How Do Older Patients With Advanced Kidney Disease, and Their Family Members, Understand Kidney Function and Failure? A Qualitative Study

How Do Older Patients With Advanced Kidney Disease, and Their Family Members, Understand Kidney Function and Failure? A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article How Do Older Patients With Advanced Kidney Disease, and Their Family Members, Understand Kidney Function and Failure? A Qualitative Study Charlotte M Snead, Robert A Kimmitt, Fergus J Caskey, Jocelyn Darling, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7325432/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Nov, 2025 Read the published version in BMC Nephrology → Version 1 posted 18 You are reading this latest preprint version Abstract Background Patients approaching kidney failure are increasingly older, and living with multiple long-term conditions. The benefits of kidney replacement therapy (KRT) are uncertain for many in this group. Supporting decisions between treatment options requires consideration of how people perceive chronic kidney disease and its treatments. This qualitative study aimed to explore how older patients and family members understand kidney function and failure, and how this impacts treatment decision-making. Methods Between September 2018 and July 2019, semi-structured interviews were conducted with older patients and family members recruited from three United Kingdom kidney units. Eligible patients had estimated glomerular filtration rate (eGFR) < 15ml/min/1.73m 2 , no previous KRT and were age ≥ 80 years, or ≥ 65 years with significant comorbidity. Interviews used a topic guide developed with patient input. Interview transcripts were analysed using inductive thematic analysis and constant comparative techniques. Results Fifteen patients and 12 family members were interviewed. Three themes were identified: (i) Critical blood-cleaning organs, where kidney function was considered vital for survival; (ii) Unwitnessed function and failure, where kidney disease was experienced invisibly; and (iii) Quantifying and predicting kidney function; conceptualisation of kidney function using numbers and graphs. Unwitnessed, intangible experiences of kidney failure appeared to accentuate reliance on clinicians for disease information. Numerical and graphical depictions of kidney function were central to formation of disease understanding. Concepts of treatment ‘thresholds’ appeared to affirm misperceptions of a binary choice between dialysis and death. Conclusions Unintended misunderstandings, including eGFR thresholds for dialysis initiation, arise from common clinical communication approaches and appear to impact upon informed decision-making. This is especially important for older patients with multiple conditions, for whom the benefits of dialysis are uncertain. Improved consultation approaches which enhance patient understanding are needed. Revising misleading terminology and shifting focus away from numerical disease metrics may help patients and families making individualised choices between treatments. Age Renal Insufficiency Kidney Failure Chronic chronic kidney disease conservative kidney management Decision Making Shared Dialysis multimorbidity Background Across high-income countries, an increasingly high proportion of people living with chronic kidney disease (CKD) and commencing kidney replacement therapy (KRT) are older, and living with multiple long-term conditions (MLTC).( 1 ) Less than 1% of this population receive transplants( 2 ) and most receive in-centre haemodialysis( 1 ), despite availability of home treatments. An alternative to KRT is conservative kidney management (CKM), where dialysis is neither planned for nor initiated, but care focuses on prevention of, and relief from, pain and other physical, psychosocial, and spiritual problems.( 3 ) The survival and quality of life benefits of dialysis versus CKM for older people with MLTC remain uncertain( 4 ), with a randomised controlled trial nearing completion in this area.( 5 ) Patients and their families require support and information to make preference-sensitive decisions between KRT and CKM.( 6 , 7 ) Shared decision-making (SDM), a model involving proactive engagement of patients, healthcare professionals, close family and/or caregivers, is recommended( 8 ), the effectiveness of which requires appropriate education and communication strategies.( 6 , 8 ) However the experience of SDM by older adults with CKD can be sub-optimal.( 9 ) Qualitative research is crucial for understanding social phenomena such as treatment decision-making, particularly when little prior evidence exists.( 10 ) In-depth qualitative interview studies have shown that individuals preparing for or receiving treatment for kidney failure often misunderstand their disease and its treatments, have knowledge gaps( 7 , 11 – 14 ), and/or are not always aware they have a treatment choice.( 13 – 15 ) Existing studies have mainly focused on the perspectives of those who have already started dialysis or CKM, on decisions between haemodialysis (HD) and peritoneal dialysis (PD), and often under-represent older patients.( 11 , 16 ) To our knowledge, no study has specifically explored how understanding of CKD by older patients and their close family members affects treatment decision-making. We aimed to explore understandings of kidney function, disease progression, and failure in this group, to inform person-centred care. Methods Study design The presented secondary qualitative analysis uses a social constructionist design and is part of a larger study examining treatment preferences of older patients and their families deciding between dialysis and CKM.(17, 18) Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative research (COREQ)(19) [Supplementary file S1] . Inclusion and exclusion criteria Patient eligibility criteria were chosen to reflect current evidence concerning the population for whom the comparative benefits of dialysis versus CKM are unclear.(4) Inclusion and exclusion criteria were as follows. Patient participants Inclusion criteria: English-speaking; In receipt of specialist nephrology care with estimated glomerular filtration rate (eGFR) <15ml/min/1.73m 2 on at least one occasion over the preceding 12 months; Aged ≥80 years irrespective of comorbidity, or ≥65 years if they had either two or more additional major long-term conditions(20) or were confined to a bed or chair more than 50% of waking hours.(21) Exclusion criteria: Having ever received outpatient KRT. Due to start KRT within the next month. Unable to provide informed consent. Family member participants Inclusion criteria: English-speaking; Aged 18 years or older; Nominated by eligible patients as a close individual whom they would involve in decisions about their health. Sampling and recruitment Patients were recruited from three English kidney units. Two were transplant centres, each providing care to approximately 600 dialysis recipients. One was a non-transplant centre caring for approximately 200 dialysis recipients. One larger centre had a long-established dedicated CKM clinic and multidisciplinary team, whereas the other centres delivered CKM within general nephrology care. Local teams assessed eligibility and provided potential participants with written information materials. The study team invited participation and arranged interviews by telephone. Patients were purposively sampled to maximise clinicodemographic variation. Patients were asked to invite up to two “ family members or friends who help with decisions about your health ”, who opted-in by contacting the study team. Data collection Semi-structured, in-person interviews were conducted between September 2018 and July 2019 in participants’ homes by BH, a white, male, trainee kidney specialist in his late-30s. This was BH’s first experience of qualitative research, conducted as part of his PhD. He had received formal training in qualitative research and interviewing skills. Unless directly asked (this occurred once), he did not disclose his medical training, describing himself as a “researcher”. Socio-demographic information was collected. Semi-structured interviews using open-ended questioning were supported by a topic guide [previously published(18); see also Supplementary file S2 ] developed and piloted based on the literature and with patient input. Interviews, conducted with only the interviewer and interviewee(s) present, were audio-recorded using an encrypted digital voice recorder, and handwritten field notes were taken. Participants received a £20 voucher for participating. Recordings were transcribed verbatim and managed with QSR NVivo 11 software. Interview technique was refined through self-reflective notes and feedback from PhD supervisors at regular meetings. Patient and public involvement (PPI) Patients and members of the public were involved in this research at every stage of the primary study, contributing to its conception, design and interview topic guide developed, as previously described.(18, 22) PPI co-author (JD) contributed to critical analysis of the over-arching themes, manuscript review and revisions. Methodological and theoretical approach This study is based on a constructionist framework, drawing from a critical realist ontology and subjectivist epistemology.(23) Critical realism, developed by Bhaskar, suggests that underlying structures exist independently of our awareness, even if they cannot be fully known.(24) Subjectivism holds that knowledge is shaped by social and cultural filters such as language, class, gender, and ethnicity. From this view, knowledge is inherently value-laden.(25) Analysis Interview transcripts were analysed inductively, using thematic analysis and constant comparative techniques.(26, 27) Braun and Clarke’s six-stepped approach was followed, which involves; 1) familiarisation with the data; (2) initial coding; (3) searching for themes; (4) reviewing themes; (5) defining themes; and (6) producing the report.(26) Transcripts were initially coded line-by-line, independently, by BH, CS and RK, starting with ‘open’ coding to identify concepts and meanings from participants’ views and experiences. Interviews and codes were discussed and compared among the study investigators, with disagreement resolved by discussion, and consideration of wider meaning, alongside reorganisation, recoding and thematic development.(17, 18) A thematic map was developed linking sub-themes into broader overarching parent themes [ Supplementary file S3] . Analysis and recruitment were conducted in parallel, with recruitment discontinued when no new themes for the primary analysis were identified.(18) Informational power for the primary analysis was determined through iterative rounds of coding development in conjunction with written analytical accounts, with feedback from the PhD supervisory team. Rigour and reflexivity During data collection, BH kept detailed field and reflective notes. During the triple line-by-line coding of interview data, and analytical account development, CS, RK and BH made reflexive notes. Reflexivity was discussed alongside thematic development during research meetings. Clear documentation was kept of analysis stages, and the presented analysis is supported by a range of excerpts including examples of contrasting excerpts where relevant. Ethical considerations The study was reviewed by Surrey Research Ethics Committee (NHS Health Research Authority and Health and Care Research Wales approval reference 18/LO/1179) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained for all participants. Results Of 33 patients approached, 15 (46%) participated. Ten (67%) patients recruited one or more family members. Overall, 27 participants (15 patients and 12 family members) were interviewed [Table 1]. Reasons for non-participation are detailed in Supplementary file S4. Patient participants were between 68 and 90 years old. All were retired. Gender was balanced, all described their ethnicity as white British, and eGFR ranged from 7 to 14ml/min/1.73m 2 , excepting one participant whose eGFR was 25ml/min/1.73m 2 at the time of interview, having been 14ml/min/1.73m 2 at recruitment. Seven patients were preparing for HD, two for PD and the remaining six for CKM; with nobody active on a transplant waiting list. Interviews lasted 29 to 84 minutes. Illustrative transcript extracts are provided, with divergent views highlighted where relevant. Quotations are reported verbatim and marked with the participant group (patient/family member) and unique identifying number; age decade; gender (male, M; female, F); and clinically documented treatment plan (HD, PD or CKM). Participants at various stages of kidney failure preparedness recounted their journey from diagnosis, generally marked by intense negative emotions, including shock and despair. Despite subsequent acceptance of kidney disease, an awareness of life’s fragility tended to have a persistent effect on individuals’ reflections upon their lives and futures. Whilst most accepted disease progression as inevitable, uncertainty lingered regarding prognosis; particularly relating to the tangled relationship between the prospect of death from kidney failure and competing risk of death from another cause. This interplay influenced perceptions of kidney function and treatment decisions: “Maybe I will have to go on dialysis eventually, whether I will or not I don’t know… I mean not everybody goes on it I suppose, they’ve probably kicked the bucket before you get there... it’s in the lap of the gods really, isn’t it?” #14 Patient (80s, F, PD) Three overarching themes were identified: (1) Kidneys as critical blood-cleaning organs, where kidney function was framed as vital for survival; (2) Unwitnessed function and failure, where disease was experienced invisibly; and (3) Quantifying and predicting kidney function; the conceptualisation of kidney function using numbers and graphs. Quotations exemplifying each theme are summarised in Table 2 . Theme 1: Critical blood-cleaning organs – “If your kidneys die, you’re dead.” All participants appeared to recognise the kidneys as vital organs. This was explicit in statements linking kidney failure and death, but also seen in metaphors describing kidney failure as a “ death sentence” (#10 patient) or “ the end of the road ” (#2 patient). Participants emphasised the blood-cleaning function of kidneys and dialysis, with few references to other functions. The only identified ‘cleaned’ substance was “potassium”. A wide variety of other negative, but abstract terminology was used including “ toxins ” (#10 patient, #12 patient, #6 patient ), “ poisons ” (#2 patient), “ nasties ” (#1 family member), “ impurities ” and “ naughty cells ” (#1 family member). #12 patient, who had been hospitalised with acute kidney injury, provided a detailed description of how “ toxin ” accumulation could be fatal: “I don’t know which one goes first, your brain or your heart or whichever just dies of too high a level of toxin in your blood and that’s it, you slip into unconsciousness and you’re dead.” #12 Patient (70s, M, HD) Patient participants appeared almost unanimous in their expectation that death from kidney failure would come, unless they die from a competing event (e.g. “ car crash ” – #14 patient) or start dialysis. An assumption that dialysis would prolong life appeared across almost all accounts. The few participants who discussed death whilst in receipt of dialysis described this in terms of death from other causes; such as a “heart attack” (#1 patient), suggesting a widespread perception that dialysis prevents death from kidney failure. Participants had varied expectations about the experience of death without dialysis: some, especially those preparing for dialysis, anticipated death may be sudden and/or frightening, or else were uncertain what to expect; others, typically those planning for CKM, expected dying to be a less traumatic “sleep to the end” (#2 patient): “…if you die from kidney failure you just go to sleep… which is quite pleasant.... You sort of die in your bed… it’s nothing to go against is it, another good point, another tick.” #5 Patient (80s, M, CKM) Although numerous participants referred to prognostic discussions with clinicians, recollections of receiving a concrete prognosis were rare. This appeared to frustrate some participants who expressed a desire for more certainty: “When we asked the doctor… ‘how long… we know you can’t say how long a piece of string is, but how long is his piece of string?’ (laughs)…. It’s sometimes worse not having all the facts.” #8 Family member (wife of #18 patient, 80s, M, HD) Where prognostic discussions were recalled, these generally related to death if dialysis was not initiated. Even those envisioning short remaining lives speculated about being compelled to start treatment, when faced with “dialysis or death” (#8 patient). Theme 2: Unwitnessed function and failure – “The kidneys, I can’t see the kidneys… ” Participants tended to depict kidney function as invisible. Several explained how they learned they had CKD from blood tests taken whilst feeling well, so the discovery came as a shock. Even after diagnosis, the asymptomatic and unwitnessed disease process appeared to allow some to consider their kidneys to be working “ properly ” (#11 patient). Other participants described how it was hard to accept having CKD, because they had never felt ill: “You really don’t sort of believe that ‘cos I think because you feel perfectly alright so that’s it, they’re talking a lot of rot, but they obviously are not of course.” #14 Patient (80s, F, PD) Several participants, more commonly those preparing for dialysis, appeared uncertain about what problems to expect if their disease progressed, and whether their various symptoms could be attributed to their kidneys. Family members mentioned symptoms less than patients, but when they did, appeared equally uncertain about what “ symptoms we’re to look out for ” (#4B family member). Most participants suggested a cause for their, or their family member’s kidney disease, but incomplete understanding and uncertainty – “ puzzlement ” (#10 family member) – was apparent. Some participants with diabetic and hypertensive kidney disease used analogies to conceptualise the cause of kidney damage, whereas those with cancer, prior operations or abnormal scans tended to present more anatomical conceptions: “It’s like filters she said on a car, if they get clogged up the engine don’t run on the car so [it] conks out.” #7 Patient (60s, M, HD) “They could see that this kidney was really quite small and probably not working very hard.” #3 Patient (80s, F, CKM) Theme 3: Quantifying and predicting kidney function – “Twenty percent out of a hundred” The use of eGFR to quantify kidney function was almost ubiquitous, despite no participant naming this term. Some referred to unitless numbers only (nine participants); whilst 13 referred to the “ percentage for how much your kidneys are working ” (#15 patient). More than half of participants discussed numerical ‘thresholds’ at which symptoms would develop, or – more commonly – “ trigger level[s]” (#2 family member – a concept raised by 11 participants in total) at which someone would “ have to be on dialysis ” (#1 patient). Kidney function thresholds for dialysis initiation ranged between five (#10 patient) and 15 (#4A family member) and tended to be portrayed as concrete, rather than points of choice or discussion, since non-initiation of dialysis at this point appeared to be perceived as fatal. Whilst few appeared to consider thresholds for dialysis initiation as flexible, one participant recalled being informed of different cut-offs by different clinicians: “…he thought that the level should be around 15, whereas the previous person had said 10 and below.” #1 Family member (wife of #1 patient , 70s, M, PD) Kidney function trends and “ scale[s] ” (#1 patient) appeared to contribute to perceptions such as “ stability ” (#4A and #4B family members), “reversal” (#15 patient) and “steady decline” (#1 patient): “…we call it bobbing along the bottom of the pond because he goes up and down on the 20 line and he’s been doing that for a number of years now…” #8 Family member (wife of #8 patient , 80s, M, HD) For some, these trends and scales appeared to have been consolidated by clinicians presenting graphs of kidney function results and extrapolating future trajectories. This practice appeared to emphasise the concept of relentlessly progressive disease and verified ‘trigger levels’ for both dialysis initiation and death from kidney failure – in many cases, considered to be one and the same: “… they said when you get down to 10 you ought to be on it and by 8 you’re definitely on it.” #1 Patient (70s, M, PD) Alongside concrete portrayals of thresholds for dialysis initiation, some participants (seven in total) appeared to understand CKD progression and the reasons for treatment initiation through non-numerical concepts, such as symptom development or overall health status: “I don’t know when it’s [dialysis] going to start or nothing… Well, if my health’s going down or something like that, it’s totally up to my doctor… It’s entirely up to my health”. #11 Patient (80s, M, HD) Nonetheless, five of these seven participants still referenced numerical estimates of kidney function, including three referring to percentage function, suggesting that these constructs are not exclusive. Indeed, several participants seemed uncertain about the relative contribution of numerical kidney disease measures to their future health in the context of comorbidities and ageing: “…how long can you live on twelve percent? I don’t know.” #5 Patient (80s, M, CKM) Discussion Our analysis has identified misperceptions about CKD and kidney failure which impact upon older patients’ and family members’ ability to make informed treatment decisions between dialysis and CKM. It appears that these reflect unintended consequences of clinical communication around kidney function. The discourse of advanced kidney disease is understood primarily through; (a) concepts of ‘toxin’ clearance; and (b) low eGFR values, often conveyed in the language of ‘percentage kidney function’. These constructs are set against an ‘invisible’ illness experience and uncertainties regarding the interconnectedness of kidney failure with concurrent health conditions and overall prognosis. They appear to drive misperceptions of a “need” for dialysis initiation upon reaching numerical thresholds, undermining many families’ capacity to envision a future living without dialysis. These misperceptions present a potentially major impediment to shared decision-making. Appropriate communication of accurate and individualised CKD information is especially important for older people deciding between treatment options for kidney failure, because the uncertain benefit of dialysis in this patient group( 4 ) makes decision-making particularly preference-sensitive( 7 ). Studies of younger patients with CKD have previously shown how knowledge gaps and misunderstandings can impact on health behaviours, such as self-management, medication concordance, and perceptions about risks of progression to kidney failure.( 28 ) However our study is the first to examine the impact in older patients choosing between treatment options for kidney failure. The important nuances of the decisions they face did not appear to have been conveyed: there was little evidence that older participants, many with multiple long-term conditions, understood that dialysis might not prolong their lives( 29 ), understanding of which is known to affect decision-making.( 7 ) We found that patients and their family members shared common perceptions of kidney function and failure. Kidneys were understood as critical organs for survival, with loss of blood-cleaning expected to result in fatal toxin accumulation. Perceptions of the prognostic implications of advanced kidney disease appeared to be limited to the loss of this blood-cleaning function, and the potential for dialysis to extend life through substituting kidney function. Kidney disease was experienced invisibly; in its place were numerical measures and trends, dominating perceptions of future health. The presumption of life-prolongation with dialysis appeared to establish the “do or die” choice between dialysis and death, which has been described before.( 30 – 32 ) Amongst our participants, this belief appeared to be perpetuated by misunderstood quantitative constructs, whereby perceptions of percentage function as absolute, future decline along a scale as relentlessly progressive, and existence of numerical trigger levels established the idea that a “ need ” to initiate dialysis treatment, or face death, was inevitable once kidney function fell below a certain threshold. The ‘unwitnessed’ nature of kidney disease appeared to increase reliance upon information and guidance from clinicians. That CKD can be experienced as ‘unwitnessed’ has been described across all age-groups.( 12 , 30 , 33 , 34 ) Feelings of uncertainty, disconnectedness and lack of control have been described previously in CKD( 30 , 33 , 35 , 36 ) and other ‘unwitnessed’ conditions such as chronic leukaemia( 37 ). The gap left by intangibility appears readily filled by blood test results: eGFR governed older patient and family understanding of disease, treatment decisions, and expectations for the future. This has been observed before amongst older patients with CKD( 30 , 35 ); however earlier studies did not involve family members, known to play an important role in shared decision-making( 15 , 38 ), nor have they demonstrated previously how perceptions, and misperceptions, of these numerical measures might influence kidney failure treatment decisions in this older patient group. Our findings suggest that, for patients to feel that CKM is a valid option, an understanding is required of individualised reasons for choosing, or not choosing, dialysis. It is well-established that failure to adequately communicate disease information, including numerical information, negatively impacts shared decision-making, empowerment, and self-management.( 39 – 41 ) Low health literacy, including numeracy, common among many groups of people with CKD( 42 , 43 ) and older people ( 44 ), can also contribute to misinterpretation of health risks.( 39 , 45 ). Whilst thresholds and trends in eGFR play a role in CKD care pathways and disease staging( 46 , 47 ), trigger levels are not supported by clinical research. No randomised controlled trial has ever identified a threshold below which careful monitoring for disease complications becomes unsafe.( 48 ) We found that eGFR communicated as unitless numbers, framed as percentages, and depicted in trends and graphs, can be misinterpreted, with unintended implications. Despite being technically inaccurate( 49 ), the shorthand “percentage” kidney function is likely intended to aid patient understanding. Like others( 33 ) we have found that the concept of “percentage function” appears difficult for older patients and family members to interpret. Amongst our older patient and family member group, there was no mention of imprecision in estimated kidney function( 50 ); of alternative explanations for “stable” or rising eGFR, such as sarcopenia; or of the possibility of abrupt decline to kidney failure.( 51 ) Defining the reasons and optimal timing for dialysis initiation for older patients is challenging, requiring consideration of individual patients’ circumstances and preferences. Potential benefits of earlier treatment initiation, such as initiation of chosen modality, must be weighed against the potential for receipt of dialysis that provides neither quality nor quantity of life benefit.( 52 ) A focus on eGFR may compel older patients to prepare for dialysis without consideration of wider factors which can have a significant personal impact, such as symptoms, quality of life, treatment burden and end-of-life wishes. Optimal communication depends on clinicians having skills and resources to facilitate complex discussions; however nephrologists describe challenges explaining disease, treatment and prognostic complexity within available consultation time( 7 , 12 , 30 , 33 , 53 ), and currently available patient information documents may misrepresent treatment options.( 54 ) Research involving consultation observation may help to identify how communication influences patient understanding and decision-making, and inform approaches that could be included in interventions.( 55 ) The strengths of this study include a rigorous application of qualitative methods and broad range of clinicodemographic variation between study participants, sampled from multiple kidney centres. The inclusion of family members brings in the views of an often neglected group, known to play an important role in treatment decision-making.( 15 , 38 ) The study has limitations. All centres were in England and all participants were white British. Culture and faith play important roles in understandings of disease and treatment decision-making, so our findings may not be transferable to non-white British patient groups. Further research with ethnically diverse groups is needed. Patient participants had a range of educational levels, with socioeconomic backgrounds skewed towards lower levels of deprivation. Experiences and understandings may differ among patients from different socioeconomic backgrounds. All findings are based on patient and caregivers’ personal experiences: direct observation of how kidney function and failure are described in clinical practice would be informative.( 54 , 55 ) As with all qualitative research, the authors’ own experiences will have influenced data and analysis. Finally, data collection was discontinued when analysis of patient interviews indicated sufficient informational power, so themes from family member interviews may have been less well developed. Conclusion In conclusion, we found older patients with advanced CKD and their family members held simplified constructs of kidney function and failure. Whilst similar misperceptions have been demonstrated amongst younger people with kidney disease, our study identifies the unique implications of these where older individuals face a decision between dialysis and CKM. Current approaches to patient education may be unsuitable for this older patient group, where decisions about preparation for kidney failure are especially preference-sensitive. Evidence-based guidance and clinician education are needed to ensure information about kidney failure and its treatments is effectively communicated. Revising inaccurate and misleading terminology may help patients and families to make better informed and holistic choices about their future priorities and treatment preferences. The recently advocated move towards use of risk-based equations for guiding CKD referral and treatment decisions( 56 , 57 ) could provide an opportunity to re-examine how best to communicate disease severity in CKD, and its implications for treatment decisions, to older patients and their families. Improvement requires the development of evidence-based communication guidance, training and education, decision aids, and health literacy assessment; adapted for specific patient groups, all of which have the potential to enhance shared decision-making, advance care planning, and patient-centred outcomes.