Kidney supportive care in advanced chronic kidney disease: a qualitative meta-synthesis of healthcare professionals perspectives and attitudes

Abstract

Aims

This study systematically reviews and synthesizes healthcare professionals’ perspectives on Kidney Supportive Care (KSC) to establish an evidence base for enhancing its clinical dissemination and implementation.

Background

KSC enhances end-of-life care quality for renal patients through a patient-centered framework integrating shared decision-making and advance care planning. This anticipatory transition management in advanced kidney disease seeks to alleviate patient/family distress while optimizing end-of-life care experiences. While KSC adoption in kidney disease care remains emergent globally, strategic investigation is critical to strengthen clinical integration.

Design

A systematic review and integration of qualitative studies conducted in accordance with ENTREQ guidelines.

Review Methods

We systematically searched ten databases, including PubMed, Web of Science, Embase, Cochrane Library, CINAHL, Science Direct, CNKI, Wanfang Data, VIP, and CBM, spanning from inception to February 29, 2024. This study systematically synthesizes qualitative evidence on clinician perspectives regarding KSC in end-stage renal disease. Methodological rigor was evaluated using Joanna Briggs Institute’s (JBI) 2020 Qualitative Research Appraisal Criteria. Primary study data underwent convergent synthesis following established methodology.

Results

Eight studies yielded 10 subordinate and 5 core themes: Professional Role Challenges, Pre-implementation cognitive-ethical conflicts, Post-decisional operational barriers, Systemic and Institutional Issues, Patient-Centered and Ethical Care.

Conclusions

KSC is recognized as a novel therapeutic paradigm in nephrology, demonstrating significant translational promise. However, clinical implementation confronts multifaceted barriers. Future research should prioritize implementation by incorporating multidisciplinary perspectives (patients, clinicians, families). Ongoing policy framework optimization must underpin sustainable KSC implementation and progression in clinical practice.

Relevance to clinical practice

These findings elucidate clinician perspectives regarding KSC clinical translation. Nurses’ strategic formulation of integrated intervention frameworks requires prioritization as pivotal KSC stakeholders. This initiative is imperative for enhancing care delivery in ESRD clinical practice.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-025-04294-x.

Highlights

1.Systematic Review of KSC Perspectives: A comprehensive analysis of healthcare professionals' views on Kidney Supportive Care (KSC) for end-stage renal disease patients was conducted, highlighting its potential in improving end-of-life care.

2.Multifaceted Challenges Identified: The review uncovered multiple challenges in implementing KSC, including professional role complexities, decision-making difficulties, communication dynamics, systemic issues, and the need for patient-centered and ethical care.

3.Crucial Role of Nurses: Nurses emerged as key players in facilitating KSC implementation, emphasizing their vital role in crafting personalized intervention strategies.

4.Policy Refinement Necessary: Continuous policy refinement is crucial to support the clinical application and advancement of KSC, fostering a stronger support system for ESRD patients in both medical and nursing practice.

5.Stakeholder Involvement: Future research should engage a diverse range of stakeholders, including patients, healthcare professionals, and family members, to further explore the clinical application of KSC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-025-04294-x.

Introduction

Chronic kidney disease (CKD) prevalence has risen steadily globally, currently affecting 13.4% of the population [1]. CKD progression culminates in ESRD, characterized by high mortality, low public awareness, and substantial healthcare costs [2]. This progression imposes a dual burden on healthcare systems and public health [3]. ESRD patients exhibit complex care trajectories with heightened end-of-life hospitalizations, ICU utilization, and intensive interventions relative to chronic conditions, culminating in diminished quality of life [4]. ESRD patients ≥ 75 years initiating dialysis exhibit accelerated cognitive decline and heightened psychological comorbidities [5]. Dialysis prolongs survival but incurs substantial financial and caregiver burdens through intensive terminal care interventions [6].

The 2013 KDIGO conference [7] established " Kidney Supportive Care” (KSC) as a palliative framework for ESRD patients with limited dialysis benefit or opting to forgo treatment. ESRD progression [8, 9] precipitates declines in symptom burden, functional status, and psychological health, culminating in marked morbidity and socioeconomic burden.KSC integrates proactive identification, holistic evaluation, and precision management of biopsychosocial domains [10]. This approach seeks to mitigate disease burden through trajectory-aligned interventions, optimizing end-of-life care quality. Encompassing symptom management, shared decision-making, advance care planning, comprehensive conservative treatment, and end-of-life care, KSC delivers a high-caliber, comprehensive approach to end-of-life care for individuals with advanced kidney disease [11]. The concept of ksc is also referred to as “maximum” or “active” or “non-dialysis” medical management, “conservative conservative renal management”, “total conservative care”, or “conservative treatment”, “active medical management”, and these terms are variable between.

