Barriers to conservative care from patients’ and nephrologists’ perspectives: the CKD-REIN study
Authors: Hamroun Aghilès , Speyer Elodie , Ayav Carole , Combe Christian , Fouque Denis , Jacquelinet Christian , Laville Maurice , Liabeuf Sophie , Massy Ziad A , Pecoits-Filho Roberto , Robinson Bruce M , Glowacki François , Stengel Bénédicte , Frimat Luc ,   CKD-REIN study Collaborators, de Pinho Natalia Alencar , Ayav Carole , Briançon Serge , Cannet Dorothée , Combe Christian , Fouque Denis , Frimat Luc , Herpe Yves-Edouard , Jacquelinet Christian , Laville Maurice , Massy Ziad A , Pascal Christophe , Robinson Bruce M , Stengel Bénédicte , Lange Céline , Legrand Karine , Liabeuf Sophie , Metzger Marie , Speyer Elodie , Hannedouche Thierry , Moulin Bruno , Mailliez Sébastien , Lebrun Gaétan , Magnant Eric , Choukroun Gabriel , Deroure Benjamin , Lacraz Adeline , Lambrey Guy , Philippe Bourdenx Jean , Essig Marie , Lobbedez Thierry , Azar Raymond , Sekhri Hacène , Smati Mustafa , Jamali Mohamed , Klein Alexandre , Delahousse Michel , Combe Christian , Martin Séverine , Landru Isabelle , Thervet Eric , Massy Ziad A , Lang Philippe , Belenfant Xavier , Urena Pablo , Vela Carlos , Frimat Luc , Chauveau Dominique , Panescu Victor , Noel Christian , Glowacki François , Hoffmann Maxime , Hourmant Maryvonne , Besnier Dominique , Testa Angelo , Kuentz François , Zaoui Philippe , Chazot Charles , Juillard Laurent , Burtey Stéphane , Keller Adrien , Kamar Nassim , Fouque Denis , Laville Maurice 
Published: January 2022

ABSTRACT

Background
Conservative care is increasingly considered an alternative to kidney replacement therapy for kidney failure management, mostly among the elderly. We investigated its status and the barriers to its implementation from patients’ and providers’ perspectives.

Methods
We analysed data from 1204 patients with advanced chronic kidney disease (CKD) [estimated glomerular filtration rate (eGFR) &lt;30 mL/min/1.73 m2] enrolled at 40 nationally representative nephrology clinics (2013–16) who completed a self-administered questionnaire about the information they received and their preferred treatment option, including conservative care, if their kidneys failed. Nephrologists (n = 137) also reported data about their clinics’ resources and practices regarding conservative care.

Results
All participating facilities reported they were routinely able to offer conservative care, but only 37% had written protocols and only 5% had a person or team primarily responsible for it. Overall, 6% of patients were estimated to use conservative care. Among nephrologists, 82% reported they were fairly or extremely comfortable discussing conservative care, but only 28% usually or always offered this option for older (&gt;75 years) patients approaching kidney failure. They used various terminology for this care, with conservative management and non-dialysis care mentioned most often. Among patients, 5% of those &gt;75 years reported receiving information about this option and 2% preferring it.

Conclusions
Although reported by nephrologists to be widely available and easily discussed, conservative care is only occasionally offered to older patients, most of whom report they were not informed of this option. The lack of a person or team responsible for conservative care and unclear information appear to be key barriers to its implementation.