( 7 , 12 , 58 ) Our findings suggest that clinicians should shift focus away from numerical measures of disease severity towards wider factors guiding treatment decisions, such as quality of life, individualised values and goals. This may help people living with advanced kidney disease to better trade-off the benefits and burdens of available treatments. Abbreviations CKD – chronic kidney disease; KRT – kidney replacement therapy; CKM – conservative kidney management; eGFR – estimated glomerular filtration rate; HD – haemodialysis, MLTC – multiple long-term conditions; PD – peritoneal dialysis; SDM – shared decision making Declarations Ethics approval and consent to participate The study was reviewed by Surrey Research Ethics Committee and granted NHS Health Research Authority and Health and Care Research Wales approval on 2/8/18 (ref: 18/LO/1179) and was conducted in accordance with the Declaration of Helsinki. All participants gave informed, written consent for participation in the study. Consent for publication All participants gave informed, written consent for their data (including quotation excerpts) to be published. Availability of data and materials Raw interview data is potentially identifiable so is not made available. Please contact the corresponding author for further details. Competing interests FC is Chief Investigator, and LR and JC are co-investigators for the Prepare for Kidney Care Study, a randomised controlled trial comparing outcomes for older people preparing for kidney dialysis vs. CKM (https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/prepare-for-kidney-care/). LR is co-applicant of the NIHR Bristol Biomedical Research Centre (BRC). The authors have no other relationships/activities/interests related to the content of this manuscript to declare. Funding This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and represents independent research sponsored by the University of Bristol. The views expressed are those of the author(s), conducted as part of an NIHR Doctoral Research Fellowship (DRF-2017-10-127), and not necessarily those of the NIHR or the Department of Health and Social Care. LS, NIHR Career Development Fellow (CDF-2018-11-ST2-009) was funded by the NIHR for this research project. Author contributions BH designed the study and conducted interviews as part of his doctoral fellowship (PhD), supported and supervised by FC, RM, JC, LR and LS. BH, CS and RK carried out line-by-line coding of interview transcripts independently. Transcripts and codes were read and discussed with the wider study team, FC, RM, JC, LR and LS, with consideration of wider meaning, alongside reorganisation, recoding and thematic development. JD was involved as an independent patient co-author, contributing to critical interpretation of the overarching themes. CS and BH wrote the initial draft of the manuscript and revised it iteratively to develop and produce a final draft with input and review from all the study team members, RK, JD, FC, RM, JC, LR and LS. All team members reviewed and approved the final manuscript. CRediT authorship contribution statement Charlotte M Snead: Conceptualization, Validation, Formal Analysis, Writing – Original Draft, Writing – Review and Editing, Visualization . Robert A Kimmitt: Validation, Formal Analysis, Writing – Review and Editing. Fergus J Caskey: Validation, Formal Analysis, Writing – Review and Editing, Supervision . Jocelyn Darling: Formal Analysis, Writing – Review and Editing. Leila Rooshenas: Validation, Formal Analysis, Writing – Review and Editing, Supervision. Joanna Coast: Validation, Formal Analysis, Writing – Review and Editing, Supervision. Rachael L Morton: Validation, Formal Analysis, Writing – Review and Editing, Supervision. Lucy E Selman: Validation, Formal Analysis, Writing – Review and Editing, Supervision. Barnaby Hole: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Review and Editing, Visualization, Supervision, Project administration, Funding acquisition. Acknowledgements The authors would like to thank all the staff working in the three recruiting kidney units and the patients and family members who invited us into their lives and homes to learn about their experiences of kidney disease. The authors would also like to acknowledge the members of the patient and public involvement group for their valuable input. Clinical trial number Not applicable. References European Renal Registry. ERA Registry Annual Report 2021. . Amsterdam UMC, location AMC, Department of Medical Informatives, Amsterdam, the Netherlands.; 2023. Pippias M, Stel VS, Kramer A, Abad Diez JM, Areste-Fosalba N, Ayav C, et al. Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry. Transpl Int. 2018;31(5):540-53. Davison SN, Pommer W, Brown MA, Douglas CA, Gelfand SL, Gueco IP, et al. Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney International. 2024;105(1):35-45. Buur LE, Madsen JK, Eidemak I, Krarup E, Lauridsen TG, Taasti LH, et al. Correction: Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? a systematic review. BMC nephrology. 2022;23(1):352-. Murphy E, Burns A, Murtagh FEM, Rooshenas L, Caskey FJ. The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease. Nephrol Dial Transplant. 2021;36(6):975-82. Murray MA, Brunier G, Chung JO, Craig LA, Mills C, Thomas A, et al. A systematic review of factors influencing decision-making in adults living with chronic kidney disease. Patient education and counseling. 2009;76(2):149-58. Sakthivel P, Mostafa A, Aiyegbusi OL. Factors that influence the selection of conservative management for end-stage renal disease–a systematic review. Clinical Kidney Journal. 2024;17(1):sfad269. Amir N, McCarthy HJ, Tong A. A working partnership: A review of shared decision‐making in nephrology. Nephrology. 2021;26(11):851-7. Frazier R, Levine S, Porteny T, Tighiouart H, Wong JB, Isakova T, et al. Shared decision making among older adults with advanced CKD. American Journal of Kidney Diseases. 2022;80(5):599-609. Bristowe K, Selman L, Murtagh FE. Qualitative research methods in renal medicine: an introduction. Nephrol Dial Transplant. 2015;30(9):1424-31. Harwood L, Clark AM. Understanding pre-dialysis modality decision-making: a meta-synthesis of qualitative studies. International journal of nursing studies. 2013;50(1):109-20. Selman LE, Bristowe K, Higginson IJ, Murtagh FEM. The views and experiences of older people with conservatively managed renal failure: a qualitative study of communication, information and decision-making. BMC Nephrol. 2019;20(1):38. Roberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, et al. Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies. BMJ open. 2018;8(9):e023507. Morton R, Tong A, Howard K, Snelling P, Webster A. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BmJ. 2010;340. Jongejan M, de Lange S, Bos WJW, Pieterse AH, Konijn WS, van Buren M, et al. Choosing conservative care in advanced chronic kidney disease: a scoping review of patients’ perspectives. Nephrology Dialysis Transplantation. 2024;39(4):659-68. Walker RC, Hanson CS, Palmer SC, Howard K, Morton RL, Marshall MR, et al. Patient and caregiver perspectives on home hemodialysis: a systematic review. American Journal of Kidney Diseases. 2015;65(3):451-63. Hole B, Coast J, Caskey FJ, Selman LE, Rooshenas L, Kimpton G, et al. A choice experiment of older patients' preferences for kidney failure treatments. Kidney Int. 2025;107(1):130-42. Hole B, Rooshenas L, Morton R, Caskey F, Scanlon M, Coast J, et al. 'It's basically 'have that or die'': a qualitative study of older patients' choices between dialysis and conservative kidney management. BMJ Open. 2025;15(3):e095185. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. Davies SJ, Phillips L, Naish PF, Russell GI. Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant. 2002;17(6):1085-92. World Health Organization. WHO Handbook for Reporting Results of Cancer Treatment. Geneva, World Health Organization. 1979. Kimmitt RA, Snead CM, Rooshenas L, Caskey FJ, Coast J, Morton RL, et al. ‘That’s why I wanted him to go on dialysis’–a qualitative inductive thematic analysis of older patients’ and their family members’ perspectives on kidney failure treatment decision-making. BMC nephrology. 2025;26(1):368. Levers M-JD. Philosophical Paradigms, Grounded Theory, and Perspectives on Emergence. SAGE Open. 2013;3(4):2158244013517243. Bhaskar R. Reclaiming reality: a critical introduction to contemporary philosophy. London, UK: Routledge.2010. Denzin NK. Introduction: The discipline and practice of qualitative research. In: NK Denzin & YS Lincoln, editors, The SAGE handbook of qualitative research 3rd ed: Thousand Oaks, California, USA.: SAGE Publications; 2005. p. 21. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. Clarke V, Braun V. Successful qualitative research: A practical guide for beginners. Successful qualitative research. 2013:1-400. Lissanu L, Lopez F, King A, Robinson E, Almazan E, Metoyer G, et al. “I try not to even think about my health going bad”: a qualitative study of chronic kidney disease knowledge and coping among a group of urban African-American patients with CKD. Journal of racial and ethnic health disparities. 2019;6:625-34. Foote C, Kotwal S, Gallagher M, Cass A, Brown M, Jardine M. Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2016;21(3):241-53. Schell JO, Patel UD, Steinhauser KE, Ammarell N, Tulsky JA. Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study. Am J Kidney Dis. 2012;59(4):495-503. Thorsteinsdottir B, Espinoza Suarez NR, Curtis S, Beck AT, Hargraves I, Shaw K, et al. Older patients with advanced chronic kidney disease and their perspectives on prognostic information: a qualitative study. Journal of general internal medicine. 2022;37(5):1031-7. Lovell S, Walker RJ, Schollum JB, Marshall MR, McNoe BM, Derrett S. To dialyse or delay: a qualitative study of older New Zealanders' perceptions and experiences of decision-making, with stage 5 chronic kidney disease. BMJ Open. 2017;7(3):e014781. Llewellyn H, Low J, Smith G, Hopkins K, Burns A, Jones L. Narratives of continuity among older people with late stage chronic kidney disease who decline dialysis. Social science & medicine. 2014;114:49-56. Meuleman Y, van der Bent Y, Gentenaar L, Caskey FJ, Bart HA, Konijn WS, et al. Exploring Patients’ Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study. International Journal of Behavioral Medicine. 2024;31(2):263-75. Vandenberg AE, Echt KV, Johnson TM, Bowling CB. Patient discourse on chronic kidney disease monitoring: a qualitative study at a Veterans Affairs Renal Clinic. BMC nephrology. 2018;19:1-9. Bristowe K, Selman L, Higginson IJ, Murtagh F. Invisible and intangible illness: a qualitative interview study of patients’ experiences and understandings of conservatively managed end-stage kidney disease. Annals of Palliative Medicine. 2019;8(2):121-9. Evans J, Ziebland S, Pettitt AR. Incurable, invisible and inconclusive: watchful waiting for chronic lymphocytic leukaemia and implications for doctor-patient communication. Eur J Cancer Care (Engl). 2012;21(1):67-77. Senghor A. How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study. Revue d'Épidémiologie et de Santé Publique. 2021;69(1):22-9. Zikmund-Fisher BJ, Smith DM, Ubel PA, Fagerlin A. Validation of the Subjective Numeracy Scale: effects of low numeracy on comprehension of risk communications and utility elicitations. Medical Decision Making. 2007;27(5):663-71. Peters E. Beyond comprehension: The role of numeracy in judgments and decisions. Current Directions in Psychological Science. 2012;21(1):31-5. Haga SB, Mills R, Pollak KI, Rehder C, Buchanan AH, Lipkus IM, et al. Developing patient-friendly genetic and genomic test reports: formats to promote patient engagement and understanding. Genome medicine. 2014;6(7):1-11. Taylor DM, Fraser SDS, Bradley JA, Bradley C, Draper H, Metcalfe W, et al. A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD. Clin J Am Soc Nephrol. 2017;12(7):1070-84. Abdel-Kader K, Dew MA, Bhatnagar M, Argyropoulos C, Karpov I, Switzer G, et al. Numeracy skills in CKD: correlates and outcomes. Clinical journal of the American Society of Nephrology: CJASN. 2010;5(9):1566. Cutilli CC, Bennett IM. Understanding the health literacy of America: results of the National Assessment of Adult Literacy. Orthop Nurs. 2009;28(1):27-32; quiz 3-4. Rolison JJ, Morsanyi K, Peters E. Understanding Health Risk Comprehension: The Role of Math Anxiety, Subjective Numeracy, and Objective Numeracy. Med Decis Making. 2020;40(2):222-34. Kidney Disease: Improving Global Outcomes CKDWG. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. Gallagher H, Methven S, Casula A, Thomas N, Tomson CR, Caskey FJ, et al. A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy. BMC nephrology. 2017;18(1):1-10. Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-19. Inker LA, Eneanya ND, Coresh J, Tighiouart H, Wang D, Sang Y, et al. New creatinine-and cystatin C–based equations to estimate GFR without race. New England Journal of Medicine. 2021;385(19):1737-49. Alaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DS, et al. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World journal of methodology. 2017;7(3):73. Kovesdy CP, Naseer A, Sumida K, Molnar MZ, Potukuchi PK, Thomas F, et al. Abrupt decline in kidney function precipitating initiation of chronic renal replacement therapy. Kidney international reports. 2018;3(3):602-9. Thorsteinsdottir B, Swetz KM, Albright RC. The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms. Clin J Am Soc Nephrol. 2015;10(11):2094-9. Ladin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, et al. Discussing conservative management with older patients with CKD: an interview study of nephrologists. American journal of kidney diseases. 2018;71(5):627-35. Sowden R, Shaw CB, Robb J, Winterbottom A, Bristowe K, Bekker HL, et al. How do patient information documents present dialysis and conservative kidney management? A document analysis. Clinical Kidney Journal. 2025. Selman LE, Shaw CB, Sowden R, Murtagh FE, Tulsky JA, Parry R, et al. Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study. BMC nephrology. 2024;25(1):417. Major RW, Shepherd D, Medcalf JF, Xu G, Gray LJ, Brunskill NJ. The kidney failure risk equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study. PLoS medicine. 2019;16(11):e1002955. Hallan SI, Rifkin DE, Potok OA, Katz R, Langlo KA, Bansal N, et al. Implementing the European Renal Best Practice Guidelines suggests that prediction equations work well to differentiate risk of end-stage renal disease vs. death in older patients with low estimated glomerular filtration rate. Kidney international. 2019;96(3):728-37. Bekker HL, Winterbottom AE, Gavaruzzi T, Finderup J, Mooney A. Decision aids to assist patients and professionals in choosing the right treatment for kidney failure. Clin Kidney J. 2023;16(Suppl 1):i20-i38. Tables Table 1. Participant characteristics (n=27) * Due to rounding, percentages may not always appear to add up to 100% ** One participant who had an eGFR of 25ml/min/1.73m 2 at the time of interview, having been 14ml/min/1.73m 2 at recruitment. Key. CKM, conservative kidney management; eGFR, estimated glomerular filtration rate; HD, haemodialysis; IMD, index of multiple deprivation; PD, peritoneal dialysis; WHO, World Health Organization Table 2. Illustrative quotations Theme Illustrative quotations 1. Critical blood cleaning organs Vital for survival “…because kidney function will stop and that’ s- you die from it, that’s what happens.” Jeremy (80s, M, HD) “Basically if your kidneys die, you’re dead… All the organs you’ve got, they’re all critical functions. You want the whole lot to be working.” #12 Patient (70s, M, HD) I “So if you’ve got kidney failure, that would be- P “That’s end of life virtually.” #3 Patient (80s, F, CKM) Toxin clearance “Maybe because they’ve got quite a lot of poison in their system, so that to take dialysis it’s being drawn away.” #2 Patient (90s, M, CKM) “…it’s probably all the toxics in her body what causes all of this ‘cos you could easily sometimes smell the poor girl when she might sit on the loo or whatever, and you go in and you can get this affect from it.” #6 Family member, husband of #6 patient (70s, F, HD) Understanding mechanisms of kidney function and disease “Once again, my non-medical knowledge, your kidneys do a certain important job of straining out so many of the nasties from your body.” #1 Family member, wife of #1 patient (70s, M, PD) “…they found some spots on my kidney so [the surgeon] cauterised it and took a third away and put the rest back…” #2 Patient (90s, M, CKM) “I think that’s when it started, through the blood transfusion. I’m not saying that’s a cause of the kidney func- the loss in kidney function but it’s something that- Something’s triggered it. Are you with me? But I don’t know what.” #10 Patient (80s, M, HD) Dialysis as life-prolonging kidney replacement “It’s that [dialysis] or die basically. That’s the alternative, as far as I know of it.” #12 Patient (70s, M, HD) I “What did you get the impression that that dialysis is there to do?” P “Well keep you going for a few more years I guess. That’s what it basically is isn’t it? #1 Patient (70s, M, PD) Death from kidney failure “[You] go to sleep and you don’t wake up and it’s part of the system. I’m quite ready for it. (pause) Yes, it’s all sleep, sleep, sleep.” #2 Patient (90s, M, CKM) “…from what I’ve read it can be quite horrible and I know that I’m going to have to face that and she might not have to ‘cos obviously there’s a lot of painkillers and stuff, you can make yourself fuzzy but I’m not looking forward to that.” #3 Family member, daughter of #1 patient (80s, F, CKM) 2.Unwitnessed function and failure Invisible organs “Well the kidneys are working properly I suppose, I don’t know ‘cos I can’t see ‘em! (laughs)” #11 Patient (80s, M, HD) “The kidneys, I can’t see the kidneys.” (sighs) #7 Patient (60s, M, HD) “Well it’s kind of silent really because I wouldn’t have been aware if nobody took these blood tests, I wouldn’t have been aware of it at all, no reason why I should.” #3 Patient (80s, F, CKM) Lack of, or uncertain, symptoms I “Do you know what you’re looking out for?” P “Well no, other than tiredness. That’s what I said to him, ‘How am I going to know?’ He said ‘You’ll only know ‘cos you’ll be so tired, and you’ll have no energy that that’s the point you’ll know’. I haven’t experienced that yet so I cannot tell you. (laughs) I cannot tell you something you haven’t had experience of.” #1 Patient (70s, M, PD) “You feel perfectly alright. I still do feel more or less perfectly alright. I have days but then it may not be anything to do with kidneys.” #14 Patient (80s, F, PD) Diagnosis as a shock “So, it… it hasn’t been a visible problem at all, to either of us, and this is why I think we find it – Oooh – a bit of a shock when we suddenly get a note, a letter to say we must consider this.” #1 Family member, wife of #1 patient (70s, M, PD) “…were just such a shock. I just couldn’t believe it ‘cos I’ve always been fit all my life…” #10 Patient (80s, M, HD) 3.Quantifying and predicting kidney function Dominance of numerical eGFR measures and their interpretation “Course every time I go now, we check on them and the 20 is percentage as opposed to percentage efficiency of the kidneys, that kind of thing…” #8 Patient (80s, M, HD) “… he said… ‘it’s about twenty percent’ and I thought what’s that twenty percent out of a hundred percent I take it… I said ‘that’s not very good is it?’ ‘No’, he said.” #7 Patient (60s, M, HD) P “I think its 11… They do it in numbers don’t they, it’s about 11, something like that.” I “What does that mean when they say that the kidney is 11?” P “I’m not hundred percent what it means.” .” #9 Family member, son of #9 patient (80s, F, CKM) Threshold trigger levels “They keep doing the blood tests every couple of months and when it gets down to a certain level, that’s when I’ll need the dialysis.” #13 Patient (60s, F, HD) “Well its 20- 20 is where they start worrying… well I went down to 13 which is chronic. Last week or so I had a check and I’m 23 now so I’ve gone above..” and “I was down at 13 and- If you’re down to zero you’re dead aren’t you? (laughs). They’re not working.” #8 Patient (80s, M, HD) “I think if you get to 15, they put you in for dialysis. That’s what I was told.” #4A Family member, daughter of #4 patient (80s, F, CKM) “Well (sighs) the 10’s the line, he told me 10. They like to start at 10. I’ve had a couple at 9, I don’t know what I am at the last blood test. So I shall know on Wednesday probably.” #6 Patient (70s, F, HD) Trends and scales “It’s not good’, he said, it’s not too bad at the moment, it’s about twenty percent. And I thought 'What’s that, twenty percent out of a hundred percent I take it', which- I said ‘That’s not very good is it?’ ‘No’, he said.” #7 Patient (60s, M, HD) “When I first went there it were 18 and then it dropped down to 16 percent… but the time before it had gone up to 25. I thought ‘They’re on the reversal’.” #15 Patient (80s, F, CKM) “I went and for years and years they stayed quite steady, around 19, 20, then they just started to go down to 9 and 10…” #6 Patient (70s, F, HD) Graphical depiction of kidney function and predicting future trends Non-numerical depictions of CKD progression and treatment initiation “They show us a graph on the screen and after sort of blood tests and things they say ‘Well, I’m afraid the reading’s dropped since last time’ or ‘Its stable, it hasn’t moved’.” #3 Patient (80s, F, CKM) “…I keep taking the pills, he says, doctors, you know, started showing me a graph, you know, levels off when I’ve been taking- I had a period when I haven’t been taking pills and the graph goes down, keep taking my pills and it keeps up.” #12 Patient (70s, M, HD) “Well, this is what (nurse) said to him. ‘I think it’s getting a bit low’, she said, she showed him the graph and she says ‘You’re not going to get better from it’.” #7 Family member, wife of #7 patient (60s, M, HD) “They just showed me on a computer… this red line, they said, ‘This is your kidney function here and it’s up at 23 percent… and this is where your target, this is what’ll happen to you’ and there were a red graph going down to the corner to zero.” #10 Patient (80s, M, HD) “I don’t know when it’s [dialysis] going to start or nothing… Well if my health’s going down or something like that, it’s totally up to my doctor… It’s entirely up to my health”. #11 Patient (80s, M, HD) “Well when I talked to you earlier about sleepiness… what it says in the books is quite correct so far as sleepiness is concerned. It’s going on and on and on and it’s becoming progressively greater as it were as time goes on.” #2 Patient (90s, M, CKM) “ I just thought why would I want to be on dialysis when I was feeling so well.” #14 Patient (80s, F, PD) Additional Declarations Competing interest reported. FC is Chief Investigator, and LR and JC are co-investigators for the Prepare for Kidney Care Study, a randomised controlled trial comparing outcomes for older people preparing for kidney dialysis vs. CKM ( https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/prepare-for-kidney-care/ ). LR is co-applicant of the NIHR Bristol Biomedical Research Centre (BRC). The authors have no other relationships/activities/interests related to the content of this manuscript to declare. Supplementary Files SupplfileS1COREQchecklist.pdf SupplfileS2InterviewTopicGuide.pdf SupplfileS3Thematicmap.pdf SupplfileS4StudyFlow.pdf Cite Share Download PDF Status: Published Journal Publication published 04 Nov, 2025 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 10 Sep, 2025 Reviews received at journal 10 Sep, 2025 Reviews received at journal 09 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviews received at journal 09 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor invited by journal 18 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 08 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7325432","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509893440,"identity":"e9235f15-862a-4f03-835b-82829c930ae1","order_by":0,"name":"Charlotte M Snead","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"M","lastName":"Snead","suffix":""},{"id":509893441,"identity":"e03ae787-2d14-4814-9338-df1bcd5439e0","order_by":1,"name":"Robert A Kimmitt","email":"","orcid":"","institution":"Royal Devon University Healthcare NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"A","lastName":"Kimmitt","suffix":""},{"id":509893442,"identity":"11170101-31b0-48e2-a9f6-5e25dc7853a3","order_by":2,"name":"Fergus J Caskey","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Fergus","middleName":"J","lastName":"Caskey","suffix":""},{"id":509893443,"identity":"aea2edfa-5d3b-4e10-905c-b331003115f7","order_by":3,"name":"Jocelyn Darling","email":"","orcid":"","institution":"Patient and Public Involvement (PPI) Contributor","correspondingAuthor":false,"prefix":"","firstName":"Jocelyn","middleName":"","lastName":"Darling","suffix":""},{"id":509893444,"identity":"77727ccb-6c0b-47fe-b630-8d4ec107a26d","order_by":4,"name":"Leila Rooshenas","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Leila","middleName":"","lastName":"Rooshenas","suffix":""},{"id":509893445,"identity":"4a5e8db5-da4e-41c3-96b6-08664476cb48","order_by":5,"name":"Joanna Coast","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Coast","suffix":""},{"id":509893446,"identity":"9c96559a-23ad-4e29-bf7a-6108f574c0fc","order_by":6,"name":"Rachael L. Morton","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"prefix":"","firstName":"Rachael","middleName":"L.","lastName":"Morton","suffix":""},{"id":509893447,"identity":"658c1ecf-57d3-40e5-9699-d0030f64ce47","order_by":7,"name":"Lucy E. Selman","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Lucy","middleName":"E.","lastName":"Selman","suffix":""},{"id":509893448,"identity":"3ab90486-5175-4b24-b288-3b0bdd756f6a","order_by":8,"name":"Barnaby Hole","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACAxDB2ABiMDcwfGxg4AHxD4DleAhqYWxgnAnSwsbAQLwWZl4gg6AWc/azzx783HEYyGhsfGy7456M/PzmAwcYauwYDM4cwKrFsifd3LD3zGEg42Czce6ZYh6DY2wJBxiOJTMYnG3A7rADaWwSvG2HGQxuJLZJ57Yl8Biw8RgcYGA7wGBwHodfzj9jk/wL0dL+2xKoRb4NpOUfHi030tikYbYwMwK1MBwDamFsO4DTYZYznrFJy55J5zE4c7BZsvcM0GHH0hIOJPYl80ji8L45fxqb5Nsd1nIGx5sPfvi5I8FevvnwwQcfvtnJ8Z1JwO4yCGhGi4MEnLECB3UE5EfBKBgFo2BEAwB20WIJ8EAQNgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Bristol","correspondingAuthor":true,"prefix":"","firstName":"Barnaby","middleName":"","lastName":"Hole","suffix":""}],"badges":[],"createdAt":"2025-08-08 08:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7325432/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7325432/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04541-1","type":"published","date":"2025-11-04T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95564201,"identity":"0c0d893e-fbb5-4381-a6f7-080112a0c33a","added_by":"auto","created_at":"2025-11-10 16:08:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1568169,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325432/v1/06a01451-a5d5-4b37-adb4-25b60746bd19.pdf"},{"id":90615691,"identity":"460989b4-64cc-4451-8aaf-8f4ee1eea03f","added_by":"auto","created_at":"2025-09-04 18:27:04","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":52472,"visible":true,"origin":"","legend":"","description":"","filename":"SupplfileS1COREQchecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325432/v1/06dea376094f69d30e6e2c45.pdf"},{"id":90615692,"identity":"5d710d3d-fe9c-438b-9996-9de1a48c9a3b","added_by":"auto","created_at":"2025-09-04 18:27:04","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":204333,"visible":true,"origin":"","legend":"","description":"","filename":"SupplfileS2InterviewTopicGuide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325432/v1/eebd025a969d6d3dddf4e4e7.pdf"},{"id":90615693,"identity":"f221e875-66ce-4baa-bd5c-1f6be24d7f21","added_by":"auto","created_at":"2025-09-04 18:27:04","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":63307,"visible":true,"origin":"","legend":"","description":"","filename":"SupplfileS3Thematicmap.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325432/v1/734b09ce3c6e731e982073d7.pdf"},{"id":90615826,"identity":"d98fa920-afa8-4bb8-aa0d-616370d4d5a9","added_by":"auto","created_at":"2025-09-04 18:35:04","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":40965,"visible":true,"origin":"","legend":"","description":"","filename":"SupplfileS4StudyFlow.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325432/v1/72acaf8c4d741b803422d895.pdf"}],"financialInterests":"Competing interest reported. FC is Chief Investigator, and LR and JC are co-investigators for the Prepare for Kidney Care Study, a randomised controlled trial comparing outcomes for older people preparing for kidney dialysis vs. CKM (https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/prepare-for-kidney-care/). LR is co-applicant of the NIHR Bristol Biomedical Research Centre (BRC). The authors have no other relationships/activities/interests related to the content of this manuscript to declare.","formattedTitle":"\u003cp\u003eHow Do Older Patients With Advanced Kidney Disease, and Their Family Members, Understand Kidney Function and Failure? A Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAcross high-income countries, an increasingly high proportion of people living with chronic kidney disease (CKD) and commencing kidney replacement therapy (KRT) are older, and living with multiple long-term conditions (MLTC).(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Less than 1% of this population receive transplants(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and most receive in-centre haemodialysis(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), despite availability of home treatments. An alternative to KRT is conservative kidney management (CKM), where dialysis is neither planned for nor initiated, but care focuses on prevention of, and relief from, pain and other physical, psychosocial, and spiritual problems.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The survival and quality of life benefits of dialysis versus CKM for older people with MLTC remain uncertain(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), with a randomised controlled trial nearing completion in this area.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003ePatients and their families require support and information to make preference-sensitive decisions between KRT and CKM.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Shared decision-making (SDM), a model involving proactive engagement of patients, healthcare professionals, close family and/or caregivers, is recommended(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), the effectiveness of which requires appropriate education and communication strategies.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) However the experience of SDM by older adults with CKD can be sub-optimal.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eQualitative research is crucial for understanding social phenomena such as treatment decision-making, particularly when little prior evidence exists.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) In-depth qualitative interview studies have shown that individuals preparing for or receiving treatment for kidney failure often misunderstand their disease and its treatments, have knowledge gaps(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and/or are not always aware they have a treatment choice.(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Existing studies have mainly focused on the perspectives of those who have already started dialysis or CKM, on decisions between haemodialysis (HD) and peritoneal dialysis (PD), and often under-represent older patients.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) To our knowledge, no study has specifically explored how understanding of CKD by older patients and their close family members affects treatment decision-making. We aimed to explore understandings of kidney function, disease progression, and failure in this group, to inform person-centred care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe presented secondary qualitative analysis uses a social constructionist design and is part of a larger study examining treatment preferences of older patients and their families deciding between dialysis and CKM.(17, 18) Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative research (COREQ)(19) \u003cstrong\u003e[Supplementary file S1]\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient eligibility criteria were chosen to reflect current evidence concerning the population for whom the comparative benefits of dialysis versus CKM are unclear.(4) Inclusion and exclusion criteria were as follows.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eEnglish-speaking;\u003c/li\u003e\n \u003cli\u003eIn receipt of specialist nephrology care with estimated glomerular filtration rate (eGFR) \u0026lt;15ml/min/1.73m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eon at least one occasion over the preceding 12 months;\u003c/li\u003e\n \u003cli\u003eAged \u0026ge;80 years irrespective of comorbidity, or \u0026ge;65 years if they had either two or more additional major long-term conditions(20) or were confined to a bed or chair more than 50% of waking hours.(21)\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHaving ever received outpatient KRT.\u003c/li\u003e\n \u003cli\u003eDue to start KRT within the next month.\u003c/li\u003e\n \u003cli\u003eUnable to provide informed consent.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily member participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEnglish-speaking;\u003c/li\u003e\n \u003cli\u003eAged 18 years or older;\u003c/li\u003e\n \u003cli\u003eNominated by eligible patients as a close individual whom they would involve in decisions about their health.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were recruited from three English kidney units. Two were transplant centres, each providing care to approximately 600 dialysis recipients. One was a non-transplant centre caring for approximately 200 dialysis recipients. One larger centre had a long-established dedicated CKM clinic and multidisciplinary team, whereas the other centres delivered CKM within general nephrology care. Local teams assessed eligibility and provided potential participants with written information materials. The study team invited participation and arranged interviews by telephone. Patients were purposively sampled to maximise clinicodemographic variation. Patients were asked to invite up to two \u0026ldquo;\u003cem\u003efamily members or friends who help with decisions about your health\u003c/em\u003e\u0026rdquo;, who opted-in by contacting the study team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSemi-structured, in-person interviews were conducted between September 2018 and July 2019 in participants\u0026rsquo; homes by BH, a white, male, trainee kidney specialist in his late-30s. This was BH\u0026rsquo;s first experience of qualitative research, conducted as part of his PhD. He had received formal training in qualitative research and interviewing skills. Unless directly asked (this occurred once), he did not disclose his medical training, describing himself as a \u0026ldquo;researcher\u0026rdquo;. Socio-demographic information was collected. Semi-structured interviews using open-ended questioning were supported by a topic guide [previously published(18); see also \u003cstrong\u003eSupplementary file S2\u003c/strong\u003e] developed and piloted based on the literature and with patient input. Interviews, conducted with only the interviewer and interviewee(s) present, were audio-recorded using an encrypted digital voice recorder, and handwritten field notes were taken. Participants received a \u0026pound;20 voucher for participating. Recordings were transcribed verbatim and managed with QSR NVivo 11 software. Interview technique was refined through self-reflective notes and feedback from PhD supervisors at regular meetings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and public involvement (PPI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients and members of the public were involved in this research at every stage of the primary study, contributing to its conception, design and interview topic guide developed, as previously described.