KSC constitutes a care framework targeting disease burden mitigation and quality-of-life optimization in ESRD, particularly salient for elderly populations [12]. Clinician-patient illness conceptualizations and existential value discrepancies currently impede optimal KSC implementation [13]. KSC’s developmental phase confronts dissemination barriers; global implementation inequities persist. KSC adoption demonstrates geographic disparities, with implementation clusters in developed nations exemplified by major Anglophone (US, Canada, UK, Australia) and Nordic (Sweden) systems [14]. Systematic investigation of KSC implementation determinants (facilitators/barriers) is therefore warranted. This necessitates synthesizing key stakeholder perspectives (patients, clinicians, families). Ongoing policy framework optimization is required to sustain KSC integration and progression.

Current qualitative studies elucidate clinician perceptions toward Kidney Supportive Care (KSC) clinical integration. Building on nephrology innovations, this study examines implementation facilitators and barriers to KSC adoption. Qualitative evidence remains unsynthesized despite its availability. This study examines clinician perspectives on KSC implementation across global practice contexts. This synthesis identifies convergent/divergent clinician perspectives through thematic analysis of existing evidence. This synthesis elucidates critical KSC implementation determinants to inform strategy optimization and support framework development. Current qualitative studies elucidate clinician perceptions toward KSC clinical integration. Building on nephrology advances, this study examines facilitators and barriers to KSC adoption. Qualitative evidence remains unsynthesized despite availability. This study examines clinician perspectives on KSC implementation across global practice contexts. This synthesis identifies convergent/divergent clinician perspectives through thematic analysis of existing evidence. This synthesis elucidates critical KSC implementation determinants to inform strategy optimization and support framework development.

Current qualitative studies among healthcare professionals have elucidated their attitudes and opinions regarding the application of KSC in clinical settings [15, 16]. Despite the abundance of qualitative evidence, existing research has primarily focused on single-country or culturally specific investigations, lacking a comprehensive systematic integration of findings. Therefore, this study aims to holistically explore healthcare professionals’ attitudes toward KSC implementation across diverse regions, cultural contexts, and practice environments. By synthesizing existing research, we seek to identify common trends, variations, and recurring themes in their perspectives. These findings will provide critical insights for refining KSC implementation strategies and strengthening future support systems.

Method

Aims

This systematic review integrates clinician perspectives on KSC through evidence synthesis. This study examines clinician understanding of KSC implementation in global clinical settings; the review advances evidence-based strategies to enhance adoption efficacy. This review proposes evidence-based strategies to optimize KSC implementation.

Study design

This study employs qualitative meta-aggregation methodology [17], adhering to ENTREQ guidelines (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) [18]. These guidelines promote transparency in qualitative research synthesis within nursing science.

Search strategy

A systematic literature search was conducted using the Joanna Briggs Institute (JBI) three-step strategy [19] across five English (PubMed, Web of Science, Embase, Cochrane Library, CINAHL) and four Chinese databases (CNKI, Wanfang Data, VIP, Chinese Biomedical Literature Database) from inception to February 29, 2024. This review explored clinician perspectives regarding KSC in ESRD clinical contexts using the PICo framework. The participant category (P) comprised clinicians with explicit nurse inclusion. The focal point of interest (I) examined clinician perspectives on KSC in ESRD through qualitative inquiry. The contextual framework (Co) focused on clinical settings. A MeSH-validated search strategy grid was developed through keyword/synonym analysis (Appendix 1). Database searches were augmented with citation tracking and handsearching to ensure comprehensive coverage.

Ligibility criteria

Citations meeting criteria were imported into Endnote 21 to remove duplicates. Two reviewers independently screened titles/abstracts against predefined criteria, with discrepancies adjudicated by a third reviewer. Eligible articles underwent full-text assessment using predefined eligibility criteria (Table 1).

Table 1.

