Family involvement and shared decision-making quality in renal replacement therapy selection: A nationwide cross-sectional study

Family involvement and shared decision-making quality in renal replacement therapy selection: A nationwide cross-sectional 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 Article Family involvement and shared decision-making quality in renal replacement therapy selection: A nationwide cross-sectional study Yasushi Kunisho, Tadashi Sofue, Noriaki Kurita, Hiroo Kawarazaki, and 49 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8905143/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Shared decision making in renal replacement therapy should reflect patient values. However, the quantitative impact of family involvement—particularly in Asian contexts—on decision-making quality remains underexplored. This nationwide, multicenter cross-sectional study (October 2022–February 2025) involved 475 adults with stage 5 chronic kidney disease across 49 facilities in Japan. Following the selection of renal replacement therapy, participants were surveyed regarding the final decision-makers and their specific roles. Shared decision-making quality was evaluated using the three-item CollaboRATE scale, assessing information exchange and preference integration. Compared with “physician-only” decisions, CollaboRATE scores (points; 95% confidence interval) were significantly higher in the “patient and physician” (+ 12.3; 1.5–23.2) and “patient, physician, and key person” groups (+ 13.7; 0.8–26.7). Role-based analyses showed that shared decision-making with the physician or key person was associated with a + 10.0 point increase (3.2–16.8) versus decisions without patient involvement. Among patients having family, scores were significantly higher for patient only (+ 9.5), patient-led with input from physician or key person (+ 10.4), and shared decision-making (+ 12.1) categories, compared with no patient involvement. Family involvement enhances shared decision-making quality when selecting renal replacement therapy, particularly when the process remains collaborative and guided by patient preferences. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Nephrology Health sciences/Urology Shared decision-making Renal replacement therapy Family involvement Chronic kidney disease Patient preference Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The global importance of shared decision-making (SDM) approaches in selecting renal replacement therapy (RRT) is growing. SDM can improve survival prognosis in patients with end-stage renal disease[ 1 ] and is associated with higher rates of selecting kidney transplantation and peritoneal dialysis.[ 2 ] However, the role of family involvement in medical decision-making varies widely across cultural contexts.[ 3 ] In many Asian cultures, patients prefer to entrust treatment decisions to family members rather than make decisions independently.[ 4 ] In Japan, patients tend to place greater value on the opinions of physicians and family members, compared with Western populations.[ 5 ] These trends are deeply rooted in cultural backgrounds, such as the emphasis on collectivism in Asian societies, which contrast with the individualism prevalent in Western societies.[ 6 , 7 ] Global guidelines (e.g., Kidney Disease: Improving Global Outcomes; guidelines in the United Kingdom, United States, and Japan) recommend family involvement in the decision-making process for selecting RRT.[ 8 – 11 ] However, decisions focused primarily on satisfying the wishes of physicians or family members are associated with greater decision regret.[ 4 ] In Japan, where relational autonomy is highly valued, patients may prioritize minimizing the burden on family members, sometimes at the expense of their own preferences.[ 4 ] Therefore, clinicians should carefully navigate family dynamics to ensure that decisions reflect the patient’s personal values rather than external pressures.[ 12 ] Despite its clinical importance, the impact of family involvement on the quality of the SDM process in RRT selection has not been quantitatively assessed. We conducted a multicenter, cross-sectional study to clarify how family involvement influences SDM quality in the Japanese clinical setting. Methods Design, Setting, and Participants This multicenter cross-sectional study was conducted between October 2022 and February 2025 at 49 facilities across Japan providing outpatient care for patients with chronic kidney disease (CKD), including dialysis initiation and, at some sites, kidney transplantation (Supplementary Figure S2).[12] Participating facilities included affiliated institutions where alumni of the principal investigator's department practiced; nearby facilities in the Kanto, Shikoku, and Kyushu regions employing co-investigators; and institutions connected to the research team through nephrology networks. Recruitment was based on personal connections within the nephrology community. Eligibility criteria included: (1) adult patients with stage 5 CKD, (2) patients who had selected a form of RRT, and (3) patients who had not yet initiated RRT. Patients with a single estimated glomerular filtration rate measurement <15 mL/min/1.73 m² were eligible if they also met criteria (2) and (3). Exclusion criteria were: (1) patients who had undergone emergency RRT initiation before making a treatment choice, (2) patients unable to complete the questionnaire owing to physical or cognitive impairment, and (3) patients who opted for conservative kidney management. Treating physicians consecutively invited eligible patients to participate. Participants received a 500 JPY gift card upon questionnaire completion. This study was approved by the Institutional Review Board of Fukushima Medical University (no. ippan-2022). All reported clinical and research activities adhered to the principles of the Declaration of Helsinki. Questionnaire on RRT Selection and SDM A self-administered questionnaire (Supplementary Items S2–S4) was developed by the study authors.[12]The questionnaire included demographic information (e.g., education, income), selected RRT modality, key persons consulted about RRT selection, the key person most relied upon by the patient, duration of the relationship with the current primary nephrologist, medical conditions discussed during RRT selection and preparation, a scale measuring quality of the SDM process, and final decision-makers and their role in RRT selection. Both paper and digital versions were available, with the paper survey featuring a unique QR code for each patient. Participants were assured that their responses would remain confidential and would not be reviewed by their primary physician. This policy was upheld through monitoring by the principal investigators at each facility. Paper-based responses were sent to a central analysis facility for processing and data integration. Primary Exposures: Final Decision-Maker and Decision-Making Role in RRT The primary exposure in this study was the final decision-maker for RRT and their role in the decision-making process. To assess this, we developed a questionnaire based on a previous study conducted among patients with heart failure.[13]The questionnaire and response options were refined through email correspondence with the first author of that study (Supplementary Item S3, first question). First, we asked: "Who ultimately made the final decision regarding your RRT?" Response options included combinations of three entities: “myself,” “my physician,” and “the key person” (e.g., a family member or close individual), resulting in seven possible options (2 3 − 1 = 7). Depending on the response, participants were then asked a follow-up question (Supplementary Item S3, Questions A–D): “Please select the option that best describes each person’s role in the decision-making process.” Based on these responses, we classified decision-making roles into six categories (see Supplementary Item S5 for the detailed classification algorithm): (1) no patient involvement – the key person and/or physician made the decision without patient participation, (2) key person-led – the key person made the decision after considering the patient’s opinion, (3) physician-led – the physician made the decision after considering the patient’s opinion, (4) patient alone – the patient made the decision independently, (5) patient-led – the patient made the decision after considering input from the key person and/or physician, (6) collaborative decision-making – the patient made the decision jointly with the key person and/or physician.[13] Outcome: SDM process The SDM process was assessed using the Japanese version of the three-item CollaboRATE scale (Supplementary Item S4).[14,15]CollaboRATE follows a formative model of SDM, with each item evaluating a distinct concept: explaining health issues, eliciting patient preferences, and integrating those preferences.[16]As a result, internal consistency reliability was not assessed.[16]Each item was scored on a scale from 0 (no effort made) to 9 (every effort made). The total score was calculated by summing the three item scores, dividing by 27, and multiplying by 100, yielding a range of 0–100. Higher scores indicate a better SDM process. The construct validity of CollaboRATE has been previously validated.[16] Clinical Data Collection Facility characteristics and clinical data were collected from the treating physicians. Patient data included age, sex, primary cause of end-stage kidney disease (ESKD), frailty (assessed using the Japanese version of the Clinical Frailty Scale 2.0[17,18]), and number of outpatient visits for RRT selection. Outpatient visits for RRT selection required the involvement of nursing staff and a minimum consultation time of 30 minutes.