Rasheeda K. Hall

Purpose: Older adults receiving hemodialysis experience geriatric problems that affect quality of life and contribute to high healthcare utilization but are often underrecognized in dialysis care. Scalable approaches to identifying these problems are needed. This study evaluated the agreement between a self-administered screening battery and a geriatrician telehealth evaluation and assessed the feasibility of implementing the screening battery in dialysis clinics. Patients and Methods: Participants aged ≥ 55 receiving hemodialysis completed the Geriatric screen for Older adults receiving Dialysis (GOLD), a screening battery assessing seven geriatric problems: depression, anxiety, functional impairment, cognitive impairment, falls risk, limited social support, and low nutritional status, followed by a blinded geriatrician telehealth evaluation. Intra-problem agreement between the GOLD and geriatrician evaluation was assessed using Cohen’s κ, and analyses evaluated alternative screening thresholds. Acceptability and feasibility of the GOLD were evaluated through participant and staff surveys. Results: The cohort included 50 participants [76% (n=38) Black race, 62% (n=31) male, 16% (n=8) Hispanic/Latino ethnicity] with a mean (SD) age of 68 (7.8) years and a median dialysis vintage of 3.5 [IQR (1, 12.5)] years. Geriatric problems were common, including fall risk (78% geriatrician; 90% GOLD), functional impairment (58% geriatrician; 44% GOLD), and low nutritional status (50% geriatrician; 40% GOLD). Agreement between the GOLD and geriatrician evaluation was substantial for anxiety (κ=0.74), functional impairment (κ=0.65), low nutritional status (κ=0.64), and limited social support (κ=0.65), but not for cognitive impairment, falls risk, or depression. Most participants (37 of 45) reported the GOLD was easy to complete, and a minority (16 of 50) required assistance. Conclusion: The GOLD demonstrated agreement with geriatrician evaluation for many geriatric problems and was feasible to implement in dialysis clinics. These findings suggest potential utility for scalable geriatric screening in dialysis care, although further work is needed to confirm these findings in larger cohorts and to refine screening for cognitive impairment and other domains.

Background: Deprescribing, a proactive systematic approach to reducing or stopping medications, may lower adverse outcomes in older adults receiving dialysis. We evaluated the feasibility of an intervention to deprescribe potentially inappropriate medications, defined as medications whose risks often outweigh the benefits in older adults. Methods: In this non-randomized feasibility study in Durham, NC, study personnel reviewed charts to identify potentially eligible patients (age ≥55, active potentially inappropriate medication prescription, and appropriate for deprescribing) and generated deprescribing recommendations. Clinicians at participating dialysis clinics received recommendations for each patient. When clinicians agreed, they or study staff engaged patients in shared decision-making. For deprescribing attempts, the study provided taper plans, guidance on alternatives, and adverse drug withdrawal event monitoring. Feasibility outcomes included demand, limited efficacy, acceptability, and practicality. To assess patient acceptability, eligible patients were invited to participate in semi-structured interviews. Results: Among 632 charts reviewed, 85 patients were potentially eligible for deprescribing. After confirming eligibility and obtaining clinician agreement, 41 of the 85 patients were approached about deprescribing; 17 (41%) agreed to attempt deprescribing. Gabapentin was the most commonly deprescribed medication (n=15; 88%). Among those who attempted deprescribing, 7 (41%) experienced symptom recurrence, but none required unplanned healthcare use. Clinician responses were mixed: five of seven reported the intervention met their approval or seemed doable, but only two reported it fit within their usual workflow. Qualitative interviews highlighted that patients generally viewed the deprescribing discussions favorably but desired clearer explanations of the deprescribing rationale. Conclusions: This feasibility study demonstrates that deprescribing potentially inappropriate medications in older adults receiving hemodialysis is achievable, with good patient engagement, and no significant adverse drug withdrawal events. Clinician support was variable, with workflow integration as a key barrier. Improved workflow integration and strengthened shared decision-making processes are needed to support implementation in a future clinical trial.