Inclusion and exclusion criteria

Inclusion criteria

Excluded criteria

1. Participants (P): Specialized doctors, nurses, and healthcare professionals in nephrology with extensive experience in caring for end-stage renal disease (ESRD) patients. Healthcare professionals with practical experience in Kidney Supportive Care or equivalent conservative kidney management practices; 2. Interesting Phenomena (I): Healthcare professionals’ experiences, perspectives, and insights regarding KSC or equivalent conservative kidney management; 3. Context (Co): This study was conducted in the Nephrology Department of a healthcare institution, involving doctors and nurses specializing in nephrology. Participants possessed extensive experience in caring for ESRD patients and had some exposure to the implementation of KSC or equivalent conservative kidney management. 4. Study (S): Included studies employed qualitative or mixed-methods approaches, reporting qualitative results. Methodologies covered various qualitative research approaches, including phenomenology, grounded theory, ethnography, feminist research, and action research. In mixed-method studies, only the qualitative components were extracted for further analysis. 5. Eligible studies included those published as full-text articles in peer-reviewed journals, with content available in English or Chinese.

Exclude quantitative studies with non-extractable qualitative results, conference abstracts, case reports, protocols, as well as systematic reviews and other review formats; Studies not presented in English or Chinese language; Exclude inaccessible, incomplete, or duplicate data.

Quality appraisal

Two reviewers independently appraised methodological rigor using the JBI Qualitative Research Checklist [20]. The 10-item tool employs a scoring system (yes = 2, unclear = 1, no = 0) with maximum attainable score of 20 per assessment. Two reviewers independently scored articles with third-reviewer adjudication, applying a ≥ 6 threshold for inclusion in analysis and data extraction.

Data extraction and synthesis

Two reviewers independently extracted data with third-reviewer adjudication of discrepancies. Study descriptors (authors, year, country) and methodological parameters (design, sampling, data collection) with substantive findings were systematically captured through a standardized data extraction template.

This study employed meta-aggregation for qualitative evidence synthesis [21]. This process entailed evidence categorization, critical appraisal, data extraction, and thematic synthesis. Two reviewers independently assessed interpretive consistency, assigning findings as unconfirmed (U), confirmed (C), or unsubstantiated (US) [22]. Researchers conducted thematic coding, comparative analysis, and systematic categorization of emergent themes. Sub-themes were developed for each theme through iterative validation to generate synthesized findings [23].

For conflicting findings across diverse healthcare settings, we systematically examined contextual factors (e.g., cultural norms, resource allocation) potentially explaining these variations. Methodological limitations (e.g., sampling bias, data collection heterogeneity) were reappraised using the JBI Critical Appraisal Checklist to assess their effects on divergence results. Discrepant findings were then compared with the aggregate dataset to determine if they represented outlier or warranted thematic framework revisions. Final consensus was reached through iterative Delphi-style deliberations among all investigators, with persistent disagreements documented to ensure methodological transparency.

Initial inductive coding of all outcomes generated 23thematic categories for subsequent qualitative meta-synthesis. Two researchers performed semantic coding through comparative analysis, developing thematic categories from the dataset. Through iterative categorization and differentiation, provisional thematic constructs were generated. Analytical rigor was ensured through third-researcher verification of themes/subthemes and subsequent team consensus validation. The validation protocol ensured interpretive rigor, theoretical saturation criteria, and methodological robustness. Ultimately, five main themes were identified as the analytical framework for this study.

Ethical considerations

Ethical approval

was waived as this the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant meta-analysis [24] analyzed exclusively published data. Ethical dimensions of included qualitative studies were rigorously appraised.

Search outcomes

Two reviewers independently conducted literature screening and data extraction using predefined eligibility criteria, the initial search strategy yielded 5,976 records. Initial title/abstract screening excluded 1,994 articles due to irrelevance, duplication, or unavailable full texts. Full-text assessment excluded 235 articles, yielding eight relevant studies for final synthesis. Reference list screening of included studies yielded no additional eligible articles. Figure 1 delineates the comprehensive search methodology.

Fig. 1.