[12]However, these consultations did not need to be scheduled separately from regular nephrology follow-up visits. Additionally, facilities providing these services were not required to meet specific criteria to claim teaching and management fees for RRT under Japan's unique reimbursement system, which allows up to two claims per patient. Statistical Analysis All statistical analyses were conducted using Stata/SE version 18 (StataCorp LLC, College Station, TX, USA). To summarize patient characteristics and SDM-related responses, continuous variables are reported as mean and standard deviation (SD); categorical variables are presented as frequency and percentage. A Venn diagram was used to visually represent the distribution of final decision-makers for RRT, and a histogram was created to illustrate the distribution of CollaboRATE scores. To examine the associations among the final decision-maker, their decision-making role, and the quality of the SDM process, we applied a series of general linear models with cluster-robust variance estimation, treating facilities as the clustering unit.[19]This method also accounts for heteroskedasticity. Candidate confounding variables were selected based on clinical expertise and were included in the model using forced entry. Additionally, because having family could influence these associations, we conducted a subgroup analysis excluding a small number of patients who answered "No" to the question "Do you have any family?" and restricted the analysis to those who responded "Yes." For predictors with missing values, multiple imputation by chained equations was performed under the assumption of missing at random. Estimates from 10 imputed datasets were combined into a single pooled estimate. Results Participant and Facility Characteristics Patient characteristics (N = 476) are summarized in Table 1 . Patients’ mean age was 67.4 years (SD, 13.1) and 65.3% were male. The leading causes of ESKD were diabetic kidney disease (38.2%), nephrosclerosis (21.0%), and chronic glomerulonephritis (19.8%). Most patients had a high school education or lower (61.9%) and an annual household income below 5 million JPY (72.4%). Over 90% reported having family. Frailty was present in 20.2% of participants. As RRT, hemodialysis, peritoneal dialysis, and kidney transplantation was chosen by 70.8%, 24.6%, and 4.4%, respectively. Among participants, 44.3% had a single outpatient visit for RRT selection, and 30.2% had two or more visits. Table 1 Baseline patient characteristics. Patient characteristics, N = 476 Age, y 67.4 (13.1) Male sex, n (%) 311 (65.3) Cause of ESKD, n (%) Diabetic kidney disease 182 (38.2) Chronic glomerulonephritis 94 (19.8) Nephrosclerosis 100 (21.0) Polycystic kidney disease 23 (4.8) Other/Unknown 77 (16.2) Education level, n (%) Junior high school or less 73 (15.6) High school graduate 216 (46.3) University/graduate school 82 (17.6) Other 96 (20.6) Missing, n 9 Household income, n (%) < 1 000 000 JPY 39 (8.7) 1 000 000 to < 5 000 000 JPY 284 (63.7) 5 000 000 to 10 000 000 JPY 36 (8.1) Missing, n 30 Having any family, n (%) No 43 (9.4) Yes 414 (90.6) Missing, n 19 Frailty, n (%) No frailty 380 (79.8) Very mild/mild frailty 76 (16.0) Moderate/severe frailty 20 (4.2) Very severe frailty/terminally ill (0) No. of outpatient visits for RRT selection, n (%) a None 121 (25.4) One 211 (44.3) Two 81 (17.0) Three or more 63 (13.2) Selected RRT, n (%) Hemodialysis 337 (70.8) Peritoneal dialysis 117 (24.6) Kidney transplantation 21 (4.4) Hemodialysis and peritoneal dialysis 1 (0.2) Time with current nephrologist, n (%) < 6 months 115 (24.6) 6 months to < 1 year 68 (14.5) 1 year to < 3 years 143 (30.6) ≥ 3 years 142 (30.3) Missing, n 8 ¥10,000 was equivalent to US$63.8 as of January 2026. The participating facilities varied in bed capacity: 4.1% were clinics and 8.2%, 18.4%, and 69.4% were low-, low- to moderate-, and moderate- to high-capacity hospitals (Table 2 ). RRT initiation in the past year also varied, with over half of facilities reporting 30–100 cases. Table 2 Characteristics of participating facilities. Facility characteristics, N = 49 Facility type by bed capacity, n (%) Clinic (no. of beds < 20) 2 (4.1) Low-capacity hospital (no. of beds 20 to < 200) 4 (8.2) Low- to moderate-capacity hospital (no. of beds 200 to < 400) 9 (18.4) Moderate- to high-capacity hospital (no. of beds ≥ 400 ) 34 (69.4) Number of RRT cases initiated over past 1 year, n (%) 100 cases 8 (16.3) RRT, renal replacement therapy. Key persons consulted for RRT selection Figure 1 shows the key person consulted for RRT selection. Spouses were the most relied upon, followed by close family members, including daughters, sons, and siblings, with biological mothers also frequently reported. A few patients listed in-laws (e.g., son's wife, mother-in-law). Some patients cited "others," such as non-relative acquaintances or friends (n = 16), distant relatives (e.g., aunts, nieces, nephews, n = 8), or (ex-)partners (e.g., common-law wife, ex-wife, n = 4). Frequency of final decision-makers and their roles in RRT selection Figure 2 shows the combinations of decision-makers for RRT selection. The most common was the patient alone (46.5%); followed by patient and physician (20%); patient and key person (13.8%); and patient, physician, and key person (13.2%). In 6.6% of cases, the decision was made by the key person, physician, or both—without the patient. Figure 3 shows the frequency of decision-maker roles in RRT selection. The most common was patient-alone decisions, followed by patient-led decisions (with the opinion of the key person or physician), and collaborative decisions (together with the key person or physician). Relationship between SDM quality and decision-maker or decision-making role Figure 4 shows the SDM level measured using CollaboRATE, with a mean score of 83.9 (SD 17.7). Of the 467 respondents, 36% (168) scored the maximum. Table 3 shows, when using the physician as the reference, there was no clear evidence that decisions made by the patient alone were associated with a higher SDM level (score difference 10.2, 95% confidence interval [CI] − 1.1 to 21.5). However, decisions made by both the physician and patient as well as by the key person, physician, and patient were associated with higher SDM levels (score difference 12.3, 95% CI 1.5 to 23.2 and 13.7, 95% CI 0.8 to 26.7, respectively). For patients having any family, decisions made by the patient alone were associated with a higher SDM level (score differences 11.6, 95% CI 0.4 to 21.5). A stronger association with SDM levels was observed for decisions made by both the physician and patient, as well as by the key person, physician, and patient (score differences 14.3, 95% CI 3.6–23.2 and 15.4, 95% CI 2.5–26.7, respectively). Table 3 Association between final decision-maker and shared decision-making (SDM) quality. Overall, unadjusted n = 467 Overall, adjusted a n = 467 Subgroup of patients with family, adjusted, a n = 407 Score difference, coefficient (95% CI) P - value Score difference, coefficient (95% CI) P -value Score difference, coefficient (95% CI) P -value Final decision-maker(s) Physician Reference Reference Reference Key person 2.6 (− 11.1 to 16.3) 0.706 3.9 (− 10.5 to 18.3) 0.588 2.3 (− 11.6 to 18.3) 0.737 Key person and physician 11.3 (− 7.5 to 30.2) 0.231 12.3 (− 5.8 to 30.4) 0.179 9.8 (− 9.3 to 30.4) 0.307 Patient 9.3 (− 1.5 to 20.1) 0.089 10.2 (− 1.1 to 21.5) 0.075 11.6 (0.4 to 21.5) 0.043 Key person and patient 7.4 (− 2.6 to 17.4) 0.143 8.5 (− 2.1 to 19.2) 0.112 10.0 (− 0.5 to 19.2) 0.061 Physician and patient 10.8 (0.4 to 21.2) 0.043 12.3 (1.5 to 23.2) 0.027 14.3 (3.6 to 23.2) 0.01 Key person, physician, and patient 12.0 (− 0.3 to 24.2) 0.055 13.7 (0.8 to 26.7) 0.039 15.4 (2.5 to 26.7) 0.021 General linear models with cluster-robust variance were used, treating facilities as the clustering unit. a Adjusted for age, sex, primary cause of ESKD, education, income, having family, frailty, and RRT selection visits (as listed in Table 1). RRT, renal replacement therapy; ESKD, end-stage kidney disease; CI, confidence interval.. Table 4 shows, when using no patient involvement as the reference, there was no clear evidence that patient-alone or patient-led decisions were associated with higher SDM levels (score differences 6.8, 95% CI − 0.5 to 14.1 and 7.4, 95% CI − 0.3 to 15.1, respectively). By contrast, collaborative decision-making was significantly associated with higher SDM levels (score difference 10.0, 95% CI 3.2 to 16.8). Among patients having any family, patient-alone and patient-led decisions were associated with higher SDM levels (score differences 9.5, 95% CI 1.8 to 17.1 and 10.4, 95% CI 2.9 to 18.0, respectively). Moreover, a stronger association with SDM levels was observed in collaborative decision-making (score difference 12.1, 95% CI 4.8 to 19.5). Table 4 Association between decision-making roles and shared decision-making (SDM) quality. Overall, unadjusted n = 467 Overall, adjusted a n = 467 Subgroup of patients with family, adjusted, a n = 407 Score difference, coefficient (95% CI) P -value Score difference, coefficient (95% CI) P -value Score difference, coefficient (95% CI) P -value Decision-making role No patient involvement Reference Reference Reference Key person-led 1.9 (− 14.8 to 18.7) 0.816 0.7 (− 17.3 to 18.8) 0.936 8.5 (− 6.9 to 24.0) 0.271 Physician-led 8.3 (− 8.2 to 24.8) 0.316 9.0 (− 7.9 to 25.9) 0.289 12.3 (− 6.5 to 31.1) 0.194 Patient alone 6.5 (− 0.4 to 13.4) 0.063 6.8 (− 0.5 to 14.1) 0.066 9.5 (1.8 to 17.1) 0.017 Patient-led 6.4 (− 0.9 to 13.8) 0.084 7.4 (− 0.3 to 15.1) 0.058 10.4 (2.9 to 18.0) 0.008 Collaborative 9.4 (2.8 to 15.9) 0.006 10.0 (3.2 to 16.8) 0.005 12.1 (4.8 to 19.5) 0.002 General linear models with cluster-robust variance were used, treating facilities as the clustering units. a Adjusted for covariates listed in Table 1. CI, confidence interval. Discussion This study evaluated the influence of family involvement on the quality of SDM among patients with advanced CKD prior to initiating RRT. To our knowledge, this is the first study to quantitatively demonstrate that collaborative involvement—specifically involving the patient, physician, and the "key person" (typically a family member)—is significantly associated with higher SDM scores in comparison with physician-led decisions. Collaborative decisions resulted in higher SDM scores than those made without patient involvement. Notably, among patients having family, the highest SDM quality was achieved when decisions were collaborative or patient-led with family input, emphasizing the crucial role of the family in the decision-making process. Collectively, these findings strongly support the implementation of an SDM approach with family involvement as a crucial strategy for improving the quality of the decision-making process in RRT selection. Our findings revealed that patient involvement with treatment decision-making in Japan was high (93.5%), similar to the rate in Singapore (84%).