events that might occur. However, any and all 
unanticipated problems, serious adverse events and protocol deviations will be recorded and 
reported immediately to the study Principal Investigator. Any serious adverse events and/or 
serious problems will be reported to the IRB within 5 business days. Additionally, the ISO and 
Privacy Officer will be notified within one hour of any improper use or disclosure of study data. 
The Principal Investigator will be the monitoring entity responsible for ensuring that all measures 
related to data security and protection of subject privacy and confidentiality are being followed. 

 
Page 10 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
 
Subjects will be informed to contact the PI for all urgent and non-urgent questions and concerns 
at the following: Susan Wong, Phone: 206-277-3012. 
6.0 
Privacy and Confidentiality 
The proposed work will use protected health information. All study personnel who will have 
access to protected health information and/or will be involved in obtaining subject consent will be 
required to complete all necessary training in the protection of human subjects and privacy. All 
study personnel who have access to study and participant data have been approved by the UW. 
 
All subjects will be given a unique study ID, and data collected for this study will be associated 
with study IDs only. A separate crosswalk file linking study IDs with personal identifiers will be 
kept separate from data analysis files. Data analysis files will not contain personal identifiers.  
 
Study data will be aggregated for presentations or publications related to the study in order to 
conceal the identities of subjects. 
7.0 
Communication Plan 
The Head of the Division of Nephrology at each medical center will be notified of any adverse 
events or changes to the study protocol.  
 
9.0      Information Security and Data Storage/Movement 
Participant data, including recruitment information and survey responses will be stored at the KRI 
in secure study folders.  
 
Survey study data will be assembled using structured forms designed in Microsoft Excel and 
saved in secure study folders. Data will be associated with study IDs only.  
 
Only approved study team members will be authorized to access the study folders  
After all data are analyzed and manuscripts summarizing study findings are published (estimated 
2029), all identifiable and crosswalk files will be destroyed. 
 
Data Sharing Plan: 
 
Partial restrictions to the data and/or materials apply: anonymized data for the study will be made 
available to interested parties upon written request and submission of a formal written research 
proposal that has undergone human subjects review. 
10.0 References 
1. USRDS. Annual Data Report, Atlas of Chronic Kidney Disease in the United States. Bethesda, 
Md.: National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney 
Diseases; 2017. 

 
Page 11 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
2. Montez-Rath ME, Zheng Y, Tamura MK, Grubbs V, Winkelmayer WC, Chang TI. 
Hospitalizations and Nursing Facility Stays During the Transition from CKD to ESRD on Dialysis: 
An Observational Study. J Gen Intern Med 2017;32:1220-7. 
3. Wong SP, Kreuter W, O'Hare AM. Healthcare intensity at initiation of chronic dialysis among 
older adults. J Am Soc Nephrol 2014;25:143-9. 
4. Purnell TS, Auguste P, Crews DC, et al. Comparison of life participation activities among 
adults treated by hemodialysis, peritoneal dialysis, and kidney transplantation: a systematic 
review. Am J Kidney Dis 2013;62:953-73. 
5. Jassal SV, Chiu E, Hladunewich M. Loss of independence in patients starting dialysis at 80 
years of age or older. New England Journal of Medicine 2009;361:1612-3. 
6. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. 
Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 
2009;361:1539-47. 
7. Kidney Disease: Improving Global O. KDIGO 2012 Clinical Practice Guidelines for the 
Evaluation and Management of Chronic Kidney Disease. Kidney Int 2012;3. 
8. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A 
comparative survival study of patients over 75 years with chronic kidney disease stage 5. 
Nephrol Dial Transplant 2007;22:1955-62. 
9. Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. Choosing 
not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-
stage renal failure. Nephron Clin Pract 2003;95:c40-6. 
10. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. 
Survival of elderly patients with stage 5 CKD: comparison of conservative management and 
renal replacement therapy. Nephrol Dial Transplant 2011;26:1608-14. 
11. Verberne WR, Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ. Comparative 
Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus 
with Dialysis. Clin J Am Soc Nephrol 2016;11:633-40. 
12. Shum CK, Tam KF, Chak WL, Chan TC, Mak YF, Chau KF. Outcomes in older adults with 
stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative 
management. J Gerontol A Biol Sci Med Sci 2014;69:308-14. 
13. Rouveure AC, Bonnefoy M, Laville M. [Conservative treatment, hemodialysis or peritoneal 
dialysis for elderly patients: The choice of treatment does not influence the survival]. Nephrol 
Ther 2016;12:32-7. 
14. Da Silva-Gane M, Wellsted D, Greenshields H, Norton S, Chandna SM, Farrington K. Quality 
of life and survival in patients with advanced kidney failure managed conservatively or by 
dialysis. Clin J Am Soc Nephrol 2012;7:2002-9. 

