The Potential Outcome-Modification Influences Introduced by ESKD Life Plan on eGFR Slopes

In a recent study published in JASN, Tabcheh et al. conducted an intriguing study investigating the influences of arteriovenous (AV) access creation on the slope of eGFR decline in patients with advanced CKD from the Chronic Kidney Disease-Renal Epidemiology and Information (CKD-REIN) cohort.1 They demonstrated that the inflection point in the eGFR slope occurred 8.1 months before AV access creation, suggesting that factors other than AV access creation contributed to retarding kidney function deterioration. We believe that their findings are noteworthy and wish to provide our thoughts on plausible contributors to this phenomenon in those with advanced CKD. First of all, the process of ESKD life planning can influence patients' eGFR trajectory. ESKD life planning aims to establish a strategy for patients to manage life before and after ESKD by introducing treatment modality choices and subsequent arrangements within the patients' foreseeable lifespan through shared decision making.2 This planning considers patients' individual medical conditions, functional status, preferences, family and social support background, and life goals. Existing literature shows that shared decision making improves CKD patients' motivation, satisfaction, and adherence to treatments, which helps to prevent CKD-related complications and further kidney function worsening.3 Moreover, when patients with CKD are motivated to monitor their physical and mental health, they may emphasize mitigating adverse influences from detrimental phenotypes such as sarcopenia and frailty, both of which can aggravate kidney outcomes. As ESKD life planning is frequently initiated during late CKD stages (4–5), there may be a lag between the start of planning and its indirect outcome benefits. This is partially supported by the approximate eGFR level (approximately 17 ml/min per 1.73 m2) when patients are at the inflection point in the study by Tabcheh et al.1 In addition, the involvement of multidisciplinary members during shared decision making, including surgeons, radiologists, nurses, and pharmacists, also assists in preserving kidney function in these patients with CKD. Medication reconciliation is associated with a lower risk of polypharmacy, which increases drug–drug interactions and aggravates patients' health.4 This can be another pathway through which the eGFR decline rate is ameliorated. In conclusion, we commend Tabcheh et al. for their insightful study and suggest that ESKD life planning and multidisciplinary care may play significant roles in the observed inflection point in eGFR decline among patients with advanced CKD.