[20]By contrast, family involvement in decision-making (30.3%) in Japan remains lower than that reported in other Asian contexts, such as that in Singapore (63%).[20]This discrepancy suggests that although Japan has successfully adopted patient-centered models in nephrology, the shift toward a “family-inclusive” or “collaborative” SDM model (13.2% in our study compared with 36% in Singapore[20]) may still be insufficiently established. Another Singaporean study emphasized the need to broaden the unit of care from the individual patient to the family.[21]Therefore, it may be necessary to shift from the conventional SDM approach to a family-inclusive SDM approach in Japan. Our study demonstrated that joint decisions (physician–patient or collaborative) were associated with higher SDM quality, which was particularly pronounced among patients having family. Patients often seek information regarding daily life limitations (66.7%), the economic burden (61.9%), and the family burden (56%).[12]In many Asian cultural contexts, including that of Japan, patients frequently prioritize reducing the burden on the family and maintaining group harmony over their personal preferences alone. Incorporating family members into discussions is not simply supplementary but a cultural necessity for achieving SDM. Family involvement also enables collaborative information sharing, allowing RRT and lifestyle concerns to be addressed from multiple perspectives. This dynamic provides patients with diverse interpretations of medical information while offering clinicians a more comprehensive understanding of the patient’s social context.[22,23]Given that RRT selection is a socially embedded and collaborative process, family support serves a crucial role in the decision-making framework.[24]Therefore, a family-inclusive SDM approach is essential to ensure that treatment decisions are both medically and socially acceptable to the entire care unit. We demonstrated that among patients having any family, patient-alone, patient-led, and collaborative decision-making were associated with higher SDM levels compared with decisions made without patient involvement. A Dutch cross-sectional study among patients after dialysis initiation found that patients were more likely to regret their decisions when greater weight was placed on the opinions of the physician or family.[4]When the family’s wishes conflict with the patient’s preferences, physicians must assess family relationships and ensure that patients’ true values are respected.[12]This aligns with our results; SDM levels were lower when decisions were primarily led by physicians or key family members, regardless of family involvement. A Dutch qualitative study also reported that most patients with CKD made RRT decisions with key persons before hospital visits,[25]suggesting that deliberation regarding RRT often takes place within the household, with family involvement. Our findings suggest that encouraging patients to consult with their family and making the patients’ own preferences during RRT selection a priority may yield high SDM levels. We hypothesize that family involvement enhances the SDM process through three mechanisms: information sharing, emotional support, and practical feasibility. First, family members function as “information bridges,” explaining medical terminology and providing essential context regarding the patient’s lifestyle or financial constraints. This information may not be made available without family involvement.[25]Second, family members provide emotional support, reducing patients’ psychological burden and promoting active engagement in decision-making. Prior research has shown that when families reinforce rather than override patients’ wishes, SDM quality and satisfaction improve.[24]Third, depending on the RRT modality, the patient may require considerable domestic support, such as transport to dialysis facilities, preparing the environment for peritoneal dialysis, or providing living donors. By involving family members early in the treatment planning process, the clinical team can more accurately assess the feasibility of the options, leading to a more practical treatment plan.[26] A key implication of our findings is that, whereas family involvement is beneficial, it must not compromise patient autonomy. Clinicians should therefore remain alert when assessing family input, ensuring that the decision-making process remains patient-centered while being family-inclusive. The strengths of this study include its multicenter, nationwide design and use of the validated CollaboRATE scale to produce quantitative evidence in the pre-RRT population. However, some limitations must be acknowledged. First, the participating facilities may have been skewed toward moderate- to high-bed-capacity hospitals, as a large proportion of facilities were institutions with highly qualified nephrologists known to the authors. This selection bias may partly explain why one-third of patients had a perfect SDM score. However, differences in facility bed capacity are unlikely to influence the involvement of key persons in RRT selection. Second, we did not assess the number of eligible patients with CKD who declined to participate or those who did not complete the survey. Based on RRT initiation rates per quarter, we estimate that 1 913 RRTs were initiated during the study period. This total includes patients who opted out or were ineligible owing to emergent RRT or dementia. Notably, study participants accounted for 25% of all RRT initiations. Third, CollaboRATE and the final decision-maker were retrospectively assessed via self-reported surveys rather than outpatient records. Thus, even if physicians provided the options for RRT, patients might not have accurately recalled the interactions or final decision-makers. However, because our study targeted patients with CKD who had chosen RRT but had not yet started therapy, their recall bias was considered minimal. Finally, in this study, we did not differentiate between cohabiting and non-cohabiting family members, and we did not assess their presence during outpatient consultations. However, the observation that differences in SDM scores emerged based solely on having family provides strong support for our interpretation. Although further research is needed to determine whether cohabitation itself influences SDM levels, the findings suggest that, regardless of cohabitation status, the family may be beneficial in achieving better SDM. In conclusion, our findings provide a strong empirical basis for recommending family participation in the RRT selection process, provided the patient–family relationship is favorable. Clinicians should actively encourage family participation in the RRT decision-making process. Family involvement enhances the quality of information sharing, provides psychological reassurance, and clarifies the feasibility of treatment options. Furthermore, this favorable effect is maximized when family involvement plays a role in strengthening the patient’s own decision-making. Declarations Data Availability Statement The data underlying this article are available from the corresponding author upon reasonable request. Acknowledgments We thank Analisa Avila, MPH, ELS, Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. We thank Ms. Takako Maeshibu and Prof. Takafumi Wakita (Department of Sociology, Kansai University) for creating and managing the online survey form. Author Contributions YK, TS, NK, and YS contributed to the study concept and design. TS, NK, TT, HK, and YS were involved in creation of the survey and data collection. NK performed the data analysis. TS, NK, TT, HK, and YS contributed to data interpretation and manuscript preparation. All authors critically reviewed, edited, and approved the final manuscript. Disclosure T. Sofue has received payment for speaking from Astrazeneca K.K., Astellas Pharma Inc., Kyowa Kirin Co., Ltd. T. NK has received consulting fees from GlaxoSmithKline K.K., and payment for speaking and educational events from Eisai Co., Ltd., Taisho Pharmaceutical Co., Ltd., Kyowa Kirin Co., Ltd., GlaxoSmithKline K.K., Takeda Pharmaceutical Co., Ltd., Kissei Pharmaceutical Co., Ltd., and Baxter Corporation. T. Toida has received consulting fees from Astellas Pharma Inc. and payment for speaking and educational events from Torii Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Ltd., AstraZeneca K.K., Nobelpharma Co., Ltd., and Novo Nordisk Pharma Ltd. S. Shibata received personal fees and/or research funding from AstraZeneca, Bayer, Daiichi-Sankyo, Fuji Yakuhin, Kyowa-Kirin, Mochida, and Torii. T. Suzuki has received payment for speaking and educational events from Astellas Pharma Inc, AstraZeneca K.K, Vantive Japan, Daiichi Sankyo Co., Ltd., Janssen Pharmaceutical K.K, Kaneka Medix Corp, Kissei Pharmaceutical Co., Ltd., Kowa Co., Ltd., Kyowa Kirin Co., Ltd, Mochida Pharmaceutical Co., Ltd., Nobelpharma Co., Ltd, Novartis Pharma K.K., Novo Nordisk Pharma., Ltd., Ono Pharmaceutical Co., Ltd., Otsuka Parmaceutical, Terumo Corp, and Torii Pharmaceutical Co., Ltd. RI has received payment for speaking and educational events from Vantive Japan. Declaration of Generative AI and AI-assisted technologies in the writing process* During the preparation of this work, the authors used Gemini 3 Flash to enhance the English clarity and grammar. All content remains original. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Ethics Statements Study approval statement: This study protocol was reviewed and approved by the Institutional Review Board of Fukushima Medical University [approval number ippan-2022]. Consent to participate statement: Written informed consent was obtained from all participants in the study. Funding This work was supported by JSPS KAKENHI [grant number JP21K10314]. The funder had no role in the design, data collection, data analysis, and reporting of this study. References Fukuzaki, H. et al. Outpatient clinic specific for end-stage renal disease improves patient survival rate after initiating dialysis. Sci. Rep. 13 , 5991 (2023). Lee, C. T. et al. Shared decision making increases living kidney transplantation and peritoneal dialysis. Transplant Proc. ;51:1321–1324. (2019). Dahm, M. R. et al. Older patients and dialysis shared decision-making. Insights from an ethnographic discourse analysis of interviews and clinical interactions. Patient Educ. Couns. 122 , 108124 (2024). 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Supplementary Files Supplementary.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 May, 2026 Reviewers agreed at journal 14 May, 2026 Reviews received at journal 10 May, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers invited by journal 24 Apr, 2026 Editor invited by journal 13 Apr, 2026 Editor assigned by journal 18 Feb, 2026 Submission checks completed at journal 18 Feb, 2026 First submitted to journal 17 Feb, 2026 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. 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process.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/9c32845dfe96f8730646ee7d.png"},{"id":108820688,"identity":"7b286d93-d1e1-49e3-9610-2f68494f00e0","added_by":"auto","created_at":"2026-05-08 16:42:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":178517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of final decision-maker combinations for renal replacement therapy (N = 456).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVenn diagram representing the overlapping roles and combinations of patients, physicians, and key persons involved in the final treatment choice.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/2b4abf2c3e4e7de1bdae68ea.png"},{"id":108821701,"identity":"550c2a8b-6926-4feb-81c7-59d6707e0372","added_by":"auto","created_at":"2026-05-08 16:46:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":233765,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFrequency of decision-making roles in renal replacement therapy selection (N = 448).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBar chart categorized according to decision-making dynamics, ranging from patient-led to collaborative or physician-led processes.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/970a694ac3aed4bf5220d2ef.png"},{"id":108820689,"identity":"6f37a644-b74e-419f-97cc-ceefd85cf46d","added_by":"auto","created_at":"2026-05-08 16:42:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":119595,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of shared decision-making quality (N = 467).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHistogram depicting total CollaboRATE scores, reflecting the perceived quality of the shared decision-making process from the patient's perspective.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/d716ddacb42e09e4f33b6db0.png"},{"id":108976808,"identity":"8b80d8bc-aa8f-42f2-a342-0b1c5e20dbd9","added_by":"auto","created_at":"2026-05-11 11:28:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1824301,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/5986fc52-6292-4427-af3a-ec22a432640a.pdf"},{"id":108821855,"identity":"85d0fde5-a69a-42df-be7c-25e5bf507a4c","added_by":"auto","created_at":"2026-05-08 16:46:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":261503,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8905143/v1/8b6ccf8d08c6540e414440f0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Family involvement and shared decision-making quality in renal replacement therapy selection: A nationwide cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global importance of shared decision-making (SDM) approaches in selecting renal replacement therapy (RRT) is growing. SDM can improve survival prognosis in patients with end-stage renal disease[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and is associated with higher rates of selecting kidney transplantation and peritoneal dialysis.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] However, the role of family involvement in medical decision-making varies widely across cultural contexts.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] In many Asian cultures, patients prefer to entrust treatment decisions to family members rather than make decisions independently.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In Japan, patients tend to place greater value on the opinions of physicians and family members, compared with Western populations.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] These trends are deeply rooted in cultural backgrounds, such as the emphasis on collectivism in Asian societies, which contrast with the individualism prevalent in Western societies.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e Global guidelines (e.g., Kidney Disease: Improving Global Outcomes; guidelines in the United Kingdom, United States, and Japan) recommend family involvement in the decision-making process for selecting RRT.[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] However, decisions focused primarily on satisfying the wishes of physicians or family members are associated with greater decision regret.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In Japan, where relational autonomy is highly valued, patients may prioritize minimizing the burden on family members, sometimes at the expense of their own preferences.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Therefore, clinicians should carefully navigate family dynamics to ensure that decisions reflect the patient\u0026rsquo;s personal values rather than external pressures.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite its clinical importance, the impact of family involvement on the quality of the SDM process in RRT selection has not been quantitatively assessed. We conducted a multicenter, cross-sectional study to clarify how family involvement influences SDM quality in the Japanese clinical setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign, Setting, and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis multicenter cross-sectional study was conducted between October 2022 and February 2025 at 49 facilities across Japan providing outpatient care for patients with chronic kidney disease\u0026nbsp;(CKD), including dialysis initiation and, at some sites, kidney transplantation (Supplementary Figure S2).[12]\u0026nbsp;Participating facilities included affiliated institutions where alumni of the principal investigator's department practiced; nearby facilities in the Kanto, Shikoku, and Kyushu regions employing co-investigators; and institutions connected to the research team through nephrology networks. Recruitment was based on personal connections within the nephrology community.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEligibility criteria included: (1) adult patients with stage 5 CKD, (2) patients who had selected a form of RRT, and (3) patients who had not yet initiated RRT. Patients with a single estimated glomerular filtration rate measurement \u0026lt;15 mL/min/1.73 m² were eligible if they also met criteria (2) and (3). Exclusion criteria were: (1) patients who had undergone emergency RRT initiation before making a treatment choice, (2) patients unable to complete the questionnaire owing to physical or cognitive impairment, and (3) patients who opted for conservative kidney management. Treating physicians consecutively invited eligible patients to participate. Participants received a 500 JPY gift card upon questionnaire completion. This study was approved by the Institutional Review Board of Fukushima Medical University (no. ippan-2022). All reported clinical and research activities adhered to the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire on RRT Selection and SDM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA self-administered questionnaire (Supplementary Items S2–S4) was developed by the study authors.[12]The questionnaire included demographic information (e.g., education, income), selected RRT modality, key persons\u0026nbsp;consulted about RRT selection,\u0026nbsp;the\u0026nbsp;key person most relied upon by the patient, duration of the relationship with the current primary nephrologist, medical conditions discussed during RRT selection and preparation, a scale measuring quality of the SDM process, and final decision-makers and their role in RRT selection. Both paper and digital versions were available, with the paper survey featuring a unique QR code for each patient. Participants were assured that their responses would remain confidential and would not be reviewed by their primary physician. This policy was upheld through monitoring by the principal investigators at each facility. Paper-based responses were sent to a central analysis facility for processing and data integration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Exposures: Final Decision-Maker and Decision-Making Role in RRT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary exposure in this study was the final decision-maker for RRT and their role in the decision-making process. To assess this, we developed a questionnaire based on a previous study conducted among patients with heart failure.