Transitions of care management in CKD: critical thinking and improving strategies

Chronic kidney disease (CKD) has a high clinical and socioeconomic impact and is often associated with multimorbidity. Improved treatment has allowed an increase in patient survival, but patient life expectancy remains limited. The disease course has a continuum of lesion, stage and treatment transitions. The focus is often placed on treatment modality, disregarding the course of a CKD patient’s disease. In addition, patient management in transitions of modalities of renal replacement therapy (RRT) can also be a vector for improving clinical outcomes. The transition between different types of CKD treatment and the transition of care from paediatric to adult team are critical processes throughout the life of a CKD patient. In the therapeutic transition, there is the need to identify better predictors of success in allocating patients with stage 5 CKD to their first dialytic modality in. There is a risk of early mortality in the induction period of dialysis, particularly of the elderly in extracorporeal dialysis regimens. Doubt remains in decision making about the ideal timing to establish the transition to renal replacement therapy and its most appropriate type. Transfer between dialytic modalities also calls for opportune and integrated policies protecting vascular resources. Renal transplantation is considered the optimal renal replacement therapy; however, transplant failure or the side effects of immunosuppression are threats to consider, which may redirect these patients back to dialysis and involves a re‑evaluation of the patient’s status. Also, end‑of‑life care and decision making between initiating renal replacement therapy or maintaining conservative management are a challenge in the elderly. This review identifies the main challenges in these transitional processes, raising awareness of areas in need of improvement in patient care. The aim should be to achieve a more comprehensive and appropriate health management than a limited focus on CKD modality treatment.