PRISMA Flow chart of initial searches and inclusion

Results

The final studies (25–32) comprised data from five countries: USA (3), UK (2), China (1), Australia (1), and Canada (1). The study cohort comprised 149 nephrologists, 80 nurses, 48 physicians, 15 allied health professionals, and 1 palliative care specialist. Of the eight studies incorporated in this research, seven are purely qualitative studies utilizing semi-structured interviews as the primary methodology, while the remaining one is a secondary qualitative study employing the secondary analysis of existing qualitative data. All included studies were original research articles published post-2016. Quality appraisal outcomes are presented in Tables 2 and 3 summarizes key extracted data. This study employs the PRISMA framework to report evidence synthesis outcomes. This systematic review identified five core themes characterizing clinicians’ perspectives on KSC implementation. The analysis revealed five core themes: Professional Role Challenges, Decision-making Dilemmas, The Challenges of End-of-Life Care Delivery, Systemic and Institutional Issues, Patient-Centered and Ethical Care. Thematic analysis generated distinct sub-themes, systematically organized in Fig. 2.

Table 2.

Methodological quality of each included studies

Included literature	①	②	③	④	⑤	⑥	⑦	⑧	⑨	⑩
Ladin, Keren et al. [25]	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Scott, Jemima et al [26]	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Tam-Tham, Helen et al [27]	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Ducharlet, Kathryn et al [28]	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Noble, Helen et al [29]	Y	Y	Y	Y	Y	N	N	Y	Y	Y
Wong, Susan P Y et al [30]	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Li X, Luo JK [31]	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Grubbs, Vanessa et al [32]	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y

Note: (1) Was there a clear statement of the aims of the research? (2) Is a qualitative methodology appropriate? (3) Was the research design appropriate to address the aims of the research? (4) Was the recruitment strategy appropriate to the aims of the research? (5) Was the data collected in a way that addressed the research issue? (6) Has the relationship between researcher and participants been adequately considered? (7) Have ethical issues been taken into consideration? (8) Was the data analysis sufficiently rigorous? (9) Is there a clear statement of findings? (10) How valuable is the research? Abbreviations: N, No; NP, not provided; Y, Yes

Table 3.

Methodological characteristics of the qualitative studies included in the meta-synthesis

References (year)	country	Research Design	Data Collection Method	Methodology	Participants	Aim	Main themes and subthemes
Ladin, Keren et al. [25]	USA	Qualitative	Semi-structured interviews	Thematic analysis	35 nephrologists from 18 practices	To examine how nephrologists decide whether to discuss conservative management with older patients and identify triggers for conservative management discussion and the barriers and facilitators to discussion	5 themes: (1) Strugglingto define nephrologists’roles (determining treatment, instilling hope, and improving patient symptoms); (2) Circumventing end-of-life conversations(contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information); (3) Confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches); Conservative management as “no care”; Moral distress.
Scott, Jemima et al. [26]	UK	Secondary qualitative analysis	Document analysis	Secondary thematic analysis	22 nephrologists, 25 nurses, one palliative care consultant and 12 allied health professionals (six social workers, three dieticians, two counsellors, one pharmacist)	To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD)	2 themes: (1) Factors taken into consideration during dialysis decision-making(Comorbidity and prognosis, The feasibility of dialysis, Quality of life, The provision of services for ESKD, Clinicians’ perceptions of social support); (2) Processes involved in dialysis decision-making(Ethico-legal aspects of decision-making, The role of advance care planning)
Tam-Tham, Helen et al. [27]	Canada	Qualitative	Semi-structured interviews	Content analysis	27 primary care physicians	To develop a comprehensive summary of barriers and facilitators experienced by PCPs when providing care to older adults with stage 5 CKD managed conservatively without renal replacement therapy	3 themes: (1) Perceived barriers to conservative CKD care: (managing expectations of kidney failure for patients and their families, dealing with the complexity of medical management of patients requiring conservative care, challenges associated with managing patients jointly with specialists); (2) Factors that facilitated conservative CKD care: (establishing patient/family expectations early, preserving continuity of care, utilizing a multidisciplinary team approach); (3) Suggested strategies for improving conservative care: (direct telephone access to clinicians familiar with conservative care, treatment decision aids for patients and their families, a conservative care clinical pathway to guide management).
Ducharlet, Kathryn et al. [28]	Australia	Exploratory qualitative	Focus groups	Interpretive phenomenology	18 physicians, 3 trainees, and 33 kidney disease nurses	To explore kidney disease clinicians’ experiences of Kidney supportive care, palliative care, and end-of-life care.	2 themes: (1)Experiences of Health Care Systems That Insufficiently Addressed the Palliative Care Needs of Kidney Patients: (Variation of KSC Services, Limited Palliative Care Integration With Kidney Care, Compromised EOLC Provision) (2)Aspirations for Ideal KSC Services (Seamless Care Provision From the Patients’ Perspective, Responsiveness to Meet Different Patient Palliative Care Needs, Perceived as a Positive Experience, An Inclusive Part of Kidney Care Available for All Patients Based on Clinical Need)
Noble, Helen et al. [29]	UK	Qualitative	Semi-structured interviews	Interpretive description	12 nephrologists and 15 clinical nurse specialists	To explore Clinician views of patient decisional conflict when deciding between dialysis and conservative management in patients with end-stage kidney disease.	3 themes: (1) Frequent changing of mind regarding treatment options(Denial and fear, Influences from families and other patients, Clinician encouragement to change mind); Obligatory beneficence(In the patient’s best interests, Influencing the decision); The intricacy of the decision(A momentous decision, A brave and informed decision, Benefits, risks and prognostic uncertainty).
Wong, Susan P Y et al. [30]	USA	Qualitative	Semi-structured interviews	Grounded theory	21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis	To describe practice approaches of US nephrologists who have provided conservative care for members of this population.	2 themes: (1) Person-centered care(Patient-centered decision-making, Presenting dialysis as a choice, Having insight into own biases, Need for flexibility); (2) Improvising a care infrastructure(Defining scope of responsibility, Filling gaps in care, Interfacing with the wider healthcare system, Challenging norms).
Li X, Luo JK [31]	China	Qualitative	Semi-structured interviews	Phenomenological analysis	10 healthcare professionals (3 physicians and 7 nurses)	To provide comprehensive insights and evaluations regarding the perspectives of Chinese healthcare professionals on KSC.	2 themes: Prospective clinical merits of KSC (Augmenting quality of life, Alleviating economic strain, Effective use of medical resources); (2) Mltiple difficulties encountered(Treatment decision difficulty, The imperfection of the palliative system).
Grubbs, Vanessa et al. [32]	USA, England	Qualitative	Semi-structured interviews	Narrative analysis	18 English nephrologists and 41 US nephrologists	Focuse on the perspectives of nephrologists in England (where conservative management pathways are readily available) and the United States (where they are not) regarding theways in which family members facilitate or impede decisions to appropriately forego or withdraw dialysistherapy.	4themes: emotional response to decision making; involvement in patient health care/awareness of Illness; trust in physician; acceptance of patient wishes.