[13]The questionnaire and response options were refined through email correspondence with the first author of that study (Supplementary Item S3, first question). First, we asked: \"Who ultimately made the final decision regarding your RRT?\" Response options included combinations of three entities: “myself,” “my physician,” and “the\u0026nbsp;key person” (e.g., a family member or close individual), resulting in seven possible options (2\u003csup\u003e3\u003c/sup\u003e − 1 = 7).\u003c/p\u003e\n\u003cp\u003eDepending on the response, participants were then asked a follow-up question (Supplementary Item S3, Questions A–D): “Please select the option that best describes each person’s role in the decision-making process.” Based on these responses, we classified decision-making roles into six categories (see Supplementary Item S5\u0026nbsp;for the detailed classification algorithm): (1) no patient involvement – the key person and/or physician made the decision without patient participation, (2) key person-led – the key person made the decision after considering the patient’s opinion, (3) physician-led – the physician made the decision after considering the patient’s opinion, (4) patient alone – the patient made the decision independently, (5) patient-led – the patient made the decision after considering input from the key person and/or physician, (6) collaborative decision-making – the patient made the decision jointly with\u0026nbsp;the\u0026nbsp;key person and/or physician.[13]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome: SDM process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SDM process was assessed using the Japanese version of the three-item CollaboRATE scale (Supplementary Item S4).[14,15]CollaboRATE follows a formative model of SDM, with each item evaluating a distinct concept: explaining health issues, eliciting patient preferences, and integrating those preferences.[16]As a result, internal consistency reliability was not assessed.[16]Each item was scored on a scale from 0 (no effort made) to 9 (every effort made). The total score was calculated by summing the three item scores, dividing by 27, and multiplying by 100, yielding a range of 0–100. Higher scores indicate a better SDM process. The construct validity of CollaboRATE has been previously validated.[16]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFacility characteristics and clinical data were collected from the treating physicians. Patient data included age, sex, primary cause of end-stage kidney disease (ESKD), frailty (assessed using the Japanese version of the Clinical Frailty Scale 2.0[17,18]), and number of outpatient visits for RRT selection. Outpatient visits for RRT selection required the involvement of nursing staff and a minimum consultation time of 30 minutes.[12]However, these consultations did not need to be scheduled separately from regular nephrology follow-up visits. Additionally, facilities providing these services were not required to meet specific criteria to claim teaching and management fees for RRT under Japan's unique reimbursement system, which allows up to two claims per patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were conducted using Stata/SE version 18 (StataCorp LLC, College Station, TX, USA). To summarize patient characteristics and SDM-related responses, continuous variables are reported as mean and standard deviation (SD); categorical variables are presented as frequency and percentage. A Venn diagram was used to visually represent the distribution of final decision-makers for RRT, and a histogram was created to illustrate the distribution of CollaboRATE scores.\u003c/p\u003e\n\u003cp\u003eTo examine the associations among the final decision-maker, their decision-making role, and the quality of the SDM process, we applied a series of general linear models with cluster-robust variance estimation, treating facilities as the clustering unit.[19]This method also accounts for heteroskedasticity. Candidate confounding variables were selected based on clinical expertise and were included in the model using forced entry. Additionally, because having family could influence these associations, we conducted a subgroup analysis excluding a small number of patients who answered \"No\" to the question \"Do you have any family?\" and restricted the analysis to those who responded \"Yes.\" For predictors with missing values, multiple imputation by chained equations was performed under the assumption of missing at random. Estimates from 10 imputed datasets were combined into a single pooled estimate.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant and Facility Characteristics\u003c/h2\u003e\n \u003cp\u003ePatient characteristics (N\u0026thinsp;=\u0026thinsp;476) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients\u0026rsquo; mean age was 67.4 years (SD, 13.1) and 65.3% were male. The leading causes of ESKD were diabetic kidney disease (38.2%), nephrosclerosis (21.0%), and chronic glomerulonephritis (19.8%). Most patients had a high school education or lower (61.9%) and an annual household income below 5 million JPY (72.4%). Over 90% reported having family. Frailty was present in 20.2% of participants. As RRT, hemodialysis, peritoneal dialysis, and kidney transplantation was chosen by 70.8%, 24.6%, and 4.4%, respectively. Among participants, 44.3% had a single outpatient visit for RRT selection, and 30.2% had two or more visits.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline patient characteristics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePatient characteristics, N\u0026thinsp;=\u0026thinsp;476\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e67.4 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale sex, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e311 (65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eCause of ESKD, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDiabetic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e182 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eChronic glomerulonephritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e94 (19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNephrosclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e100 (21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePolycystic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e23 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOther/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e77 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eJunior high school or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e73 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHigh school graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e216 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eUniversity/graduate school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e82 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e96 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMissing, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt; 1 000 000 JPY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e39 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1 000 000 to \u0026lt;\u0026thinsp;5 000 000 JPY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e284 (63.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e5 000 000 to \u0026lt;\u0026thinsp;10 000 000 JPY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e87 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt; 10 000 000 JPY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e36 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMissing, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaving any family, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e43 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e414 (90.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMissing, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrailty, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e380 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVery mild/mild frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e76 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eModerate/severe frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVery severe frailty/terminally ill\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of outpatient visits for RRT selection, n (%)\u003c/strong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e121 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e211 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTwo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e81 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eThree or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e63 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelected RRT, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHemodialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e337 (70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePeritoneal dialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e117 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKidney transplantation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e21 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHemodialysis and peritoneal dialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime with current nephrologist, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt; 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e115 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e6 months to \u0026lt;\u0026thinsp;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e68 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1 year to \u0026lt;\u0026thinsp;3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e143 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026ge; 3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e142 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMissing, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026yen;10,000 was equivalent to US$63.8 as of January 2026.