(18, 22) PPI co-author (JD) contributed to critical analysis of the over-arching themes, manuscript review and revisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological and theoretical approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is based on a constructionist framework, drawing from a critical realist ontology and subjectivist epistemology.(23) Critical realism, developed by Bhaskar, suggests that underlying structures exist independently of our awareness, even if they cannot be fully known.(24) Subjectivism holds that knowledge is shaped by social and cultural filters such as language, class, gender, and ethnicity. From this view, knowledge is inherently value-laden.(25)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterview transcripts were analysed inductively, using thematic analysis and constant comparative techniques.(26, 27) Braun and Clarke\u0026rsquo;s six-stepped approach was followed, which involves; 1) familiarisation with the data; (2) initial coding; (3) searching for themes; (4) reviewing themes; (5) defining themes; and (6) producing the report.(26) Transcripts were initially coded line-by-line, independently, by BH, CS and RK, starting with \u0026lsquo;open\u0026rsquo; coding to identify concepts and meanings from participants\u0026rsquo; views and experiences. Interviews and codes were discussed and compared among the study investigators, with disagreement resolved by discussion, and consideration of wider meaning, alongside reorganisation, recoding and thematic development.(17, 18) \u0026nbsp;A thematic map was developed linking sub-themes into broader overarching parent themes [\u003cstrong\u003eSupplementary file S3]\u003c/strong\u003e. Analysis and recruitment were conducted in parallel, with recruitment discontinued when no new themes for the primary analysis were identified.(18) Informational power for the primary analysis was determined through iterative rounds of coding development in conjunction with written analytical accounts, with feedback from the PhD supervisory team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigour and reflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring data collection, BH kept detailed field and reflective notes. During the triple line-by-line coding of interview data, and analytical account development, CS, RK and BH made reflexive notes. Reflexivity was discussed alongside thematic development during research meetings. Clear documentation was kept of analysis stages, and the presented analysis is supported by a range of excerpts including examples of contrasting excerpts where relevant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reviewed by Surrey Research Ethics Committee (NHS Health Research Authority and Health and Care Research Wales approval reference 18/LO/1179) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained for all participants.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf 33 patients approached, 15 (46%) participated. Ten (67%) patients recruited one or more family members. Overall, 27 participants (15 patients and 12 family members) were interviewed \u003cstrong\u003e[Table 1].\u0026nbsp;\u003c/strong\u003eReasons for non-participation are detailed in\u003cstrong\u003e\u0026nbsp;Supplementary file S4.\u0026nbsp;\u003c/strong\u003ePatient participants were between 68 and 90 years old. All were retired. Gender was balanced, all described their ethnicity as white British, and eGFR ranged from 7 to 14ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, excepting one participant whose eGFR was 25ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e at the time of interview, having been 14ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e at recruitment. Seven patients were preparing for HD, two for PD and the remaining six for CKM; with nobody active on a transplant waiting list.\u003c/p\u003e\n\u003cp\u003eInterviews lasted 29 to 84 minutes. Illustrative transcript extracts are provided, with divergent views highlighted where relevant. Quotations are reported verbatim and marked with the participant group (patient/family member) and unique identifying number; age decade; gender (male, M; female, F); and clinically documented treatment plan (HD, PD or CKM).\u003c/p\u003e\n\u003cp\u003eParticipants at various stages of kidney failure preparedness recounted their journey from diagnosis, generally marked by intense negative emotions, including shock and despair. Despite subsequent acceptance of kidney disease, an awareness of life\u0026rsquo;s fragility tended to have a persistent effect on individuals\u0026rsquo; reflections upon their lives and futures. Whilst most accepted disease progression as inevitable, uncertainty lingered regarding prognosis; particularly relating to the tangled relationship between the prospect of death from kidney failure and competing risk of death from another cause. This interplay influenced perceptions of kidney function and treatment decisions:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe I will have to go on dialysis eventually, whether I will or not I don\u0026rsquo;t know\u0026hellip; I mean not everybody goes on it I suppose, they\u0026rsquo;ve probably kicked the bucket before you get there... it\u0026rsquo;s in the lap of the gods really, isn\u0026rsquo;t it?\u0026rdquo; \u003cstrong\u003e#14 Patient (80s, F, PD)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree overarching themes were identified: (1) Kidneys as critical blood-cleaning organs, where kidney function was framed as vital for survival; (2) Unwitnessed function and failure, where disease was experienced invisibly; and (3) Quantifying and predicting kidney function; the conceptualisation of kidney function using numbers and graphs. Quotations exemplifying each theme are summarised in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Critical blood-cleaning organs \u0026ndash;\u003cem\u003e\u0026nbsp;\u0026ldquo;If your kidneys die, you\u0026rsquo;re dead.\u0026rdquo;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants appeared to recognise the kidneys as vital organs. This was explicit in statements linking kidney failure and death, but also seen in metaphors describing kidney failure as a \u0026ldquo;\u003cem\u003edeath sentence\u0026rdquo;\u0026nbsp;\u003c/em\u003e(#10 patient)\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eor \u0026ldquo;\u003cem\u003ethe end of the road\u003c/em\u003e\u0026rdquo; (#2 patient). Participants emphasised the blood-cleaning function of kidneys and dialysis, with few references to other functions. The only identified \u0026lsquo;cleaned\u0026rsquo; substance was \u0026ldquo;potassium\u0026rdquo;. A wide variety of other negative, but abstract terminology was used including \u0026ldquo;\u003cem\u003etoxins\u003c/em\u003e\u0026rdquo; (#10 patient, #12 patient, #6 patient\u003cem\u003e),\u0026nbsp;\u003c/em\u003e\u0026ldquo;\u003cem\u003epoisons\u003c/em\u003e\u0026rdquo; (#2 patient), \u0026ldquo;\u003cem\u003enasties\u003c/em\u003e\u0026rdquo; (#1 family member), \u0026ldquo;\u003cem\u003eimpurities\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003enaughty cells\u003c/em\u003e\u0026rdquo; (#1 family member). #12 patient, who had been hospitalised with acute kidney injury, provided a detailed description of how \u0026ldquo;\u003cem\u003etoxin\u003c/em\u003e\u0026rdquo; accumulation could be fatal:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know which one goes first, your brain or your heart or whichever just dies of too high a level of toxin in your blood and that\u0026rsquo;s it, you slip into unconsciousness and you\u0026rsquo;re dead.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#12 Patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(70s, M, HD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient participants appeared almost unanimous in their expectation that death from kidney failure would come, unless they die from a competing event (e.g. \u0026ldquo;\u003cem\u003ecar crash\u003c/em\u003e\u0026rdquo; \u0026ndash; #14 patient) or start dialysis. An assumption that dialysis would prolong life appeared across almost all accounts. The few participants who discussed death whilst in receipt of dialysis described this in terms of death from other causes; such as a \u003cem\u003e\u0026ldquo;heart attack\u0026rdquo;\u003c/em\u003e (#1 patient), suggesting a widespread perception that dialysis prevents death from kidney failure. Participants had varied expectations about the experience of death without dialysis: some, especially those preparing for dialysis, anticipated death may be sudden and/or frightening, or else were uncertain what to expect; others, typically those planning for CKM, expected dying to be a less traumatic \u0026ldquo;sleep to the end\u0026rdquo; (#2 patient):\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;if you die from kidney failure you just go to sleep\u0026hellip; which is quite pleasant.... You sort of die in your bed\u0026hellip; it\u0026rsquo;s nothing to go against is it, another good point, another tick.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#5 Patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(80s, M, CKM)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough numerous participants referred to prognostic discussions with clinicians, recollections of receiving a concrete prognosis were rare. This appeared to frustrate some participants who expressed a desire for more certainty:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When we asked the doctor\u0026hellip; \u0026lsquo;how long\u0026hellip; we know you can\u0026rsquo;t say how long a piece of string is, but how long is his piece of string?\u0026rsquo; (laughs)\u0026hellip;. It\u0026rsquo;s sometimes worse not having all the facts.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#8 Family member (wife of #18 patient, 80s, M, HD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhere prognostic discussions were recalled, these generally related to death if dialysis was not initiated. Even those envisioning short remaining lives speculated about being compelled to start treatment, when faced with \u003cem\u003e\u0026ldquo;dialysis or death\u0026rdquo;\u003c/em\u003e (#8 patient).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Unwitnessed function and failure \u0026ndash; \u003cem\u003e\u0026ldquo;The kidneys, I can\u0026rsquo;t see the kidneys\u0026hellip;\u003c/em\u003e\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants tended to depict kidney function as invisible. Several explained how they learned they had CKD from blood tests taken whilst feeling well, so the discovery came as a shock. Even after diagnosis, the asymptomatic and unwitnessed disease process appeared to allow some to consider their kidneys to be working \u0026ldquo;\u003cem\u003eproperly\u003c/em\u003e\u0026rdquo; (#11 patient). Other participants described how it was hard to accept having CKD, because they had never felt ill:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You really don\u0026rsquo;t sort of believe that \u0026lsquo;cos I think because you feel perfectly alright so that\u0026rsquo;s it, they\u0026rsquo;re talking a lot of rot, but they obviously are not of course.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#14 Patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(80s, F, PD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants, more commonly those preparing for dialysis, appeared uncertain about what problems to expect if their disease progressed, and whether their various symptoms could be attributed to their kidneys. Family members mentioned symptoms less than patients, but when they did, appeared equally uncertain about what \u0026ldquo;\u003cem\u003esymptoms we\u0026rsquo;re to look out for\u003c/em\u003e\u0026rdquo; (#4B family member).\u003c/p\u003e\n\u003cp\u003eMost participants suggested a cause for their, or their family member\u0026rsquo;s kidney disease, but incomplete understanding and uncertainty \u0026ndash; \u0026ldquo;\u003cem\u003epuzzlement\u003c/em\u003e\u0026rdquo; (#10 family member) \u0026ndash; was apparent. Some participants with diabetic and hypertensive kidney disease used analogies to conceptualise the cause of kidney damage, whereas those with cancer, prior operations or abnormal scans tended to present more anatomical conceptions:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s like filters she said on a car, if they get clogged up the engine don\u0026rsquo;t run on the car so [it] conks out.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#7 Patient (60s, M, HD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They could see that this kidney was really quite small and probably not working very hard.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#3 Patient (80s, F, CKM)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Quantifying and predicting kidney function \u0026ndash; \u0026ldquo;Twenty percent out of a hundred\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of eGFR to quantify kidney function was almost ubiquitous, despite no participant naming this term. Some referred to unitless numbers only (nine participants); whilst 13 referred to the \u0026ldquo;\u003cem\u003epercentage for how much your kidneys are working\u003c/em\u003e\u0026rdquo; (#15 patient).\u003c/p\u003e\n\u003cp\u003eMore than half of participants discussed numerical \u0026lsquo;thresholds\u0026rsquo; at which symptoms would develop, or \u0026ndash; more commonly \u0026ndash; \u0026ldquo;\u003cem\u003etrigger level[s]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(#2 family member \u0026ndash; a concept raised by 11 participants in total) at which someone would \u0026ldquo;\u003cem\u003ehave to be on dialysis\u003c/em\u003e\u0026rdquo; (#1 patient). Kidney function thresholds for dialysis initiation ranged between five (#10 patient) and 15 (#4A family member) and tended to be portrayed as concrete, rather than points of choice or discussion, since non-initiation of dialysis at this point appeared to be perceived as fatal. Whilst few appeared to consider thresholds for dialysis initiation as flexible, one participant recalled being informed of different cut-offs by different clinicians:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;he thought that the level should be around 15, whereas the previous person had said 10 and below.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#1 Family member\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(wife of\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e#1 patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e, 70s, M, PD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKidney function trends and \u0026ldquo;\u003cem\u003escale[s]\u003c/em\u003e\u0026rdquo;\u003cem\u003e\u0026nbsp;\u003c/em\u003e(#1 patient) appeared to contribute to perceptions such as \u0026ldquo;\u003cem\u003estability\u003c/em\u003e\u0026rdquo; (#4A and #4B family members), \u003cem\u003e\u0026ldquo;reversal\u0026rdquo;\u003c/em\u003e (#15 patient) and \u003cem\u003e\u0026ldquo;steady decline\u0026rdquo;\u003c/em\u003e (#1 patient):\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we call it bobbing along the bottom of the pond because he goes up and down on the 20 line and he\u0026rsquo;s been doing that for a number of years now\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e#8 Family member\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e(wife of\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e#8 patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e, 80s, M, HD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor some, these trends and scales appeared to have been consolidated by clinicians presenting graphs of kidney function results and extrapolating future trajectories. This practice appeared to emphasise the concept of relentlessly progressive disease and verified \u0026lsquo;trigger levels\u0026rsquo; for both dialysis initiation and death from kidney failure \u0026ndash; in many cases, considered to be one and the same:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; they said when you get down to 10 you ought to be on it and by 8 you\u0026rsquo;re definitely on it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e#1 Patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(70s, M, PD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlongside concrete portrayals of thresholds for dialysis initiation, some participants (seven in total) appeared to understand CKD progression and the reasons for treatment initiation through non-numerical concepts, such as symptom development or overall health status:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know when it\u0026rsquo;s [dialysis] going to start or nothing\u0026hellip; Well, if my health\u0026rsquo;s going down or something like that, it\u0026rsquo;s totally up to my doctor\u0026hellip; It\u0026rsquo;s entirely up to my health\u0026rdquo;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e#11 Patient\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(80s, M, HD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNonetheless, five of these seven participants still referenced numerical estimates of kidney function, including three referring to percentage function, suggesting that these constructs are not exclusive. Indeed, several participants seemed uncertain about the relative contribution of numerical kidney disease measures to their future health in the context of comorbidities and ageing:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;how long can you live on twelve percent? I don\u0026rsquo;t know.