Fig. 2.

Theme reporting summary

Theme 1: professional role challenges

Challenges in nephrology roles

The implementation of KSC in clinical practice presents significant challenges to healthcare professionals’ roles and responsibilities. KSC establishes a coordinated care framework requiring proactive patient-provider communication, contrasting traditional renal care models relying on discrete clinical teams managing fragmented care. This paradigm transformation is essential for optimizing care delivery and ensuring patient comprehension of clinically viable treatment pathways. Nephrologists must navigate transformative adaptations to conventional care paradigms amidst evolving clinical demands. A nephrologist highlighted the patient’s right to choose in decision-making, stating, “There are times when patients are not willing to make a decision, and as a patient, they have a right… because that’s their life, and if they do not want to decide what they want to do with end-stage renal disease (ESRD) imminent, they can do that.“[25] This statement highlights a critical tension in KSC implementation: while promoting shared decision-making, the model must also respect varying patient engagement preferences,, from deferral to refusal. Moreover, professional responsibilities are transforming in both scope and nature.

Another nephrologist also mentioned that they serve in informal or formal consulting roles in renal and/or palliative care clinics. “As consultants, our responsibilities could vary from advising other clinicians to co-managing patients with their primary nephrologists on a variety of issues including complex medical decision-making, advance care planning, and symptom management.“[30] While necessary, this evolution towards blurred professional boundaries and co-management in KSC highlights a key challenge for nephrology roles.

