Beyond the Guidelines
4 August 2020

Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Publication: Annals of Internal Medicine
Volume 173, Number 3


About 15% of adults in the United States—37 million persons—have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts—a nephrologist and a general internist–palliative care physician—reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

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Supplemental Material

Supplement. Beyond the Guidelines: Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia (slide set)


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Information & Authors


Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 173Number 34 August 2020
Pages: 217 - 225


Published online: 4 August 2020
Published in issue: 4 August 2020




Risa B. Burns, MD, MPH
Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
Sushrut S. Waikar, MD, MPH
Boston University Medical Center, Boston, Massachusetts (S.S.W.)
Melissa W. Wachterman, MD, MPH, MSc
VA Boston Healthcare System, Boston, Massachusetts (M.W.W.)
Zahir Kanjee, MD, MPH
Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
Acknowledgment: The authors thank the patient and his daughter for sharing their story.
Grant Support: Beyond the Guidelines receives no external support.
Disclosures: Dr. Waikar reports personal fees from Public Health Advocacy Institute, CVS, Roth Capital Partners, Kantum Pharma, Mallinckrodt, Wolters Kluwer, GE Healthcare, GSK, Mass Medical International, Baron and Budd (vs. Fresenius), Johnson & Johnson, Venbio, Strataca, Takeda, Cerus, Pfizer, Bunch and James, and Harvard Clinical Research Institute (Baim Institute) and grants and personal fees from Allena Pharmaceuticals outside the submitted work. Dr. Wachterman reports grant funding from the National Institute on Aging during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Risa B. Burns, MD, MPH, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail, [email protected].
Current Author Addresses: Drs. Burns and Kanjee: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Dr. Waikar: Nephrology Section, Boston University School of Medicine and Boston Medical Center, 650 Albany Street, EBRC5, Boston, MA 02118.
Dr. Wachterman: Section of General Medicine, VA Boston Healthcare System, Building 9 (152G), 150 South Huntington Avenue, Boston, MA 02130.

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Risa B. Burns, Sushrut S. Waikar, Melissa W. Wachterman, et al. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med.2020;173:217-225. [Epub 4 August 2020]. doi:10.7326/M20-2640

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