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e#5 Patient (80s, M, CKM)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur analysis has identified misperceptions about CKD and kidney failure which impact upon older patients\u0026rsquo; and family members\u0026rsquo; ability to make informed treatment decisions between dialysis and CKM. It appears that these reflect unintended consequences of clinical communication around kidney function. The discourse of advanced kidney disease is understood primarily through; (a) concepts of \u0026lsquo;toxin\u0026rsquo; clearance; and (b) low eGFR values, often conveyed in the language of \u0026lsquo;percentage kidney function\u0026rsquo;. These constructs are set against an \u0026lsquo;invisible\u0026rsquo; illness experience and uncertainties regarding the interconnectedness of kidney failure with concurrent health conditions and overall prognosis. They appear to drive misperceptions of a \u0026ldquo;need\u0026rdquo; for dialysis initiation upon reaching numerical thresholds, undermining many families\u0026rsquo; capacity to envision a future living without dialysis.\u003c/p\u003e\u003cp\u003eThese misperceptions present a potentially major impediment to shared decision-making. Appropriate communication of accurate and individualised CKD information is especially important for older people deciding between treatment options for kidney failure, because the uncertain benefit of dialysis in this patient group(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) makes decision-making particularly preference-sensitive(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Studies of younger patients with CKD have previously shown how knowledge gaps and misunderstandings can impact on health behaviours, such as self-management, medication concordance, and perceptions about risks of progression to kidney failure.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) However our study is the first to examine the impact in older patients choosing between treatment options for kidney failure. The important nuances of the decisions they face did not appear to have been conveyed: there was little evidence that older participants, many with multiple long-term conditions, understood that dialysis might not prolong their lives(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), understanding of which is known to affect decision-making.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eWe found that patients and their family members shared common perceptions of kidney function and failure. Kidneys were understood as critical organs for survival, with loss of blood-cleaning expected to result in fatal toxin accumulation. Perceptions of the prognostic implications of advanced kidney disease appeared to be limited to the loss of this blood-cleaning function, and the potential for dialysis to extend life through substituting kidney function.\u003c/p\u003e\u003cp\u003eKidney disease was experienced invisibly; in its place were numerical measures and trends, dominating perceptions of future health. The presumption of life-prolongation with dialysis appeared to establish the \u0026ldquo;do or die\u0026rdquo; choice between dialysis and death, which has been described before.(\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Amongst our participants, this belief appeared to be perpetuated by misunderstood quantitative constructs, whereby perceptions of percentage function as absolute, future decline along a scale as relentlessly progressive, and existence of numerical trigger levels established the idea that a \u0026ldquo;\u003cem\u003eneed\u003c/em\u003e\u0026rdquo; to initiate dialysis treatment, or face death, was inevitable once kidney function fell below a certain threshold.\u003c/p\u003e\u003cp\u003eThe \u0026lsquo;unwitnessed\u0026rsquo; nature of kidney disease appeared to increase reliance upon information and guidance from clinicians. That CKD can be experienced as \u0026lsquo;unwitnessed\u0026rsquo; has been described across all age-groups.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Feelings of uncertainty, disconnectedness and lack of control have been described previously in CKD(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and other \u0026lsquo;unwitnessed\u0026rsquo; conditions such as chronic leukaemia(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The gap left by intangibility appears readily filled by blood test results: eGFR governed older patient and family understanding of disease, treatment decisions, and expectations for the future. This has been observed before amongst older patients with CKD(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e); however earlier studies did not involve family members, known to play an important role in shared decision-making(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), nor have they demonstrated previously how perceptions, and misperceptions, of these numerical measures might influence kidney failure treatment decisions in this older patient group. Our findings suggest that, for patients to feel that CKM is a valid option, an understanding is required of individualised \u003cem\u003ereasons\u003c/em\u003e for choosing, or not choosing, dialysis.\u003c/p\u003e\u003cp\u003eIt is well-established that failure to adequately communicate disease information, including numerical information, negatively impacts shared decision-making, empowerment, and self-management.(\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) Low health literacy, including numeracy, common among many groups of people with CKD(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) and older people (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), can also contribute to misinterpretation of health risks.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Whilst thresholds and trends in eGFR play a role in CKD care pathways and disease staging(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), trigger levels are not supported by clinical research. No randomised controlled trial has ever identified a threshold below which careful monitoring for disease complications becomes unsafe.(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) We found that eGFR communicated as unitless numbers, framed as percentages, and depicted in trends and graphs, can be misinterpreted, with unintended implications. Despite being technically inaccurate(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), the shorthand \u0026ldquo;percentage\u0026rdquo; kidney function is likely intended to aid patient understanding. Like others(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) we have found that the concept of \u0026ldquo;percentage function\u0026rdquo; appears difficult for older patients and family members to interpret. Amongst our older patient and family member group, there was no mention of imprecision in estimated kidney function(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e); of alternative explanations for \u0026ldquo;stable\u0026rdquo; or rising eGFR, such as sarcopenia; or of the possibility of abrupt decline to kidney failure.(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eDefining the reasons and optimal timing for dialysis initiation for older patients is challenging, requiring consideration of individual patients\u0026rsquo; circumstances and preferences. Potential benefits of earlier treatment initiation, such as initiation of chosen modality, must be weighed against the potential for receipt of dialysis that provides neither quality nor quantity of life benefit.(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) A focus on eGFR may compel older patients to prepare for dialysis without consideration of wider factors which can have a significant personal impact, such as symptoms, quality of life, treatment burden and end-of-life wishes. Optimal communication depends on clinicians having skills and resources to facilitate complex discussions; however nephrologists describe challenges explaining disease, treatment and prognostic complexity within available consultation time(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), and currently available patient information documents may misrepresent treatment options.(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) Research involving consultation observation may help to identify how communication influences patient understanding and decision-making, and inform approaches that could be included in interventions.(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe strengths of this study include a rigorous application of qualitative methods and broad range of clinicodemographic variation between study participants, sampled from multiple kidney centres. The inclusion of family members brings in the views of an often neglected group, known to play an important role in treatment decision-making.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) The study has limitations. All centres were in England and all participants were white British. Culture and faith play important roles in understandings of disease and treatment decision-making, so our findings may not be transferable to non-white British patient groups. Further research with ethnically diverse groups is needed. Patient participants had a range of educational levels, with socioeconomic backgrounds skewed towards lower levels of deprivation. Experiences and understandings may differ among patients from different socioeconomic backgrounds. All findings are based on patient and caregivers\u0026rsquo; personal experiences: direct observation of how kidney function and failure are described in clinical practice would be informative.(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) As with all qualitative research, the authors\u0026rsquo; own experiences will have influenced data and analysis. Finally, data collection was discontinued when analysis of patient interviews indicated sufficient informational power, so themes from family member interviews may have been less well developed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, we found older patients with advanced CKD and their family members held simplified constructs of kidney function and failure. Whilst similar misperceptions have been demonstrated amongst younger people with kidney disease, our study identifies the unique implications of these where older individuals face a decision between dialysis and CKM. Current approaches to patient education may be unsuitable for this older patient group, where decisions about preparation for kidney failure are especially preference-sensitive. Evidence-based guidance and clinician education are needed to ensure information about kidney failure and its treatments is effectively communicated. Revising inaccurate and misleading terminology may help patients and families to make better informed and holistic choices about their future priorities and treatment preferences. The recently advocated move towards use of risk-based equations for guiding CKD referral and treatment decisions(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) could provide an opportunity to re-examine how best to communicate disease severity in CKD, and its implications for treatment decisions, to older patients and their families. Improvement requires the development of evidence-based communication guidance, training and education, decision aids, and health literacy assessment; adapted for specific patient groups, all of which have the potential to enhance shared decision-making, advance care planning, and patient-centred outcomes.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e) Our findings suggest that clinicians should shift focus away from numerical measures of disease severity towards wider factors guiding treatment decisions, such as quality of life, individualised values and goals. This may help people living with advanced kidney disease to better trade-off the benefits and burdens of available treatments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCKD \u0026ndash; chronic kidney disease; KRT \u0026ndash; kidney replacement therapy; CKM \u0026ndash; conservative kidney management; eGFR \u0026ndash; estimated glomerular filtration rate; HD \u0026ndash; haemodialysis, MLTC \u0026ndash; multiple long-term conditions; PD \u0026ndash; peritoneal dialysis; SDM \u0026ndash; shared decision making\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reviewed by Surrey Research Ethics Committee and granted NHS Health Research Authority and Health and Care Research Wales approval on 2/8/18 (ref: 18/LO/1179) and was conducted in accordance with the Declaration of Helsinki. All participants gave informed, written consent for participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave informed, written consent for their data (including quotation excerpts) to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaw interview data is potentially identifiable so is not made available. Please contact the corresponding author for further details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFC is Chief Investigator, and LR and JC are co-investigators for the Prepare for Kidney Care Study, a randomised controlled trial comparing outcomes for older people preparing for kidney dialysis vs. CKM (https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/prepare-for-kidney-care/). LR is co-applicant of the NIHR Bristol Biomedical Research Centre (BRC). \u0026nbsp;The authors have no other relationships/activities/interests related to the content of this manuscript to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and represents independent research sponsored by the University of Bristol. The views expressed are those of the author(s), conducted as part of an NIHR Doctoral Research Fellowship (DRF-2017-10-127), and not necessarily those of the NIHR or the Department of Health and Social Care. \u0026nbsp; LS, NIHR Career Development Fellow (CDF-2018-11-ST2-009) was funded by the NIHR for this research project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBH designed the study and conducted interviews as part of his doctoral fellowship (PhD), supported and supervised by FC, RM, JC, LR and LS. BH, CS and RK carried out line-by-line coding of interview transcripts independently. Transcripts and codes were read and discussed with the wider study team, FC, RM, JC, LR and LS, with consideration of wider meaning, alongside reorganisation, recoding and thematic development. JD was involved as an independent patient co-author, contributing to critical interpretation of the overarching themes. CS and BH wrote the initial draft of the manuscript and revised it iteratively to develop and produce a final draft with input and review from all the study team members, RK, JD, FC, RM, JC, LR and LS. All team members reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharlotte M Snead:\u003c/strong\u003e Conceptualization, Validation, Formal Analysis, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review and Editing, Visualization\u003cstrong\u003e. Robert A Kimmitt:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing. \u003cstrong\u003eFergus J Caskey:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing, Supervision\u003cstrong\u003e. Jocelyn Darling:\u003c/strong\u003e Formal Analysis, Writing \u0026ndash; Review and Editing. \u003cstrong\u003eLeila Rooshenas:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing, Supervision. \u003cstrong\u003eJoanna Coast:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing, Supervision. \u003cstrong\u003eRachael L Morton:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing, Supervision. \u003cstrong\u003eLucy E Selman:\u003c/strong\u003e Validation, Formal Analysis, Writing \u0026ndash; Review and Editing, Supervision. \u003cstrong\u003eBarnaby Hole:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Data Curation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review and Editing, Visualization, Supervision, Project administration, Funding acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the staff working in the three recruiting kidney units and the patients and family members who invited us into their lives and homes to learn about their experiences of kidney disease. The authors would also like to acknowledge the members of the patient and public involvement group for their valuable input.