Defining professional roles

KSC implementation necessitates multidisciplinary collaboration with defined role clarity, structured communication protocols, and coordinated responsibilities to ensure care quality optimization. Clinicians encounter interprofessional communication barriers with nephrologists, particularly in patient co-management, stemming from role ambiguity and ineffective communication strategies. Primary care physicians advocate workflow-integrated frameworks, as one participant noted: “It takes an effort from the family or the primary care physician to actually liaise with the renal clinic to establish who does what and how do we do things.”[27] This quote highlights the ad hoc, effort-intensive nature of current role negotiation—a core challenge stemming from the absence of standardized frameworks for defining responsibilities and communication between primary and renal care teams. Nephrologists transitioning to KSC advisory roles require professional role adaptation, particularly when lacking prior dialysis-alternative decision-making experience. A nephrologist elaborated,“As consultants, our responsibilities could vary from advising other clinicians to co-managing patients with their primary nephrologists on a variety of issues including complex medical decision-making, advance care planning, and symptom management.”[30] This description illustrates the inherent fluidity of the Professional role. While essential for KSC, this fluidity also fuels the core challenge of role ambiguity.As a strictly standardized role definition has not yet been established in clinical practice, the acceptability and operational definition of this fluid role is likely to be significantly influenced by the prevailing professional hierarchies, team-based care norms, and formal care coordination mechanisms within the specific healthcare systems of different countries.

Theme 2: Pre-implementation cognitive-ethical conflicts

Cultural-emotional entanglements

Nephrologists recognize key KSC implementation barriers rooted in sociocultural factors. Inadequate patient/family understanding of dialysis and KSC principles impairs decision-making across disease progression stages.As exemplified by a family member’s misconception, “I get patients with mobility problems and dementia problems and vascular problems and their relatives believe that dialysis will cure all of the above.”[26] Familial involvement adds complexity by culturally mediating decision-making and emotional conflicts. In individualistic Western settings (e.g., UK), clinicians may exercise authority to alleviate familial guilt, as one nephrologist noted that excluding familial emotional considerations compromises evidence-based decision-making in dialysis withdrawal scenarios.“It is not upto you and I’m sorry you’d be angry with me or upset but it’s not up to you.”[32] This highlights varied implementation challenges: individualistic cultures (e.g., UK or US) prioritize exercising clinical authority. Conversely, in family-centric collectivist cultures (e.g., across Asia), familial decision-making predominates, with physicians often adopting deferential approaches. Consequently, KSC implementation and decision-making are significantly shaped by these Cultural-Emotional Entanglements. Concurrently, primary care physicians (PCPs) report limited awareness of renal conservative care resources [27], further impeding KSC adoption. These disparities reveal how cultural norms fundamentally shape implementation processes.

Clinical-existential complexity

During pre-terminal illness, clinical decisions are required for all therapeutic options, yet multimorbidity and individual needs add complexity into this process.As a Clinical Nurse Specialist stated, “This is one of the most complex areas in medicine to make decisions on, and it’s becoming more complex because of the types of patients we’re now being asked to deal with.These are patients that are elderly and frail, with lots of comorbidities, sometimes very severe, like dementia, cancer, and these are the decisions which are becoming really, really difficult to make, and no consultant I know can make these decisions easily. If they do make them easily, they’re doing it wrong. These decisions are extremely difficult. They have to be individualised for each patient. They take hours of talking. Very rarely is this decision easy in the majority of elderly frail patients. [29] This explanation illustrates clinical complexity—where multimorbidity and frailty impacts decision-making in progressive disease—challenging KSC’s goal of standardize care pathways while maintaining patient-centered flexibility. Nephrologists from five units reported being involved in regular multidisciplinary best interests meetings, involving clinicians, social workers and often the general practitioner, while others did not.We don’t have a discussion forum where we…or a multidisciplinary meeting where we discuss patients with these RRT decisions. [26] At a macro level, KSC decision-making reveals that variations in interdisciplinary support across nations reflect systemic healthcare differences. Countries with strong primary care integration (e.g., the UK) are better positioned to institutionalize such multidisciplinary forums. Conversely, fragmented systems often assign coordination to individual institutions.

Theme 3: Post-decisional operational barriers

Prognostic communication challenges

Prognostic communication with patients and families becomes increasingly complex as end-stage disease approaches, closely tied to cultural beliefs about mortality. These deeply held beliefs often lead to avoidance of end-of-life discussions, posing significant challenges for clinicians in conducting sensitive care transition dialogues. As clinicians acknowledge,“We are really, as a profession…so terrible at prognosis… To some extent it’s false optimism and realistic optimism and unwillingness to face death…also the realization that we’re just so terrible at predicting the future”[25] Doctor 2 observed, “Clinically, when broaching topics of mortality with patients or their kin, there’s a conspicuous predilection to circumvent these discussions.” These avoidance behaviors lead to a fundamental misalignment between KSC’s proposed palliative care paradigm and current clinical practice. The implementation gap is notably evident in East Asian cultural contexts where mortality discussions remain culturally proscribed, in contrast to more individual-oriented Western societies where KSC’s patient-centered approach faces distinct yet equally complex challenges during terminal care transitions.Similarly, Nurse 6 noted, “Rooted in our deep-seated familial values, numerous families find the decision to cease treatments profoundly challenging.[31] Thus, developing culturally adapted KSC guidelines that take for account documented cross-cultural differences in terminal care decision-making paradigms will be critical for enhancing implementation effectiveness during end-of-life prognostic communication and treatment transitions.

