Nurses Emerge as Potential Leaders in Implementing CKD Care Strategies

Nurses could play a key role in helping health systems incorporate the Kidney Disease – Improving Global Outcomes (KDIGO) Kidney Supportive Care (KSC) framework, elevating care quality and access for patients with chronic kidney disease (CKD) around the world, according to a recent report.¹

Nurse can play key role in helping health care systems implement new palliative care strategies to improve quality of life for patients with end-stage renal disease. | Image credit: NanSan - stock.adobe.com

The systematic review, published in BMC Nephrology, synthesized the perspectives of health care professionals to establish an evidence base for enhancing the clinical dissemination and implementation of the KSC framework for patients with end-stage renal disease (ESRD). Although the review sought to contextualize the perspectives of all health care professionals, nurses were crucial contributors to KSC implementation, highlighting their essential role in developing tailored intervention strategies for CKD populations around the globe.

“Nurses’ strategic formulation of integrated intervention frameworks requires prioritization as pivotal KSC stakeholders,” wrote the authors. "This initiative is imperative for enhancing care delivery in ESRD clinical practice."

In 2013, the KDIGO conference created the KSC as a palliative framework for patients who’ve benefited little from dialysis treatment or opted to forgo treatment.² The KSC framework aims to mitigate disease burden and optimize patient quality of life, particularly for elderly patients.³

Differences in how clinicians and patients understood illness and its meaning hindered effective implementation of KSC.¹ During its developmental phase, KSC faced global dissemination challenges, with adoption largely limited to developed countries such as the US, Canada, the United Kingdom, Australia, and Sweden. The authors said the disparities highlighted the need to examine key implementation barriers and facilitators from the perspectives of patients, clinicians, and families. Building on prior studies of clinician perceptions, the present study explored broader factors influencing KSC adoption.

Researchers utilized a qualitative meta-aggregation methodology to conduct a literature search of 5 English and 4 Chinese databases through February 29, 2024. Two reviewers independently extracted data, and the researchers examined conflating findings across diverse health care settings. Contextual factors, such as cultural norms and resource allocation, as well as methodological limitations (eg, sampling bias and data collection heterogeneity), were considered to help explain variations in perspectives on KSC.

This systematic review included 8 original qualitative studies published after 2016, drawing data from 5 countries: the US (n = 3), UK (n = 2), China (n = 1), Australia (n = 1), and Canada (n = 1). The cohort comprised 149 nephrologists, 80 nurses, 48 physicians, 15 allied health professionals, and one palliative care specialist. Seven studies used semi-structured interviews, while 1 involved secondary analysis of existing qualitative data.

Using the PRISMA framework, the review identified 5 major themes reflecting clinician perspectives on the barriers and facilitators to implementing KSC:

1. Professional role challenges
2. Pre-implementation cognitive-ethical conflicts
3. Post-decisional operational barriers
4. Systemic and institutional issues
5. Patient-centered and ethical care

Clinicians described how the shift toward KSC disrupted traditional care models by requiring multidisciplinary collaboration, proactive communication, and new decision-making roles—particularly for nephrologists adapting to co-management and advisory responsibilities. Many reported ambiguities around professional boundaries and insufficient institutional support to define and coordinate roles across primary and renal care teams.

Sociocultural factors further complicated implementation. Nephrologists and nurses cited family dynamics, cultural expectations, and emotional conflicts as key obstacles to shared decision-making, particularly around dialysis withdrawal. In Western settings, clinicians often navigated tensions between honoring patient autonomy and managing family guilt. In contrast, in collectivist cultures (eg, parts of Asia), clinicians deferred to family consensus, creating additional ethical and emotional challenges.

Clinicians also faced substantial operational barriers following treatment decisions. Prognostic communication was fraught with difficulty, especially in cultures where discussing death remains taboo. Providers expressed frustration over systemic inadequacies in facilitating these conversations, highlighting a gap between KSC’s emphasis on transparent end-of-life planning and real-world practice. Emotional distress, distrust from families, and lack of support for sensitive conversations added further strain.

Systemic and institutional barriers—such as time constraints, fragmented care infrastructure, and limited integration of palliative care—were cited across settings. Providers emphasized that conservative care could not be successfully implemented without adequate resources, interprofessional collaboration, and shifts in hospital priorities, particularly in regions where life-extending interventions remain the default.

Despite these challenges, clinicians valued KSC’s emphasis on ethics, quality of life, and patient-centered care. They noted that KSC’s framing—distinct from traditional palliative care—helped make conservative care more acceptable to patients. Strategies included advance care planning, coaching patients to express preferences, and engaging families and care teams to honor those goals. Clinicians stressed the need for cultural sensitivity, standardized communication frameworks, and clear policies to ensure that patients receive care aligned with their values, particularly in the final stages of life.

“Targeted support systems are essential to optimize complex decision-making pathways," the authors wrote. "Future progress requires continuous improvement through multidisciplinary stakeholder engagement, strengthened policy frameworks, and advancing equitable delivery of comprehensive supportive and palliative care within established clinical frameworks."

References

1. Li X, Ji W, Wang D, Xu Y, Zhao X, Liang S. Kidney supportive care in advanced chronic kidney disease: a qualitative meta-synthesis of healthcare professionals perspectives and attitudes. BMC Nephrol. 2025;26(1):382. doi:10.1186/s12882-025-04294-x

2. Lupu D, Moss AH. The role of kidney supportive care and active medical management without dialysis in supporting well-being in kidney care. Semin Nephrol. 2021;41(6):580-591. doi:10.1016/j.semnephrol.2021.10.010

3. Davison SN. Personalized approach and precision medicine in supportive and end-of-life care for patients with advanced and end-stage kidney disease. Semin Nephrol. 2018;38(4):336-345. doi:10.1016/j.semnephrol.2018.05.004