The Centers for Medicare & Medicaid Services uses the Star quality program to evaluate Medicare Advantage (Medicare Part C) care quality. Since the 21st Century Cures Act, ESRD enrollment within Medicare has shifted from e.g ., customer service). The American Society of Nephrology committee evaluated 25 (of 45) Star quality measures that were directly related to clinical outcomes. The committee assessment identified 13 high-validity Star measures that monitored care related to diabetes, hypertension, and care transitions, as well as 12 medium-validity measures that evaluated preventive care and other chronic care areas. The appropriateness and clinical evidence base of Star measures were generally strong but weaker in patients with kidney failure. The committee noted concerns with ten Stars measures that may exclude patients with kidney failure. Only one measure captured guideline-directed kidney care (albuminuria screening in patients with diabetes). No Stars measures captured other guideline-directed recommendations, such as CKD screening and risk stratification, nephrology referral, use of kidney pharmacotherapies, CKD education, or preemptive kidney transplantation referral. The Medicare 2026 Part C and D Stars measures represent a missed opportunity to align care measures and guideline-directed kidney care to improve outcomes, reduce costs, and advance high-value care for the millions of Americans living with kidney disease.

Key Points: Conservative management is part of the standard of care for kidney failure management. Conservative management tailors kidney care to align with individual goals and values. Conservative management involves a multidisciplinary team to provide customized CKD care, symptom management, and navigation across care transitions. Conservative management is a holistic, whole-person model of care for people with kidney failure. A proactive, ethical treatment pathway, conservative management can help align personal goals and plan of care for people who prioritize quality of life and symptom management over potential life-prolonging therapies. The Kidney Health Guidance (KHG) on Conservative Management in People with Kidney Failure provides evidence-based clinical guidance supporting best practices in three components of the conservative management care pathway: customized CKD care to align with a person's values and goals, symptom management, and navigation of care transitions. The guidance also emphasizes the importance of shared decision-making in providing goal-concordant kidney care, engaging care partners and collaborating across disciplines. In this Executive Summary, a practical companion to the KHG, we highlight the key points of the KHG to facilitate implementation of conservative management into clinical practice. Podcast: This article contains a podcast at https://dts.podtrac.com/redirect.mp3//www.asn-online.org/media/podcast/JASN/2026_03_18_KTS_March2026.mp3

Key Points: Conservative management is customized CKD care, symptom management, and support to navigate care across the CKD trajectory through end of life. Conservative management is defined by shared decision-making and interdisciplinary teamwork in alliance with patients and care partners. Implementation of conservative management hinges on each practice's logistical considerations and resource availability. Conservative management is holistic and whole-person care for people with kidney failure. This care pathway is often a good choice for patients who prioritize independence, quality of life, and avoidance of burdens associated with life-prolonging therapies such as dialysis. This Kidney Health Guidance aims to provide evidence-based clinical guidance to promote best practices in conservative management care delivery. Conservative management comprises three components, including customized CKD care, symptom management, and smooth navigation of care transitions. This Kidney Health Guidance describes the application of these three components across the illness trajectory, including the role of shared decision-making, care partner engagement, and interdisciplinary collaboration. Practical strategies are outlined for health care professionals to integrate conservative management care delivery into practice. Podcast: This article contains a podcast at https://dts.podtrac.com/redirect.mp3//www.asn-online.org/media/podcast/JASN/2026_03_18_KTS_March2026.mp3