Navigating emotional challenges

The implementation of end-of-life EOL care is frequently challenged by healthcare providers’ negative emotional experiences, which stem from the complex interplay between communication barriers, emotional responses, and erosion of clinician-patient trust.As a US nephrologist described, “It was really challenging because I could tell that this family member was distrustful. I could tell that he felt like everyone was ‘trying to pull the plug on his mother.’ I really didn’t think it was good to dialyze her. I felt like it was really hard to get around that or to avoid doing it.”[32] Physicians face considerable ethical conflict when familial skepticism clashes with medical recommendations, with is further intensified in cultural contexts emphasizing collective family consensus over individual patient autonomy in healthcare decisions. A Clinical Nurse Specialist reported, “So they focus more on the bad side and what will happen to them because they think that once they have kidney failure, they die. There is no hope. So it depends on the staff, how you give them the information that will give them inspiration. We have this patient, but they are doing well’, so you kind of in a way encourage them as well, don’t tell them all the side effects, and you tell them ‘You are fit person – it could be good to you – you don’t scare them’.[29] As patients approach the end of life, KSC advocates for hospice care. However, cultural resistance to end-of-life discussions hinders clinicians’ ability to manege care transition conversations. KSC implementation must respect diverse cultural perspectives on mortality globally while addressing emotional challenges through regionally tailored communication frameworks.

Theme 4: systemic and institutional issues

Confronting institutional barriers

Currently, many healthcare systems lack established institutional frameworks to facilitate the clinical implementation of KSC. These systemic barriers not only exacerbate the challenges faced by clinicians but also significantly hinder broader understanding and adoption of KSC treatment strategies among stakeholders.“We talk about quality of life to the patients, we try to gauge what is important for them, but I do believe we do a poor jobbecause of the limits of time”[25] KSC implementation necessitates interprofessional collaboration, trust-building, and optimized communication within integrated health systems – critical success factors emphasized by nephrologists, “conservative management does take some collaboration between us and primary doctors and other supports. We as a nephrology division can’t do conservative management on our own, without any of those additional services to help out.”[25]Systemic deficiencies in palliative care infrastructure impede KSC integration into clinical practice. Nurse 3 opined, “Given that hospitals primarily focus on disease amelioration and life preservation, KSC’s widespread adoption seems implausible. Contemporary Chinese medical institutions typically relegate palliative endeavors to specialized hospices or dedicated wards. Propagating this care approach in top-tier hospitals remains fraught with complexities.”[31] The identified systemic barriers underscore fundamental disparities in palliative care adoption among nephrology patients globally. Leading medical centers in China and comparable healthcare systems persist in prioritizing disease-modifying interventions over palliative approaches, resulting in significant care quality disparities for end-stage renal disease patients. As the renal-palliative care field gains momentum globally, strategic resource reallocation is essential to to address disparities in care delivery.

Limited integration of palliative care

Current KSC clinical support remains constrained, manifested through insufficient palliative care integration and clinician training deficits within healthcare systems. A nurse delineates resource constraints as follows, “We would love to refer to palliative care for symptom management, but, when it actually comes to the crunch, neither of us have the resources to make it work”[28]. The constrained integration of palliative approaches with renal disease management creates significant implementation challenges, ultimately hindering the development and widespread adoption of KSC.

Doctor 3 highlighted a crucial distinction, “The nuances of palliative care for Renal ailments differ markedly from oncological palliation. The evolution of palliative care for ESRD lags, with palpable deficits in awareness among both patients and their families, posing challenges for KSC’s broad-based implementation.”[31] Resource limitations reflect systemic underfunding of palliative care frameworks in kidney disease management, highlighting the necessity for paradigm-shifting education to reclassify dialysis as an elective rather than mandatory intervention - a particularly formidable barrier in cultural contexts where palliative care remains socially stigmatized.