 
Page 12 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
15. Yong DS, Kwok AO, Wong DM, Suen MH, Chen WT, Tse DM. Symptom burden and quality 
of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care. Palliat 
Med 2009;23:111-9. 
16. Seow YY, Cheung YB, Qu LM, Yee AC. Trajectory of quality of life for poor prognosis stage 
5D chronic kidney disease with and without dialysis. Am J Nephrol 2013;37:231-8. 
17. Davis JL, Davison SN. Hard choices, better outcomes: a review of shared decision-making 
and patient decision aids around dialysis initiation and conservative kidney management. Curr 
Opin Nephrol Hypertens 2017;26:205-13. 
18. Hussain JA, Flemming K, Murtagh FE, Johnson MJ. Patient and health care professional 
decision-making to commence and withdraw from renal dialysis: a systematic review of 
qualitative research. Clin J Am Soc Nephrol 2015;10:1201-15. 
19. Song MK, Lin FC, Gilet CA, Arnold RM, Bridgman JC, Ward SE. Patient perspectives on 
informed decision-making surrounding dialysis initiation. Nephrol Dial Transplant 2013;28:2815-
23. 
 
 
1. 
Wong SPY, Rubenzik T, Zelnick L, et al. Long-term Outcomes Among Patients With 
Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review. JAMA Netw 
Open. Mar 1 2022;5(3):e222255. doi:10.1001/jamanetworkopen.2022.2255 
2. 
Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A 
comparative survival study of patients over 75 years with chronic kidney disease stage 5. 
Nephrol Dial Transplant. Jul 2007;22(7):1955-62. doi:10.1093/ndt/gfm153 
3. 
Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. 
Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients 
with end-stage renal failure. Nephron Clin Pract. 2003;95(2):c40-6. doi:10.1159/000073708 
4. 
Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. 
Survival of elderly patients with stage 5 CKD: comparison of conservative management and 
renal replacement therapy. Nephrol Dial Transplant. May 2011;26(5):1608-14. 
doi:10.1093/ndt/gfq630 
5. 
Verberne WR, Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ. Comparative 
Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus 
with Dialysis. Clin J Am Soc Nephrol. Apr 7 2016;11(4):633-40. doi:10.2215/CJN.07510715 
6. 
Shum CK, Tam KF, Chak WL, Chan TC, Mak YF, Chau KF. Outcomes in older adults 
with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative 
management. J Gerontol A Biol Sci Med Sci. Mar 2014;69(3):308-14. doi:10.1093/gerona/glt098 
7. 
Rouveure AC, Bonnefoy M, Laville M. [Conservative treatment, hemodialysis or 
peritoneal dialysis for elderly patients: The choice of treatment does not influence the survival]. 
Nephrol Ther. Feb 2016;12(1):32-7. Traitement conservateur, hemodialyse ou dialyse 
peritoneale chez le sujet age : le choix du traitement ne modifie pas la survie. 
doi:10.1016/j.nephro.2015.07.473 
8. 
Da Silva-Gane M, Wellsted D, Greenshields H, Norton S, Chandna SM, Farrington K. 
Quality of life and survival in patients with advanced kidney failure managed conservatively or by 
dialysis. Clin J Am Soc Nephrol. Dec 2012;7(12):2002-9. doi:10.2215/CJN.01130112 