Key Points: The clinical frailty scale has the strongest psychometric validity in kidney disease apart from the physical frailty phenotype. Existing frailty instruments have strong predictive validity for mortality and hospitalizations across kidney disease populations. Future work should test validity in younger adults, psychosocial and physiologic domains, and use of frailty instruments as screeners. Background: Frailty is a multisystem syndrome of decreased physiologic reserve with high prevalence, early incidence, and prognostic significance in kidney disease. Apart from the physical frailty phenotype (PFP), less is known regarding psychometric properties of other instruments. We critically appraise the validity and reliability of frailty instruments across the kidney disease continuum, acknowledge limitations, and highlight knowledge gaps. Methods: Following Preferred Reporting Items for Scoping Reviews guidelines, we searched PubMed, EMBASE, Cochrane, Cumulated Index in Nursing and Allied Health Literature, Web of Science, ClinicalTrials.gov, and PsycInfo from website inception through September 2024. Eligible studies applied a validated frailty instrument apart from the PFP to a kidney disease population. Results: We identified 136 articles after screening 4048 initial results. The most commonly cited instruments were the clinical frailty scale (CFS; N =56); Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight Scale ( N =30); and Edmonton frail scale ( N =16). Most studies included adults receiving hemodialysis ( N =85) and with CKD ( N =39). Median age ranges were 53–83 years. Most frailty instruments demonstrated predictive validity for mortality and hospitalizations. Concurrent validity was most frequently demonstrated between frailty and older age, female sex, greater comorbidities, and lower albumin. Seven studies reported reliability. While some instruments were feasible (CFS, Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight scale), their measurement could result in higher frailty prevalence compared with the PFP. Existing instruments do not capture the full spectrum of psychosocial and physiologic domains of frailty. Conclusions: The CFS demonstrates the strongest validity, apart from the PFP, although its use may result in higher measured frailty prevalence. Further research should test the feasibility of screening for frailty in clinical practice; the psychometric properties ( i.e ., responsiveness) of frailty instruments in younger adults, those with AKI, kidney transplant recipients, and those receiving conservative kidney management; and whether adding psychosocial and/or physiologic markers improves frailty measurement validity. Addressing these gaps will facilitate wider frailty measurement in kidney disease research and aid adoption into practice.

Key Points: Addressing geriatric syndromes in CKD likely requires implementation of an interdisciplinary model of care. Experts shared multilevel barriers to implementation of this model and strategies to mitigate each barrier. Experts felt that patient satisfaction and clinician burnout could improve with implementing interdisciplinary care in CKD. Background: Despite their prevalence, prognostic significance, and prioritization by patients, key geriatric syndromes, such as cognitive impairment, frailty, and depression, are not routinely addressed in CKD care in the United States (US). In an interdisciplinary care model, health professionals with diverse expertise collaborate to address all symptoms and functional impairments occurring alongside a patient's chronic disease. Thus, routinely addressing geriatric syndromes in CKD may require implementing this evidence-based model of care and adapting it to the needs of patients with CKD. In a formative step to understanding how health systems could implement an interdisciplinary model of care to address geriatric syndromes in CKD, we interviewed health professionals around the world with relevant expertise. Methods: We conducted a qualitative study informed by the Consolidated Framework for Implementation Research. We interviewed nephrologists, administrators, geriatricians, palliative medicine specialists, subspecialists, and allied health professionals working in other interdisciplinary clinics from the United States, United Kingdom, India, and Canada. We analyzed results using an inductive-deductive approach. Results: Thematic saturation occurred at 42 experts. Three major domains emerged: barriers to implementation, strategies to mitigate barriers, and benefits of implementation. Barriers were categorized into overarching themes related to (1) aging-friendly policy and workforce availability, (2) organizational culture and structure, and (3) nephrologist and patient perceptions. Strategies to mitigate barriers were categorized into themes related to (1) demonstrating viability, (2) facilitating effective health communication, (3) soliciting support from administrators and clinicians, and (4) expanding the base for patient information and treatment evidence. Proposed benefits of implementation included improved shared decision making and reduced nephrologist burnout. Conclusions: Implementing an interdisciplinary model of care that addresses geriatric syndromes in CKD is possible but will require overcoming policy-related, financial, cultural, and structural barriers. Such a model of care may ultimately benefit patients and nephrologists.