\u003c/p\u003e\n \u003cp\u003eThe participating facilities varied in bed capacity: 4.1% were clinics and 8.2%, 18.4%, and 69.4% were low-, low- to moderate-, and moderate- to high-capacity hospitals (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). RRT initiation in the past year also varied, with over half of facilities reporting 30\u0026ndash;100 cases.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of participating facilities.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFacility characteristics, N\u0026thinsp;=\u0026thinsp;49\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFacility type by bed capacity, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eClinic (no. of beds\u0026thinsp;\u0026lt;\u0026thinsp;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e2 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eLow-capacity hospital (no. of beds 20 to \u0026lt;\u0026thinsp;200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e4 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eLow- to moderate-capacity hospital (no. of beds 200 to \u0026lt;\u0026thinsp;400)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e9 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eModerate- to high-capacity hospital (no. of beds\u0026thinsp;\u0026ge;\u0026thinsp;400 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e34 (69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of RRT cases initiated over past 1 year, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt; 30 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e15 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e30\u0026ndash;100 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e26 (53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt; 100 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e8 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eRRT, renal replacement therapy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eKey persons consulted for RRT selection\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the key person consulted for RRT selection. Spouses were the most relied upon, followed by close family members, including daughters, sons, and siblings, with biological mothers also frequently reported. A few patients listed in-laws (e.g., son\u0026apos;s wife, mother-in-law). Some patients cited \u0026quot;others,\u0026quot; such as non-relative acquaintances or friends (n\u0026thinsp;=\u0026thinsp;16), distant relatives (e.g., aunts, nieces, nephews, n\u0026thinsp;=\u0026thinsp;8), or (ex-)partners (e.g., common-law wife, ex-wife, n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eFrequency of final decision-makers and their roles in RRT selection\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the combinations of decision-makers for RRT selection. The most common was the patient alone (46.5%); followed by patient and physician (20%); patient and key person (13.8%); and patient, physician, and key person (13.2%). In 6.6% of cases, the decision was made by the key person, physician, or both\u0026mdash;without the patient. Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the frequency of decision-maker roles in RRT selection. The most common was patient-alone decisions, followed by patient-led decisions (with the opinion of the key person or physician), and collaborative decisions (together with the key person or physician).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eRelationship between SDM quality and decision-maker or decision-making role\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the SDM level measured using CollaboRATE, with a mean score of 83.9 (SD 17.7). Of the 467 respondents, 36% (168) scored the maximum.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003eshows, when using the physician as the reference, there was no clear evidence that decisions made by the patient alone were associated with a higher SDM level (score difference 10.2, 95% confidence interval [CI]\u0026thinsp;\u0026minus;\u0026thinsp;1.1 to 21.5). However, decisions made by both the physician and patient as well as by the key person, physician, and patient were associated with higher SDM levels (score difference 12.3, 95% CI 1.5 to 23.2 and 13.7, 95% CI 0.8 to 26.7, respectively). For patients having any family, decisions made by the patient alone were associated with a higher SDM level (score differences 11.6, 95% CI 0.4 to 21.5). A stronger association with SDM levels was observed for decisions made by both the physician and patient, as well as by the key person, physician, and patient (score differences 14.3, 95% CI 3.6\u0026ndash;23.2 and 15.4, 95% CI 2.5\u0026ndash;26.7, respectively).\u0026nbsp;\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between final decision-maker and shared decision-making (SDM) quality.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eOverall, unadjusted n\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eOverall, adjusted\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eSubgroup of patients with family, adjusted,\u003csup\u003ea\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;407\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-\u003c/p\u003e\n \u003cp\u003evalue\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c9\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal decision-maker(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKey person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2.6 (\u0026minus;\u0026thinsp;11.1 to 16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.706\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e3.9 (\u0026minus;\u0026thinsp;10.5 to 18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e2.3 (\u0026minus;\u0026thinsp;11.6 to 18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.737\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKey person and physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11.3 (\u0026minus;\u0026thinsp;7.5 to 30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e12.3 (\u0026minus;\u0026thinsp;5.8 to 30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e9.8 (\u0026minus;\u0026thinsp;9.3 to 30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e9.3 (\u0026minus;\u0026thinsp;1.5 to 20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e10.2 (\u0026minus;\u0026thinsp;1.1 to 21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e11.6 (0.4 to 21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKey person and patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7.4 (\u0026minus;\u0026thinsp;2.6 to 17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e8.5 (\u0026minus;\u0026thinsp;2.1 to 19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e10.0 (\u0026minus;\u0026thinsp;0.5 to 19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePhysician and patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e10.8 (0.4 to 21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e12.3 (1.5 to 23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e14.3 (3.6 to 23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKey person, physician, and patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e12.0 (\u0026minus;\u0026thinsp;0.3 to 24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e13.7 (0.8 to 26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e15.4 (2.5 to 26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eGeneral linear models with cluster-robust variance were used, treating facilities as the clustering unit.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAdjusted for age, sex, primary cause of ESKD, education, income, having family, frailty, and RRT selection visits (as listed in Table 1).\u003c/p\u003e\n \u003cp\u003eRRT, renal replacement therapy; ESKD, end-stage kidney disease; CI, confidence interval..\u003c/p\u003e\n \u003cp\u003eTable \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eshows, when using no patient involvement as the reference, there was no clear evidence that patient-alone or patient-led decisions were associated with higher SDM levels (score differences 6.8, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;0.5 to 14.1 and 7.4, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;0.3 to 15.1, respectively). By contrast, collaborative decision-making was significantly associated with higher SDM levels (score difference 10.0, 95% CI 3.2 to 16.8). Among patients having any family, patient-alone and patient-led decisions were associated with higher SDM levels (score differences 9.5, 95% CI 1.8 to 17.1 and 10.4, 95% CI 2.9 to 18.0, respectively). Moreover, a stronger association with SDM levels was observed in collaborative decision-making (score difference 12.1, 95% CI 4.8 to 19.5).\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between decision-making roles and shared decision-making (SDM) quality.