 
Page 13 of 13 
A Study of CKM-EMPOWER 
Protocol 
3/29/24 
9. 
Yong DS, Kwok AO, Wong DM, Suen MH, Chen WT, Tse DM. Symptom burden and 
quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care. 
Palliat Med. Mar 2009;23(2):111-9. doi:10.1177/0269216308101099 
10. 
Seow YY, Cheung YB, Qu LM, Yee AC. Trajectory of quality of life for poor prognosis 
stage 5D chronic kidney disease with and without dialysis. Am J Nephrol. 2013;37(3):231-8. 
doi:10.1159/000347220 
11. 
van Loon IN, Goto NA, Boereboom FTJ, Verhaar MC, Bots ML, Hamaker ME. Quality of 
life after the initiation of dialysis or maximal conservative management in elderly patients: a 
longitudinal analysis of the Geriatric assessment in OLder patients starting Dialysis (GOLD) 
study. BMC Nephrol. Mar 29 2019;20(1):108. doi:10.1186/s12882-019-1268-3 
12. 
Verberne WR, Dijkers J, Kelder JC, et al. Value-based evaluation of dialysis versus 
conservative care in older patients with advanced chronic kidney disease: a cohort study. BMC 
Nephrol. Aug 16 2018;19(1):205. doi:10.1186/s12882-018-1004-4 
13. 
Wong SP, Yu MK, Green PK, Liu CF, Hebert PL, O’Hare AM. End-of-life care for patients 
with advanced kidney disease in the US Veterans Affairs Health Care System, 2000-2011. 
American Journal of Kidney Diseases. 2018:(in press). doi:10.1053/j.ajkd.2017.11.007 
14. 
Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management 
an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? 
Clin J Am Soc Nephrol. Oct 2009;4(10):1611-9. doi:10.2215/CJN.00510109 
15. 
Kwok AO, Yuen SK, Yong DS, Tse DM. The Symptoms Prevalence, Medical 
Interventions, and Health Care Service Needs for Patients With End-Stage Renal Disease in a 
Renal Palliative Care Program. Am J Hosp Palliat Care. Dec 2016;33(10):952-958. 
doi:10.1177/1049909115598930 
16. 
Verberne WR, Ocak G, van Gils-Verrij LA, van Delden JJM, Bos WJW. Hospital 
Utilization and Costs in Older Patients with Advanced Chronic Kidney Disease Choosing 
Conservative Care or Dialysis: A Retrospective Cohort Study. Blood Purif. 2020;49(4):479-489. 
doi:10.1159/000505569 
17. 
Wong SPY, Boyapati S, Engelberg RA, Thorsteinsdottir B, Taylor JS, O'Hare AM. 
Experiences of US Nephrologists in the Delivery of Conservative Care to Patients With 
Advanced Kidney Disease: A National Qualitative Study. Am J Kidney Dis. Sep 27 
2019;doi:10.1053/j.ajkd.2019.07.006 
18. 
Neumann ME. Medical management without dialysis offers alternative therapy. 
Nephrology News & Issues. 2021;35(January 2020):18-21.  
19. 
Ladin K, Pandya R, Kannam A, et al. Discussing Conservative Management With Older 
Patients With CKD: An Interview Study of Nephrologists. Am J Kidney Dis. Jan 31 
2018;71(5):627-635. doi:10.1053/j.ajkd.2017.11.011 
20. 
Wong SPY, McFarland LV, Liu CF, Laundry RJ, Hebert PL, O’Hare AM. Care practices 
for patients with advanced kidney disease who forgo maintenance dialysis. JAMA Intern Med. 
2019;179(3):305-313. doi:10.1001/jamainternmed.2018.6197