Social-ecological Model and Renal Replacement Therapy Decision Making

Chronic kidney disease (CKD) is a condition that affects more than 10% of the general population worldwide and amounts to greater than 800 million affected individuals (National Library of Medicine, 2022). To put it in a national perspective, 1 in 10 Canadians has kidney disease (Kidney Foundation of Canada, 2022). Populations with diabetes, hypertension and cardiovascular disease have high chances of being diagnosed with CKD. Populations who fall into end-stage renal disease (ESRD) require renal replacement therapies, which are life-sustaining treatments to filter out toxins and remove excess water from a patient’s blood. Currently, there is no cure for populations with this disease, and 58% of Canadians with ESRD require dialysis treatment.

As a healthcare professional working in a clinical renal area, I see the progression of care CKD and ESRD patients need to sustain life and live comfortably with their disease. Patients are initially referred by a family physician or another medical doctor overseeing their care to a multi-care kidney clinic. The multi-care kidney clinic is the first step in the CKD journey process and is used to determine if an individual does require CKD care. Patients whose symptoms are not severe can be supported through an interdisciplinary team in the clinic, and patients whose kidney function is deteriorating will be transitioned to dialysis.

Renal replacement therapies and the Social-ecological model:

Dialysis and transplant are the only treatments available for patients with ESRD. There are many factors that can influence a patient’s response to ESRD treatment and, ultimately, their quality of life. Factors such as dialysis modality, family support, transplant opportunities, and compliance with treatment play a critical role in a patient's CKD progression. Ultimately a CKD/ESRD patient must make a decision as to which treatment modality they want to pursue. Using a Social-ecological model can explain the process of renal replacement therapy decision making and I will also apply experiences from my clinical setting to explain. The Social Ecological Model used by the Centres for Disease Control and Prevention (CDC) is a framework that consists of four levels to identify the different range of factors that affect the prevention and control of a health issue. The four levels in the model are individual, relationship, community, and societal. Factors at one level of the model can influence another and overlap (CDC, 2022).

Social-ecological model for dialysis modality decision making:

Dialysis treatment comes in forms such as In-center Hemodialysis, Peritoneal Dialysis and Home Hemodialysis. All treatments perform the same goal of removing waste and toxins from the patient’s body but have different ways of doing so. A patient’s selection of a dialysis modality will affect their progression of CKD depending on their suitability; therefore, making the incorrect modality decision will be detrimental to their health. Researchers from the University of Iowa conducted a qualitative study to explore factors surrounding the dialysis modality selection process. The study concluded that time spent in pre-dialysis clinics, medical eligibility, geographical location, knowledge about modality choices, and healthcare access are some factors that influence a patient’s dialysis modality decision (Velez-Burmudez et al., 2022). These decision-making factors are prevalent from my experience working in the renal area of care, and I will expand on those most common in my clinical setting.

Eligibility criteria for dialysis modality decision refers to an assessment of a patient’s medical history and comorbidities. For example, a patient requiring dialysis treatment who presents with severe obesity will not be a candidate for peritoneal dialysis and will have to opt for hemodialysis. In regards to the Social Ecological Model, the eligibility criterion is a factor that affects patients on the individual level.

Information given by nephrology staff refers to the amount of time a CKD patient spends in a pre-dialysis clinic. Patients who spend more time in the pre-dialysis clinic can learn more about the different modalities and have more time to choose an appropriate modality (Velez-Burmudez et al., 2022). Information given by the nephrology team can be considered both relationship and environment-level factors. In my clinical setting, patients who fail to follow up and comply with pre-dialysis clinic appointments do not build a conducive relationship with clinical staff to allow for information exchange. A strong relationship between patients and clinicians allows a holistic approach of care, which includes dietary, social welfare, and medication implementation assistance. When these holistic levels of care are implemented, it gives patients more time and knowledge to choose an appropriate dialysis modality.