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eOverall, unadjusted n\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eOverall, adjusted\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eSubgroup of patients with family, adjusted,\u003csup\u003ea\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;407\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eScore difference, coefficient (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c9\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision-making role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo patient involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKey person-led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.9 (\u0026minus;\u0026thinsp;14.8 to 18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.816\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.7 (\u0026minus;\u0026thinsp;17.3 to 18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e8.5 (\u0026minus;\u0026thinsp;6.9 to 24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.271\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePhysician-led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8.3 (\u0026minus;\u0026thinsp;8.2 to 24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e9.0 (\u0026minus;\u0026thinsp;7.9 to 25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e12.3 (\u0026minus;\u0026thinsp;6.5 to 31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePatient alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6.5 (\u0026minus;\u0026thinsp;0.4 to 13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e6.8 (\u0026minus;\u0026thinsp;0.5 to 14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e9.5 (1.8 to 17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePatient-led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6.4 (\u0026minus;\u0026thinsp;0.9 to 13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e7.4 (\u0026minus;\u0026thinsp;0.3 to 15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e10.4 (2.9 to 18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCollaborative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e9.4 (2.8 to 15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e10.0 (3.2 to 16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e12.1 (4.8 to 19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eGeneral linear models with cluster-robust variance were used, treating facilities as the clustering units.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAdjusted for covariates listed in Table 1.\u003c/p\u003e\n \u003cp\u003eCI, confidence interval.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the influence of family involvement on\u0026nbsp;the quality of\u0026nbsp;SDM among patients with advanced\u0026nbsp;CKD\u0026nbsp;prior to initiating RRT. To our knowledge, this is the first study to quantitatively demonstrate that\u0026nbsp;collaborative involvement—specifically involving the patient, physician, and the \"key person\" (typically a family member)—is\u0026nbsp;significantly associated with higher SDM scores in\u0026nbsp;comparison with\u0026nbsp;physician-led decisions.\u0026nbsp;Collaborative decisions\u0026nbsp;resulted in\u0026nbsp;higher SDM scores than those made without patient involvement. Notably,\u0026nbsp;among patients having family,\u0026nbsp;the highest\u0026nbsp;SDM\u0026nbsp;quality was achieved when\u0026nbsp;decisions were collaborative or patient-led with family input, emphasizing the crucial role of the family in the decision-making process.\u0026nbsp;Collectively, these findings\u0026nbsp;strongly support\u0026nbsp;the implementation of\u0026nbsp;an SDM approach\u0026nbsp;with\u0026nbsp;family\u0026nbsp;involvement as a\u0026nbsp;crucial strategy for improving\u0026nbsp;the quality of the decision-making process in RRT selection.\u003c/p\u003e\n\u003cp\u003eOur findings revealed that patient involvement with\u0026nbsp;treatment decision-making\u0026nbsp;in Japan was high (93.5%), similar to the rate in\u0026nbsp;Singapore\u0026nbsp;(84%).[20]By contrast, family involvement in decision-making\u0026nbsp;(30.3%)\u0026nbsp;in Japan\u0026nbsp;remains\u0026nbsp;lower than that reported in\u0026nbsp;other Asian contexts, such as that in\u0026nbsp;Singapore\u0026nbsp;(63%).[20]This discrepancy\u0026nbsp;suggests\u0026nbsp;that although Japan has successfully adopted patient-centered models in nephrology, the shift toward a “family-inclusive” or “collaborative”\u0026nbsp;SDM model (13.2% in our study compared with 36% in\u0026nbsp;Singapore[20])\u0026nbsp;may still be insufficiently established.\u0026nbsp;Another Singaporean study\u0026nbsp;emphasized the need to broaden the unit of care from the individual patient to the family.[21]Therefore, it may be necessary to shift\u0026nbsp;from\u0026nbsp;the conventional\u0026nbsp;SDM\u0026nbsp;approach to a\u0026nbsp;family-inclusive\u0026nbsp;SDM approach in Japan.\u003c/p\u003e\n\u003cp\u003eOur study demonstrated that\u0026nbsp;joint\u0026nbsp;decisions (physician–patient\u0026nbsp;or\u0026nbsp;collaborative)\u0026nbsp;were associated with higher SDM\u0026nbsp;quality, which was\u0026nbsp;particularly pronounced among patients having family.\u0026nbsp;Patients\u0026nbsp;often\u0026nbsp;seek information\u0026nbsp;regarding\u0026nbsp;daily life\u0026nbsp;limitations\u0026nbsp;(66.7%), the economic burden (61.9%), and the family\u0026nbsp;burden\u0026nbsp;(56%).[12]In many Asian cultural contexts, including that of Japan, patients frequently prioritize reducing the burden on the family and maintaining group harmony over their personal preferences alone.\u0026nbsp;Incorporating family members into discussions is not simply supplementary but a cultural necessity for achieving SDM.\u0026nbsp;Family\u0026nbsp;involvement\u0026nbsp;also\u0026nbsp;enables\u0026nbsp;collaborative\u0026nbsp;information sharing, allowing RRT and lifestyle concerns to be addressed\u0026nbsp;from\u0026nbsp;multiple perspectives.\u0026nbsp;This dynamic provides patients\u0026nbsp;with\u0026nbsp;diverse\u0026nbsp;interpretations of medical information while offering clinicians a\u0026nbsp;more comprehensive\u0026nbsp;understanding\u0026nbsp;of the\u0026nbsp;patient’s social context.[22,23]Given\u0026nbsp;that RRT selection is a socially embedded and collaborative process, family support serves a crucial role in the decision-making framework.[24]Therefore, a family-inclusive SDM approach is essential to ensure that\u0026nbsp;treatment decisions\u0026nbsp;are\u0026nbsp;both medically and socially\u0026nbsp;acceptable to the\u0026nbsp;entire care unit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;We demonstrated that among\u0026nbsp;patients having any family, patient-alone, patient-led, and\u0026nbsp;collaborative decision-making were associated with\u0026nbsp;higher SDM\u0026nbsp;levels\u0026nbsp;compared with decisions made without patient involvement.\u0026nbsp;A Dutch cross-sectional\u0026nbsp;study among patients after dialysis initiation\u0026nbsp;found that\u0026nbsp;patients were more likely to regret their decisions\u0026nbsp;when greater weight was placed on the opinions of the\u0026nbsp;physician or family.[4]When the family’s wishes conflict with the patient’s preferences, physicians must assess family relationships\u0026nbsp;and ensure that patients’ true values are respected.[12]This aligns with our results; SDM levels were lower when decisions were primarily led by physicians or key family members, regardless of family involvement. A Dutch\u0026nbsp;qualitative study\u0026nbsp;also reported that\u0026nbsp;most patients with\u0026nbsp;CKD\u0026nbsp;made RRT\u0026nbsp;decisions\u0026nbsp;with key persons before hospital\u0026nbsp;visits,[25]suggesting\u0026nbsp;that deliberation regarding\u0026nbsp;RRT\u0026nbsp;often takes place within the household,\u0026nbsp;with\u0026nbsp;family involvement. Our findings suggest that encouraging patients to consult with their family and making the patients’ own preferences during RRT selection a priority may yield high SDM\u0026nbsp;levels.\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe hypothesize that family involvement enhances\u0026nbsp;the SDM process through three mechanisms: information sharing, emotional support, and practical feasibility. First, family members function as “information bridges,” explaining medical terminology and providing essential context regarding the patient’s lifestyle or financial constraints. This information may not be made available without family involvement.[25]Second, family members provide emotional support, reducing patients’ psychological burden and promoting active engagement in decision-making. Prior research has shown that when families reinforce rather than override patients’ wishes, SDM quality and satisfaction improve.[24]Third, depending on the RRT modality, the patient may require considerable domestic support, such as transport to dialysis facilities, preparing the environment for peritoneal dialysis, or providing living donors. By involving family members early in the treatment planning process, the clinical team can more accurately assess the feasibility of the options, leading to a more practical treatment plan.[26] A key implication of our findings is that, whereas family involvement is beneficial, it must not compromise patient autonomy. Clinicians should therefore remain alert when assessing family input, ensuring that the decision-making process remains patient-centered while being family-inclusive.\u003c/p\u003e\n\u003cp\u003eThe strengths of this study include its multicenter, nationwide design and use of the validated CollaboRATE scale to produce quantitative evidence in the pre-RRT population. However, some limitations must be acknowledged. First, the participating facilities may have been skewed toward moderate- to high-bed-capacity hospitals, as a large proportion of facilities were institutions with highly qualified nephrologists known to the authors. This selection bias may partly explain why one-third of patients had a perfect SDM score. However, differences in facility bed capacity are unlikely to influence\u0026nbsp;the involvement of\u0026nbsp;key persons\u0026nbsp;in RRT selection. Second, we did not assess the number of eligible patients with CKD who declined to participate or those who did not complete the survey. Based on RRT initiation rates per quarter, we estimate that 1 913 RRTs were initiated during the study period. This total includes patients who opted out or were ineligible owing to emergent RRT or dementia. Notably, study participants accounted for 25% of all RRT initiations. Third, CollaboRATE and the final decision-maker were retrospectively assessed via self-reported surveys rather than outpatient records. Thus, even if physicians provided the options for RRT, patients might not have accurately recalled the interactions or final decision-makers. However, because our study targeted patients with CKD who had chosen RRT but had not yet started therapy, their recall\u0026nbsp;bias\u0026nbsp;was\u0026nbsp;considered minimal.