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEuropean Renal Registry. ERA Registry Annual Report 2021. . Amsterdam UMC, location AMC, Department of Medical Informatives, Amsterdam, the Netherlands.; 2023.\u003c/li\u003e\n \u003cli\u003ePippias M, Stel VS, Kramer A, Abad Diez JM, Areste-Fosalba N, Ayav C, et al. Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry. Transpl Int. 2018;31(5):540-53.\u003c/li\u003e\n \u003cli\u003eDavison SN, Pommer W, Brown MA, Douglas CA, Gelfand SL, Gueco IP, et al. Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney International. 2024;105(1):35-45.\u003c/li\u003e\n \u003cli\u003eBuur LE, Madsen JK, Eidemak I, Krarup E, Lauridsen TG, Taasti LH, et al. Correction: Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? a systematic review. BMC nephrology. 2022;23(1):352-.\u003c/li\u003e\n \u003cli\u003eMurphy E, Burns A, Murtagh FEM, Rooshenas L, Caskey FJ. The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease. Nephrol Dial Transplant. 2021;36(6):975-82.\u003c/li\u003e\n \u003cli\u003eMurray MA, Brunier G, Chung JO, Craig LA, Mills C, Thomas A, et al. A systematic review of factors influencing decision-making in adults living with chronic kidney disease. Patient education and counseling. 2009;76(2):149-58.\u003c/li\u003e\n \u003cli\u003eSakthivel P, Mostafa A, Aiyegbusi OL. Factors that influence the selection of conservative management for end-stage renal disease\u0026ndash;a systematic review. Clinical Kidney Journal. 2024;17(1):sfad269.\u003c/li\u003e\n \u003cli\u003eAmir N, McCarthy HJ, Tong A. A working partnership: A review of shared decision‐making in nephrology. Nephrology. 2021;26(11):851-7.\u003c/li\u003e\n \u003cli\u003eFrazier R, Levine S, Porteny T, Tighiouart H, Wong JB, Isakova T, et al. Shared decision making among older adults with advanced CKD. American Journal of Kidney Diseases. 2022;80(5):599-609.\u003c/li\u003e\n \u003cli\u003eBristowe K, Selman L, Murtagh FE. Qualitative research methods in renal medicine: an introduction. Nephrol Dial Transplant. 2015;30(9):1424-31.\u003c/li\u003e\n \u003cli\u003eHarwood L, Clark AM. Understanding pre-dialysis modality decision-making: a meta-synthesis of qualitative studies. International journal of nursing studies. 2013;50(1):109-20.\u003c/li\u003e\n \u003cli\u003eSelman LE, Bristowe K, Higginson IJ, Murtagh FEM. The views and experiences of older people with conservatively managed renal failure: a qualitative study of communication, information and decision-making. BMC Nephrol. 2019;20(1):38.\u003c/li\u003e\n \u003cli\u003eRoberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, et al. Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies. BMJ open. 2018;8(9):e023507.\u003c/li\u003e\n \u003cli\u003eMorton R, Tong A, Howard K, Snelling P, Webster A. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BmJ. 2010;340.\u003c/li\u003e\n \u003cli\u003eJongejan M, de Lange S, Bos WJW, Pieterse AH, Konijn WS, van Buren M, et al. Choosing conservative care in advanced chronic kidney disease: a scoping review of patients\u0026rsquo; perspectives. Nephrology Dialysis Transplantation. 2024;39(4):659-68.\u003c/li\u003e\n \u003cli\u003eWalker RC, Hanson CS, Palmer SC, Howard K, Morton RL, Marshall MR, et al. Patient and caregiver perspectives on home hemodialysis: a systematic review. American Journal of Kidney Diseases. 2015;65(3):451-63.\u003c/li\u003e\n \u003cli\u003eHole B, Coast J, Caskey FJ, Selman LE, Rooshenas L, Kimpton G, et al. A choice experiment of older patients\u0026apos; preferences for kidney failure treatments. Kidney Int. 2025;107(1):130-42.\u003c/li\u003e\n \u003cli\u003eHole B, Rooshenas L, Morton R, Caskey F, Scanlon M, Coast J, et al. \u0026apos;It\u0026apos;s basically \u0026apos;have that or die\u0026apos;\u0026apos;: a qualitative study of older patients\u0026apos; choices between dialysis and conservative kidney management. BMJ Open. 2025;15(3):e095185.\u003c/li\u003e\n \u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57.\u003c/li\u003e\n \u003cli\u003eDavies SJ, Phillips L, Naish PF, Russell GI. Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant. 2002;17(6):1085-92.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. WHO Handbook for Reporting Results of Cancer Treatment. Geneva, World Health Organization. 1979.\u003c/li\u003e\n \u003cli\u003eKimmitt RA, Snead CM, Rooshenas L, Caskey FJ, Coast J, Morton RL, et al. \u0026lsquo;That\u0026rsquo;s why I wanted him to go on dialysis\u0026rsquo;\u0026ndash;a qualitative inductive thematic analysis of older patients\u0026rsquo; and their family members\u0026rsquo; perspectives on kidney failure treatment decision-making. BMC nephrology. 2025;26(1):368.\u003c/li\u003e\n \u003cli\u003eLevers M-JD. Philosophical Paradigms, Grounded Theory, and Perspectives on Emergence. SAGE Open. 2013;3(4):2158244013517243.\u003c/li\u003e\n \u003cli\u003eBhaskar R. Reclaiming reality: a critical introduction to contemporary philosophy. London, UK: Routledge.2010.\u003c/li\u003e\n \u003cli\u003eDenzin NK. Introduction: The discipline and practice of qualitative research. In: NK Denzin \u0026amp; YS Lincoln, editors, The SAGE handbook of qualitative research 3rd ed: Thousand Oaks, California, USA.: SAGE Publications; 2005. p. 21.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101.\u003c/li\u003e\n \u003cli\u003eClarke V, Braun V. Successful qualitative research: A practical guide for beginners. Successful qualitative research. 2013:1-400.\u003c/li\u003e\n \u003cli\u003eLissanu L, Lopez F, King A, Robinson E, Almazan E, Metoyer G, et al. \u0026ldquo;I try not to even think about my health going bad\u0026rdquo;: a qualitative study of chronic kidney disease knowledge and coping among a group of urban African-American patients with CKD. Journal of racial and ethnic health disparities. 2019;6:625-34.\u003c/li\u003e\n \u003cli\u003eFoote C, Kotwal S, Gallagher M, Cass A, Brown M, Jardine M. Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2016;21(3):241-53.\u003c/li\u003e\n \u003cli\u003eSchell JO, Patel UD, Steinhauser KE, Ammarell N, Tulsky JA. Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study. Am J Kidney Dis. 2012;59(4):495-503.\u003c/li\u003e\n \u003cli\u003eThorsteinsdottir B, Espinoza Suarez NR, Curtis S, Beck AT, Hargraves I, Shaw K, et al. Older patients with advanced chronic kidney disease and their perspectives on prognostic information: a qualitative study. Journal of general internal medicine. 2022;37(5):1031-7.\u003c/li\u003e\n \u003cli\u003eLovell S, Walker RJ, Schollum JB, Marshall MR, McNoe BM, Derrett S. To dialyse or delay: a qualitative study of older New Zealanders\u0026apos; perceptions and experiences of decision-making, with stage 5 chronic kidney disease. BMJ Open. 2017;7(3):e014781.\u003c/li\u003e\n \u003cli\u003eLlewellyn H, Low J, Smith G, Hopkins K, Burns A, Jones L. Narratives of continuity among older people with late stage chronic kidney disease who decline dialysis. Social science \u0026amp; medicine. 2014;114:49-56.\u003c/li\u003e\n \u003cli\u003eMeuleman Y, van der Bent Y, Gentenaar L, Caskey FJ, Bart HA, Konijn WS, et al. Exploring Patients\u0026rsquo; Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study. International Journal of Behavioral Medicine. 2024;31(2):263-75.\u003c/li\u003e\n \u003cli\u003eVandenberg AE, Echt KV, Johnson TM, Bowling CB. Patient discourse on chronic kidney disease monitoring: a qualitative study at a Veterans Affairs Renal Clinic. BMC nephrology. 2018;19:1-9.\u003c/li\u003e\n \u003cli\u003eBristowe K, Selman L, Higginson IJ, Murtagh F. Invisible and intangible illness: a qualitative interview study of patients\u0026rsquo; experiences and understandings of conservatively managed end-stage kidney disease. Annals of Palliative Medicine. 2019;8(2):121-9.\u003c/li\u003e\n \u003cli\u003eEvans J, Ziebland S, Pettitt AR. Incurable, invisible and inconclusive: watchful waiting for chronic lymphocytic leukaemia and implications for doctor-patient communication. Eur J Cancer Care (Engl). 2012;21(1):67-77.\u003c/li\u003e\n \u003cli\u003eSenghor A. How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study. Revue d\u0026apos;\u0026Eacute;pid\u0026eacute;miologie et de Sant\u0026eacute; Publique. 2021;69(1):22-9.\u003c/li\u003e\n \u003cli\u003eZikmund-Fisher BJ, Smith DM, Ubel PA, Fagerlin A. Validation of the Subjective Numeracy Scale: effects of low numeracy on comprehension of risk communications and utility elicitations. Medical Decision Making. 2007;27(5):663-71.\u003c/li\u003e\n \u003cli\u003ePeters E. Beyond comprehension: The role of numeracy in judgments and decisions. Current Directions in Psychological Science. 2012;21(1):31-5.\u003c/li\u003e\n \u003cli\u003eHaga SB, Mills R, Pollak KI, Rehder C, Buchanan AH, Lipkus IM, et al. Developing patient-friendly genetic and genomic test reports: formats to promote patient engagement and understanding. Genome medicine. 2014;6(7):1-11.\u003c/li\u003e\n \u003cli\u003eTaylor DM, Fraser SDS, Bradley JA, Bradley C, Draper H, Metcalfe W, et al. A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD. Clin J Am Soc Nephrol. 2017;12(7):1070-84.\u003c/li\u003e\n \u003cli\u003eAbdel-Kader K, Dew MA, Bhatnagar M, Argyropoulos C, Karpov I, Switzer G, et al. Numeracy skills in CKD: correlates and outcomes. Clinical journal of the American Society of Nephrology: CJASN. 2010;5(9):1566.\u003c/li\u003e\n \u003cli\u003eCutilli CC, Bennett IM. Understanding the health literacy of America: results of the National Assessment of Adult Literacy. Orthop Nurs. 2009;28(1):27-32; quiz 3-4.\u003c/li\u003e\n \u003cli\u003eRolison JJ, Morsanyi K, Peters E. Understanding Health Risk Comprehension: The Role of Math Anxiety, Subjective Numeracy, and Objective Numeracy. Med Decis Making. 2020;40(2):222-34.\u003c/li\u003e\n \u003cli\u003eKidney Disease: Improving Global Outcomes CKDWG. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.\u003c/li\u003e\n \u003cli\u003eGallagher H, Methven S, Casula A, Thomas N, Tomson CR, Caskey FJ, et al. A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy. BMC nephrology. 2017;18(1):1-10.\u003c/li\u003e\n \u003cli\u003eCooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-19.\u003c/li\u003e\n \u003cli\u003eInker LA, Eneanya ND, Coresh J, Tighiouart H, Wang D, Sang Y, et al. New creatinine-and cystatin C\u0026ndash;based equations to estimate GFR without race. New England Journal of Medicine. 2021;385(19):1737-49.\u003c/li\u003e\n \u003cli\u003eAlaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DS, et al. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World journal of methodology. 2017;7(3):73.\u003c/li\u003e\n \u003cli\u003eKovesdy CP, Naseer A, Sumida K, Molnar MZ, Potukuchi PK, Thomas F, et al. Abrupt decline in kidney function precipitating initiation of chronic renal replacement therapy. Kidney international reports. 2018;3(3):602-9.\u003c/li\u003e\n \u003cli\u003eThorsteinsdottir B, Swetz KM, Albright RC. The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms. Clin J Am Soc Nephrol. 2015;10(11):2094-9.\u003c/li\u003e\n \u003cli\u003eLadin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, et al. Discussing conservative management with older patients with CKD: an interview study of nephrologists. American journal of kidney diseases. 2018;71(5):627-35.\u003c/li\u003e\n \u003cli\u003eSowden R, Shaw CB, Robb J, Winterbottom A, Bristowe K, Bekker HL, et al. How do patient information documents present dialysis and conservative kidney management? A document analysis. Clinical Kidney Journal. 2025.\u003c/li\u003e\n \u003cli\u003eSelman LE, Shaw CB, Sowden R, Murtagh FE, Tulsky JA, Parry R, et al. Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study. BMC nephrology. 2024;25(1):417.\u003c/li\u003e\n \u003cli\u003eMajor RW, Shepherd D, Medcalf JF, Xu G, Gray LJ, Brunskill NJ. The kidney failure risk equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study. PLoS medicine. 2019;16(11):e1002955.\u003c/li\u003e\n \u003cli\u003eHallan SI, Rifkin DE, Potok OA, Katz R, Langlo KA, Bansal N, et al. Implementing the European Renal Best Practice Guidelines suggests that prediction equations work well to differentiate risk of end-stage renal disease vs. death in older patients with low estimated glomerular filtration rate. Kidney international. 2019;96(3):728-37.\u003c/li\u003e\n \u003cli\u003eBekker HL, Winterbottom AE, Gavaruzzi T, Finderup J, Mooney A. Decision aids to assist patients and professionals in choosing the right treatment for kidney failure. Clin Kidney J. 2023;16(Suppl 1):i20-i38.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Participant characteristics (n=27)\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"595\" height=\"1035\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e*\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eDue to rounding, percentages may not always appear to add up to 100%\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e**\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eOne participant who had an eGFR of 25ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e at the time of interview, having been 14ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e at recruitment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey.\u0026nbsp;\u003c/strong\u003eCKM, conservative kidney management; eGFR, estimated glomerular filtration rate; HD, haemodialysis; IMD, index of multiple deprivation; PD, peritoneal dialysis; WHO, World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Illustrative quotations\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1068\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative quotations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.\u003c/strong\u003e\u003cstrong\u003eCritical blood cleaning organs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eVital for survival\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;because kidney function will stop and that\u0026rsquo; s- you die from it, that\u0026rsquo;s what happens.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eJeremy (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Basically if your kidneys die, you\u0026rsquo;re dead\u0026hellip; All the organs you\u0026rsquo;ve got, they\u0026rsquo;re all critical functions. You want the whole lot to be working.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#12 Patient (70s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;So if you\u0026rsquo;ve got kidney failure, that would be-\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ldquo;That\u0026rsquo;s end of life virtually.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#3 Patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eToxin clearance\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe because they\u0026rsquo;ve got quite a lot of poison in their system, so that to take dialysis it\u0026rsquo;s being drawn away.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#2 Patient (90s, M, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;it\u0026rsquo;s probably all the toxics in her body what causes all of this \u0026lsquo;cos you could easily sometimes smell the poor girl when she might sit on\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ethe loo or whatever, and you go in and you can get this affect from it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#6 Family member, husband of #6 patient (70s, F, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eUnderstanding mechanisms of kidney function and disease\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Once again, my non-medical knowledge, your kidneys do a certain important job of straining out so many of the nasties from your body.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#1 Family member, wife of #1 patient (70s, M, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;they found some spots on my kidney so [the surgeon] cauterised it and took a third away and put the rest back\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#2 Patient (90s, M, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think that\u0026rsquo;s when it started, through the blood transfusion. I\u0026rsquo;m not saying that\u0026rsquo;s a cause of the kidney func- the loss in kidney function but it\u0026rsquo;s something that- Something\u0026rsquo;s triggered it. Are you with me? But I don\u0026rsquo;t know what.