For Healthcare Providers

Patients with End Stage Kidney Disease have two primary treatment options: long-term dialysis or kidney transplantation1. For most patients with kidney disease, transplantation is the optimal treatment because of longer survival, better quality of life, and lower hospitalization rates compared to dialysis 2,3. Adjusted 5-year survival is 36% for dialysis patients vs. 85% for patients who receive a kidney transplant 1.  However, the relative survival advantage associated with transplantation varies substantially depending on individual characteristics, including age, race, and various medical comorbidities 4. 

The purpose of iChoose Kidney is to provide individualized, tailored prognosis estimates to patients with kidney disease so they can be informed of the mortality risks associated with either dialysis vs. living or deceased donor kidney transplantation. The risk estimates of mortality provided in iChoose Kidney are based on data from the United States Renal Data System (2005-2015), a national surveillance data that includes nearly all patients with End Stage Kidney Disease in the United States from 2005-2015 who were followed for outcomes of transplantation and mortality.  The individualized risk estimates that are provided were generated and validated using multivariable logistic regression models; therefore the risks provided are risks of mortality based on patients similar with respect to age, race, and comorbidities as the patient whose information is entered into the patient information form. Please see the technical document to learn how estimates in the tool are calculated, or refer to the publications describing development of the original5 and updated6risk prediction models."

The intended use of this tool is as a shared decision making tool for providers – including family physicians, nephrologists, transplant surgeons, nurses, social workers, and/or patient educators – to use with patients they think may be reasonable candidates for transplantation.  The mortality risk estimates are intended for patients who have late stage Chronic Kidney Disease or End Stage Kidney Disease (estimated Glomerular Filtration Rate < 15 mL/min/1.73m2). By law, physicians are required to inform patients with end stage kidney disease about treatment options, including transplantation. Shared decision making about treatment options for these patients should occur in chronic kidney disease clinics prior to starting dialysis, at the time of initiation of long-term dialysis, and during transplant evaluation.

Field testing of the tool among 34 patients and 8 providers across multiple locations showed that the iChoose Kidney was an acceptable tool among patients and health professionals. The majority of patients reported learning something new from the tool and would recommend it to other patients. One patient stated, “The beauty of the tool is it does not require one to be analytical. That part’s already done. The tool gives one a broad brush look at the statistics involved and encourages further research by the individual patient or caregiver.” Nephrologists believed the tool was useful in discussing treatment options with their patients.

While there are few absolute contraindications for transplant, there may be some patients for whom transplant is not a good option or is not the patient’s preference for treatment. For these patients, the use of this risk calculator is discouraged.  Of note, this application was built using data for adult patients (18 years and older), and thus the use of this tool with children who have kidney disease is not validated.

References

  1. USRDS. US Renal Data System 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases;2010.
  2. Danovitch GM. Options for Patients with Kidney Failure. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2005:1-22
  3. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. Oct 2011;11(10):2093-2109.
  4. Wolfe RA, VB Ashby, EL Milford, AO Ojo, RE Ettenger, LY Agodoa, PJ Held, FK Port. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Eng J Med. 1999;341(23):1725-1730.
  5. Patzer RE, Basu M, Larsen C, Pastan SO, Mohan S, Patzer MC, Konomos M, McClellan WM, Lea J, Howard D, Gander J, Arriola KJ iChoose Kidney: a Clinical Decision Aid for Kidney Transplantation vs. Dialysis Treatment Transplantation. 2016; 100(3): 630-9.
  6. . Gander J, Basu M, McPherson L, Garber M, Pastan SO, Manatunga A, Arriola KJ, Patzer RE(2018). SiChoose Kidney for Treatment Options: Updated Models for Shared Decision Aid. Transplantation.