\u0026nbsp;Finally, in this study, we did not differentiate between cohabiting and non-cohabiting family members, and we did not assess\u0026nbsp;their presence\u0026nbsp;during outpatient consultations.\u0026nbsp;However, the observation that differences in SDM scores emerged based solely on having family provides strong support for our interpretation.\u0026nbsp;Although further research is needed to determine whether cohabitation itself influences SDM\u0026nbsp;levels, the findings suggest that, regardless of cohabitation status, the family may be beneficial in achieving better SDM.\u003c/p\u003e\n\u003cp\u003eIn conclusion,\u0026nbsp;our findings provide a strong empirical basis for recommending family participation in the RRT selection process, provided the patient–family relationship is favorable.\u0026nbsp;Clinicians should actively encourage family participation in the RRT decision-making process. Family involvement enhances the quality of information sharing, provides psychological reassurance, and clarifies the feasibility of treatment options.\u0026nbsp;Furthermore, this\u0026nbsp;favorable\u0026nbsp;effect is maximized when family involvement\u0026nbsp;plays a role in strengthening\u0026nbsp;the patient’s\u0026nbsp;own decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Analisa Avila, MPH, ELS, Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u0026nbsp;We thank Ms. Takako Maeshibu and Prof. Takafumi Wakita (Department of Sociology, Kansai University)\u0026nbsp;for creating and managing the online survey form.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYK, TS, NK, and YS contributed to the study concept and design. TS, NK, TT, HK, and YS were involved in creation of the survey and data collection. NK performed the data analysis. TS, NK, TT, HK, and YS contributed to data interpretation and manuscript preparation. All authors critically reviewed, edited, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT. Sofue has received payment for speaking from Astrazeneca K.K., Astellas Pharma Inc., Kyowa Kirin Co., Ltd. T. NK has received consulting fees from GlaxoSmithKline K.K., and payment for speaking and educational events from Eisai Co., Ltd., Taisho Pharmaceutical Co., Ltd., Kyowa Kirin Co., Ltd., GlaxoSmithKline K.K., Takeda Pharmaceutical Co., Ltd., Kissei Pharmaceutical Co., Ltd., and Baxter Corporation. T. Toida has received consulting fees from Astellas Pharma Inc. and payment for speaking and educational events from Torii Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Kyowa Kirin Co., Ltd., AstraZeneca K.K., Nobelpharma Co., Ltd., and Novo Nordisk Pharma Ltd. S. Shibata received personal fees and/or research funding from AstraZeneca, Bayer, Daiichi-Sankyo, Fuji Yakuhin, Kyowa-Kirin, Mochida, and Torii. T. Suzuki has received payment for speaking and educational events from Astellas Pharma Inc, AstraZeneca K.K, Vantive Japan, Daiichi Sankyo Co., Ltd., Janssen Pharmaceutical K.K, Kaneka Medix Corp, Kissei Pharmaceutical Co., Ltd., Kowa Co., Ltd., Kyowa Kirin Co., Ltd, Mochida Pharmaceutical Co., Ltd., Nobelpharma Co., Ltd, Novartis Pharma K.K., Novo Nordisk Pharma., Ltd., Ono Pharmaceutical Co., Ltd., Otsuka Parmaceutical, Terumo Corp, and Torii Pharmaceutical Co., Ltd. RI has received payment for speaking and educational events from Vantive Japan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-assisted technologies in the writing process*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used Gemini 3 Flash to enhance the English clarity and grammar. All content remains original. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy approval statement:\u0026nbsp;\u003c/strong\u003eThis study protocol was reviewed and approved by the Institutional Review Board of Fukushima Medical University [approval number ippan-2022].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate statement:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by JSPS KAKENHI [grant number JP21K10314]. The funder had no role in the design, data collection, data analysis, and reporting of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFukuzaki, H. et al. Outpatient clinic specific for end-stage renal disease improves patient survival rate after initiating dialysis. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 5991 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee, C. T. et al. Shared decision making increases living kidney transplantation and peritoneal dialysis. \u003cem\u003eTransplant Proc.\u003c/em\u003e ;51:1321\u0026ndash;1324. (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahm, M. R. et al. Older patients and dialysis shared decision-making. Insights from an ethnographic discourse analysis of interviews and clinical interactions. \u003cem\u003ePatient Educ. 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Treatment decision-making in chronic diseases: What are the family members' roles, needs and attitudes? A systematic review. \u003cem\u003ePatient Educ. Couns.\u003c/em\u003e \u003cb\u003e100\u003c/b\u003e, 2172\u0026ndash;2181 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerberne, W. R., Stiggelbout, A. M., Bos, W. J. W. \u0026amp; Delden, J. J. M. Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients. \u003cem\u003eBMC Med. Ethics\u003c/em\u003e. \u003cb\u003e23\u003c/b\u003e, 47 (2022).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Shared decision-making, Renal replacement therapy, Family involvement, Chronic kidney disease, Patient preference","lastPublishedDoi":"10.21203/rs.3.rs-8905143/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8905143/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eShared decision making in renal replacement therapy should reflect patient values. However, the quantitative impact of family involvement\u0026mdash;particularly in Asian contexts\u0026mdash;on decision-making quality remains underexplored. This nationwide, multicenter cross-sectional study (October 2022\u0026ndash;February 2025) involved 475 adults with stage 5 chronic kidney disease across 49 facilities in Japan. Following the selection of renal replacement therapy, participants were surveyed regarding the final decision-makers and their specific roles. Shared decision-making quality was evaluated using the three-item CollaboRATE scale, assessing information exchange and preference integration. Compared with \u0026ldquo;physician-only\u0026rdquo; decisions, CollaboRATE scores (points; 95% confidence interval) were significantly higher in the \u0026ldquo;patient and physician\u0026rdquo; (+\u0026thinsp;12.3; 1.5\u0026ndash;23.2) and \u0026ldquo;patient, physician, and key person\u0026rdquo; groups (+\u0026thinsp;13.7; 0.8\u0026ndash;26.7). Role-based analyses showed that shared decision-making with the physician or key person was associated with a\u0026thinsp;+\u0026thinsp;10.0 point increase (3.2\u0026ndash;16.8) versus decisions without patient involvement. Among patients having family, scores were significantly higher for patient only (+\u0026thinsp;9.5), patient-led with input from physician or key person (+\u0026thinsp;10.4), and shared decision-making (+\u0026thinsp;12.1) categories, compared with no patient involvement. Family involvement enhances shared decision-making quality when selecting renal replacement therapy, particularly when the process remains collaborative and guided by patient preferences.\u003c/p\u003e","manuscriptTitle":"Family involvement and shared decision-making quality in renal replacement therapy selection: A nationwide cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:20:37","doi":"10.21203/rs.3.rs-8905143/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"124018576135612506089512163000430148418","date":"2026-05-18T00:56:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229693381969371958027258402389189417971","date":"2026-05-14T07:00:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T04:15:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101791791736244705788682760556067956071","date":"2026-04-29T18:06:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107988290346146063269203410220322936071","date":"2026-04-29T07:47:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T07:19:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T07:10:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T04:17:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T04:16:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-02-18T02:09:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb7be73f-4e3b-493c-afdc-d359f06a2cb9","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"124018576135612506089512163000430148418","date":"2026-05-18T00:56:37+00:00","index":176,"fulltext":""},{"type":"reviewerAgreed","content":"229693381969371958027258402389189417971","date":"2026-05-14T07:00:50+00:00","index":169,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T04:15:58+00:00","index":128,"fulltext":""},{"type":"reviewerAgreed","content":"101791791736244705788682760556067956071","date":"2026-04-29T18:06:56+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"107988290346146063269203410220322936071","date":"2026-04-29T07:47:11+00:00","index":115,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":67461274,"name":"Health sciences/Diseases"},{"id":67461275,"name":"Health sciences/Health care"},{"id":67461276,"name":"Health sciences/Medical research"},{"id":67461277,"name":"Health sciences/Nephrology"},{"id":67461278,"name":"Health sciences/Urology"}],"tags":[],"updatedAt":"2026-05-08T16:20:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:20:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8905143","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8905143","identity":"rs-8905143","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}