#1746 Comprehensive kidney care: adopting principles of comprehensive geriatric assessment within an advanced kidney care clinic
Authors: Sanhueza Patricio Abarca , Minen Isa , Nixon Andrew C 
Published: May 2024

Abstract

Background and Aims
Chronic Kidney Disease (CKD) is increasingly prevalent among older people, a trend that presents significant healthcare challenges. This project introduces the Comprehensive Kidney Care (CKC) clinic model which incorporates elements from Comprehensive Geriatric Assessment within the Advanced Kidney Care clinic. By focusing on a holistic care, this model aims to enhance symptom management, facilitate appropriate referrals, improve documentation, and offer advance care planning (ACP), ultimately to improve care quality for older people with advanced CKD.

Method
We evaluated 27 patients ≥65 years old with CKD stage 4 and 5, attending the CKC clinic between 23/11/2022 and 22/11/2023. Demographics and clinical characteristics were recorded, including Charlson Comorbidity Index (CCI). Individual symptoms and total score were screened in each clinic using the Integrated Palliative Outcome Score (IPOS)-Renal Symptom Survey. Geriatric impairments were assessed including frailty (Clinical Frailty Scale [CFS]), mobility, polypharmacy (≥5 medications), activities of daily living (ADLs), falls and cognition. Actions were documented, including initiation of ACP discussions and other relevant interventions.

Results
Patients’ average age was 82 (SD 5.8), they were predominantly male (20 patients, 74%) and had a median eGFR of 18 ml/min/1.73 m2 (IQR 10). They exhibited a high burden of comorbidities (CCI mean 8.4, SD 2) and a high prevalence of geriatric impairments: 74% (20 patients) had a CFS score ≥4, 63% (17) required mobility aids, 26% (7) reported falls, 30% (8) required assistance with ADLs, and all had polypharmacy. IPOS was recorded for 20 patients. Mean total score was 10.25 (IQR 8). Fig. 1 demonstrates the symptoms reported as experienced ‘moderately’ or worse at first IPOS completion. Thirteen patients had more than one IPOS completed, allowing each symptom to be compared at two consecutive clinic attendances 239 times. Symptom improvement was more common than worsening (37 [15.5%] versus 11 [4.6%]). Most times symptoms remained stable (43, 18%) or were absent (132, 55.2%), with a minority appearing 16 times (6.7%). Seventeen relevant actions were identified, including symptom management (14 patients, 51.9%), physical activity advice (7, 25.9%), referrals to other teams (12, 44.4%; 2 referred to more than one), including dietitian (4), psychology (3), frailty team (2), physiotherapy (2), memory assessment clinic, social care, falls clinic and palliative care (1 each). Preferred kidney management was discussed with 9 patients (33%); 9 patients had documented preferences before attending the CKC clinic. Ten (37%) preferred conservative care, 4 (15%) haemodialysis and 13 (48%) remained undecided. Undecided patients had a significantly higher eGFR (median 21 [IQR 4] versus 12 ml/min/1.73 m2 [IQR 6.75], p-value 0.012). ACP was discussed with 8 patients; these patients had higher CFS scores (median 6 versus 4, IQR 1.25, p-value 0.005) and higher ADL dependence (Odds ratio 8.9, p-value 0.026).

Conclusion
The CKC clinic model shows promise as an effective approach for assessing and managing older people with advanced CKD. Most times symptoms improved or remained unchanged, suggesting actions were effective at managing symptom burden. ACP discussions were more commonly initiated in patients with higher frailty severity and ADL dependence; obtaining geriatric impairment information may help prompt ACP discussions.