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;#10 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDialysis as life-prolonging kidney replacement\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s that [dialysis] or die basically. That\u0026rsquo;s the alternative, as far as I know of it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#12 Patient (70s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;What did you get the impression that that dialysis is there to do?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP \u0026ldquo;Well keep you going for a few more years I guess. That\u0026rsquo;s what it basically is isn\u0026rsquo;t it?\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#1 Patient (70s, M, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDeath from kidney failure\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[You] go to sleep and you don\u0026rsquo;t wake up and it\u0026rsquo;s part of the system. \u0026nbsp;I\u0026rsquo;m quite ready for it. (pause) Yes, it\u0026rsquo;s all sleep, sleep, sleep.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#2 Patient (90s, M, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;from what I\u0026rsquo;ve read it can be quite horrible and I know that I\u0026rsquo;m going to have to face that and she might not have to \u0026lsquo;cos obviously there\u0026rsquo;s a lot of painkillers and stuff, you can make yourself fuzzy but I\u0026rsquo;m not looking forward to that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#3 Family member, daughter of #1 patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.Unwitnessed function and failure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eInvisible organs\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well the kidneys are working properly I suppose, I don\u0026rsquo;t know \u0026lsquo;cos I can\u0026rsquo;t see \u0026lsquo;em! (laughs)\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#11 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The kidneys, I can\u0026rsquo;t see the kidneys.\u0026rdquo; (sighs)\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#7 Patient (60s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well it\u0026rsquo;s kind of silent really because I wouldn\u0026rsquo;t have been aware if nobody took these blood tests, I wouldn\u0026rsquo;t have been aware of it at all,\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eno reason why I should.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#3 Patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLack of, or uncertain, symptoms\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003eI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Do you know what you\u0026rsquo;re looking out for?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ldquo;Well no, other than tiredness. \u0026nbsp;That\u0026rsquo;s what I said to him, \u0026lsquo;How am I going to know?\u0026rsquo; \u0026nbsp; \u0026nbsp; He said \u0026lsquo;You\u0026rsquo;ll only know \u0026lsquo;cos you\u0026rsquo;ll be so \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;tired, and \u0026nbsp;you\u0026rsquo;ll have no energy that that\u0026rsquo;s the point you\u0026rsquo;ll know\u0026rsquo;. \u0026nbsp;I haven\u0026rsquo;t experienced that yet so I cannot tell you. (laughs) I\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;cannot tell you something you haven\u0026rsquo;t had experience of.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#1 Patient (70s, M, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You feel perfectly alright. I still do feel more or less perfectly alright. I have days but then it may not be anything to do with kidneys.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#14 Patient (80s, F, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDiagnosis as a shock\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So, it\u0026hellip; it hasn\u0026rsquo;t been a visible problem at all, to either of us, and this is why I think we find it \u0026ndash; Oooh \u0026ndash; a bit of a shock when we suddenly get a note, a letter to say we must consider this.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#1 Family member, wife of #1 patient (70s, M, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;were just such a shock. I just couldn\u0026rsquo;t believe it \u0026lsquo;cos I\u0026rsquo;ve always been fit all my life\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#10 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.Quantifying and predicting kidney function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDominance of numerical eGFR measures and their interpretation\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Course every time I go now, we check on them and the 20 is percentage as opposed to percentage efficiency of the kidneys, that kind of thing\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#8 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; he said\u0026hellip; \u0026lsquo;it\u0026rsquo;s about twenty percent\u0026rsquo; and I thought what\u0026rsquo;s that twenty percent out of a hundred percent I take it\u0026hellip; I said \u0026lsquo;that\u0026rsquo;s not very good is it?\u0026rsquo; \u0026lsquo;No\u0026rsquo;, he said.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#7 Patient (60s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ldquo;I think its 11\u0026hellip; They do it in numbers don\u0026rsquo;t they, it\u0026rsquo;s about 11, something like that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;What does that mean when they say that the kidney is 11?\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ldquo;I\u0026rsquo;m not hundred percent what it means.\u0026rdquo; .\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#9 Family member, son of #9 patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eThreshold trigger levels\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They keep doing the blood tests every couple of months and when it gets down to a certain level, that\u0026rsquo;s when I\u0026rsquo;ll need the dialysis.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#13 Patient (60s, F, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well its 20- 20 is where they start worrying\u0026hellip; well I went down to 13 which is chronic. Last week or so I had a check and I\u0026rsquo;m 23 now so I\u0026rsquo;ve gone above..\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cem\u003e\u0026ldquo;I was down at 13 and- If you\u0026rsquo;re down to zero you\u0026rsquo;re dead aren\u0026rsquo;t you? (laughs). They\u0026rsquo;re not working.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e#8 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think if you get to 15, they put you in for dialysis. That\u0026rsquo;s what I was told.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#4A Family member, daughter of #4 patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well (sighs) the 10\u0026rsquo;s the line, he told me 10. They like to start at 10. I\u0026rsquo;ve had a couple at 9, I don\u0026rsquo;t know what I am at the last blood test. So I shall know on Wednesday probably.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#6 Patient (70s, F, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTrends and scales\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not good\u0026rsquo;, he said, it\u0026rsquo;s not too bad at the moment, it\u0026rsquo;s about twenty percent. And I thought \u0026apos;What\u0026rsquo;s that, twenty percent out of a hundred percent I take it\u0026apos;, which- I said \u0026lsquo;That\u0026rsquo;s not very good is it?\u0026rsquo; \u0026lsquo;No\u0026rsquo;, he said.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#7 Patient (60s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When I first went there it were 18 and then it dropped down to 16 percent\u0026hellip; but the time before it had gone up to 25. I thought \u0026lsquo;They\u0026rsquo;re on the reversal\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#15 Patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I went and for years and years they stayed quite steady, around 19, 20, then they just started to go down to 9 and 10\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#6 Patient (70s, F, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eGraphical depiction of kidney function and predicting future trends\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNon-numerical depictions of CKD progression and treatment initiation\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 765px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They show us a graph on the screen and after sort of blood tests and things they say \u0026lsquo;Well, I\u0026rsquo;m afraid the reading\u0026rsquo;s dropped since last time\u0026rsquo; or \u0026lsquo;Its stable, it hasn\u0026rsquo;t moved\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#3 Patient (80s, F, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I keep taking the pills, he says, doctors, you know, started showing me a graph, you know, levels off when I\u0026rsquo;ve been taking- I had a period when I haven\u0026rsquo;t been taking pills and the graph goes down, keep taking my pills and it keeps up.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#12 Patient (70s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, this is what (nurse) said to him. \u0026lsquo;I think it\u0026rsquo;s getting a bit low\u0026rsquo;, she said, she showed him the graph and she says \u0026lsquo;You\u0026rsquo;re not going to get better from it\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#7 Family member, wife of #7 patient (60s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They just showed me on a computer\u0026hellip; this red line, they said, \u0026lsquo;This is your kidney function here and it\u0026rsquo;s up at 23 percent\u0026hellip; and this is where your target, this is what\u0026rsquo;ll happen to you\u0026rsquo; and there were a red graph going down to the corner to zero.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#10 Patient (80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know when it\u0026rsquo;s [dialysis] going to start or nothing\u0026hellip; Well if my health\u0026rsquo;s going down or something like that, it\u0026rsquo;s totally up to my doctor\u0026hellip; It\u0026rsquo;s entirely up to my health\u0026rdquo;.\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#11 Patient\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(80s, M, HD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well when I talked to you earlier about sleepiness\u0026hellip; what it says in the books is quite correct so far as sleepiness is concerned. It\u0026rsquo;s going on and on and on and it\u0026rsquo;s becoming progressively greater as it were as time goes on.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#2 Patient (90s, M, CKM)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI just thought why would I want to be on dialysis when I was feeling so well.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e#14 Patient (80s, F, PD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Age, Renal Insufficiency, Kidney Failure, Chronic, chronic kidney disease, conservative kidney management, Decision Making, Shared, Dialysis, multimorbidity","lastPublishedDoi":"10.21203/rs.3.rs-7325432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7325432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePatients approaching kidney failure are increasingly older, and living with multiple long-term conditions. The benefits of kidney replacement therapy (KRT) are uncertain for many in this group. Supporting decisions between treatment options requires consideration of how people perceive chronic kidney disease and its treatments. This qualitative study aimed to explore how older patients and family members understand kidney function and failure, and how this impacts treatment decision-making.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eBetween September 2018 and July 2019, semi-structured interviews were conducted with older patients and family members recruited from three United Kingdom kidney units. Eligible patients had estimated glomerular filtration rate (eGFR)\u0026thinsp;\u0026lt;\u0026thinsp;15ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, no previous KRT and were age\u0026thinsp;\u0026ge;\u0026thinsp;80 years, or \u0026ge;\u0026thinsp;65 years with significant comorbidity. Interviews used a topic guide developed with patient input. Interview transcripts were analysed using inductive thematic analysis and constant comparative techniques.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFifteen patients and 12 family members were interviewed. Three themes were identified: (i) Critical blood-cleaning organs, where kidney function was considered vital for survival; (ii) Unwitnessed function and failure, where kidney disease was experienced invisibly; and (iii) Quantifying and predicting kidney function; conceptualisation of kidney function using numbers and graphs. Unwitnessed, intangible experiences of kidney failure appeared to accentuate reliance on clinicians for disease information. Numerical and graphical depictions of kidney function were central to formation of disease understanding. Concepts of treatment \u0026lsquo;thresholds\u0026rsquo; appeared to affirm misperceptions of a binary choice between dialysis and death.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eUnintended misunderstandings, including eGFR thresholds for dialysis initiation, arise from common clinical communication approaches and appear to impact upon informed decision-making. This is especially important for older patients with multiple conditions, for whom the benefits of dialysis are uncertain. Improved consultation approaches which enhance patient understanding are needed. Revising misleading terminology and shifting focus away from numerical disease metrics may help patients and families making individualised choices between treatments.\u003c/p\u003e","manuscriptTitle":"How Do Older Patients With Advanced Kidney Disease, and Their Family Members, Understand Kidney Function and Failure? A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 18:26:25","doi":"10.21203/rs.3.rs-7325432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-11T01:32:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-11T01:28:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-10T00:06:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35545684078329846933317507990488871049","date":"2025-09-09T23:35:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T15:54:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28130694419915264073552538890661928584","date":"2025-09-09T15:24:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10593428044724040067089633812230450523","date":"2025-09-09T13:27:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234647952667402510732462366347965063453","date":"2025-09-07T23:58:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T07:17:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245237180452186758754822751766767144803","date":"2025-09-06T10:21:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243814448319922288332883217931951703026","date":"2025-09-04T12:17:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109789190370754006199435322196577692849","date":"2025-09-04T11:24:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50201354792535958777659554005775204180","date":"2025-08-28T04:33:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T03:23:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T12:25:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T12:06:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T12:06:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-08-08T08:45:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fc7777e-214d-444a-9684-a37f3f557221","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:06:03+00:00","versionOfRecord":{"articleIdentity":"rs-7325432","link":"https://doi.org/10.1186/s12882-025-04541-1","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-11-04 15:58:10","publishedOnDateReadable":"November 4th, 2025"},"versionCreatedAt":"2025-09-04 18:26:25","video":"","vorDoi":"10.1186/s12882-025-04541-1","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04541-1","workflowStages":[]},"version":"v1","identity":"rs-7325432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7325432","identity":"rs-7325432","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}