Information given by the nephrology team can also be considered a community-level factor due to the community demand. In my clinical setting, there is a significant demand for renal services in the community, and this delays an appropriate referral and follow-up time for patients to be seen in a pre-dialysis clinic. The delay in being accepted and followed up by a nephrology team often leads to acute or incident hemodialysis because the patient’s kidneys have deteriorated without any attention or clinical support. The burdening demand on community hospitals has been ongoing, and it is essential to note that in 2020, more than 25% of ESRD patients were late referrals to a nephrology team (Kidney Foundation Canada, 2020).

Social ecological model for transplant decision making

Transplant is another form of treatment for patients with ESRD and in almost all circumstances occur after a patient has been placed on dialysis treatment. The decision to be placed on a transplant waiting list is a decision made by the patient and nephrology team. Kidney transplant is the most desired and cost-effective modality of renal replacement therapy for patients with ESRD (Abecassis et al., 2008). With this being said, it's interesting to know that in 2020, only 11% of Canadians who are receiving dialysis are placed on a transplant waiting list (Kidney Foundation Canada, 2020). The University of Toledo College of Medicine wrote an article explaining that factors unrelated to medical eligibility are influencing a patient’s decision to elect for a kidney transplant. Education, health care and access, economic stability, neighborhood and built environment, and social and community context were the social determinants of health on CKD/ESRD and the kidney transplant process (Lombardi et al., 2021).

Applying the social-ecological model to these factors will help better understand why there are few ESRD patients who have decided to opt for a kidney transplant. Education is an individual factor that affects the transplant decision making process. Lower levels of educational achievement affect dialysis modality decisions and patients with a lower level of education are less likely to choose a kidney transplant because the process is a difficult and complex progression of determining candidate suitability (Lombardi et al., 2021). I do find this point relevant in my clinical setting when the transplant decision is being offered to ESRD patients. I have experienced patients who are medically suitable for kidney transplants but have challenges understanding the transplant work-up process and defer back to hemodialysis treatment.

Social support is a relationship factor in respects to the social-ecological model of renal replacement decision making. Social support plays a significant role in the outcome of CKD and ESRD patients and is influential in determining patient suitability for transplant (Ladin et al., 2018). As previously mentioned, the transplant workup is comprehensive, and patients do require family support to navigate the process. Tracking dialysis compliance rates, attending medical appointments/procedures related to the work-up process, maintaining compliance with dietary and physical exercise requirements are some of the many requirements to maintain a spot on the kidney transplant list. It is crucial to have social support in place and many patients decide on not pursuing a kidney transplant because of this limiting factor.

Determinants such as economic stability are individual-related factors, but I don’t believe they play a significantly influential role in renal replacement decision making in a Canadian context because of our publicly available healthcare system. I have had the pleasure of seeing patients who come from challenging economic conditions be approved for kidney transplants.

A social-ecological model for CKD/ESRD treatment decision process can explain how determinants from individual, relationship, community and environment levels can impact how a patient selects a renal replacement therapy option.

References

Abecassis, M., Bartlett, S. T., Collins, A. J., Davis, C. L., Delmonico, F. L., Friedewald, J. J., ... & Gaston, R. S. (2008). Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI™) conference. Clinical Journal of the American Society of Nephrology, 3(2), 471-480.

Ladin, K., Emerson, J., Butt, Z., Gordon, E. J., Hanto, D. W., Perloff, J., ... & Lavelle, T. A. (2018). How important is social support in determining patients’ suitability for transplantation? Results from a National Survey of Transplant Clinicians. Journal of medical ethics, 44(10), 666-674.

Lombardi, C., Glosser, L., Knauss, H., Norwood, T., Berry, J., & Ekwenna, O. (2021). Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation: Socioeconomic Impact on Kidney Transplant. Translation: The University of Toledo Journal of Medical Sciences, 9(1).

The Social-Ecological Model: A Framework for Prevention |Violence Prevention|Injury Center|CDC. (n.d.). https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html

Vélez-Bermúdez, M., Adamowicz, J. L., Askelson, N. M., Lutgendorf, S. K., Fraer, M., & Christensen, A. J. (2022). Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach. BMC nephrology, 23(1), 1-13.