Theme 5: Patient-centered and ethical care

Patient-centered values

Clinicians recognize KSC’s clinical value in nephrology, prioritizing patient-centered approaches and integrating palliative care principles. Unlike palliative care, KSC emphasizes ethical principle centrality, enhancing patient acceptability and care accessibility. A nurse mentioned, “KSC is my link for palliative care for my patients, regardless of all the best plans you can make, it’s a nice, hopefully smooth transition.“[28] Nephrologists emphasized mandating documentation of patient-initiated dialysis refusal in clinical records. Clinicians emphasized systematic documentation of advance care planning directives and life-sustaining treatment orders. Clinicians acknowledged potential noncompliance with documentation protocols and accessibility challenges during emergent clinical scenarios. To handle these kinds of situations, some nephrologists described coaching patients on how to voice their preferences and communicate with other clinicians who might not be familiar with their goals. They also worked to build consensus among other clinicians and family members around supporting patients’ treatment preferences in order to increase the likelihood that patients’ wishes would be respected[30]. KSC’s transitional role addresses a critical gap in nephrology care, whereas traditional palliative models may be viewed as a form of surrender. Its ethical framework as active patient-centered care improves acceptability among dialysis-dependent populations. Its structured approach equips clinicians with practical tools to operationalize patient autonomy while sustaining therapeutic relationships.

Ethical considerations and strategies

KSC prioritizes ethical principles including beneficence and patient autonomy while advocating optimized conservative management strategies for CKD. The nephrologists whom we interviewed spoke of how clarifying patients’ preferences alone did not guarantee that they would receive the kind of care that they desired. Therefore, explicit strategies were developed to help patients ensure that their wishes were upheld when interacting with the wider healthcare system. These included educating patients about the signs and symptoms that they might develop and helping them to formulate a plan of action in the event of a health crisis[30]. While renal replacement therapy extends survival in ESRD patients, treatment-related morbidity and potential dialysis intolerance persist, particularly in elderly populations. KSC emphasizes QOL optimization and ongoing assessment aligned with disease progression over survival prolongation, thereby upholding life dignity. Therefore, a nurse emphasized the profound essence of KSC, affirming its significance, “Mere extension of life, devoid of inherent quality, borders on the futile. It’s imperative we uphold patient autonomy and prioritize quality in the terminal stages.”[31] KSC emphasizes ethical principles, such as beneficence and patient autonomy, while promoting optimized conservative management strategies for CKD. However, as our study’s nephrologists highlighted, simple clarification of patient preferences does not ensure goal-concordant care. By reframing “active care” as symptom management instead of dialysis persistence, KSC aligns with value-based care models emerging in Europe and North America.

Discussion

This study synthesized eight qualitative studies exploring clinicians’ perspectives on KSC to establish an evidence base. The methodological rigor and robust findings establish an evidence-based foundation for advancing clinical practice. This qualitative synthesis identified critical KSC dimensions in advanced chronic kidney disease through analysis of clinician perspectives. Thematic synthesis identified inherent complexities and critical challenges in KSC implementation. Among the eight included studies, KSC definitions varied, with alternative terms (e.g., ‘conservative management,’ ‘non-dialysis therapy’) utilized in some instances. We attribute this variability to the historical evolution of terminological standards. Critical analysis of the eight studies’ full texts reveals conceptual alignment with KSC principles despite terminological heterogeneity. The relationship between these substitute words and KSC is summarized in Table 4. While KSC is an emerging concept, its foundational principles demonstrate pre-2013 origins with global implementation disparities reflecting diverse developmental trajectories. KSC programs demonstrate advanced implementation in Canada, the United Kingdom, Australia, New Zealand, and Hong Kong, reflecting prioritized integration within these healthcare systems [10].

Table 4.

Terminological evolution and conceptual alignment in kidney supportive care literature

Study (Year, Citations)	Original term used	Core conceptual focus	The relationship with the concept of Kidney supportive care (KSC)	Replaceable lexical units
Tavares, Alze Pereira Dos Santos et al. ([10], 10)	Palliative Nephrology	Adequate communication, shared decision making, planning future health care, treatment, and Pain/symptom control alongside dialysis	KSC is an update of the current state of the art of palliative care in CKD patients	Renal palliative care
Lupu, D, & Moss, A. H. ([7],7)	Conservative kidney management	Exclusive non-dialytic care, improve quality of life, and plan for the end of life	A vailability of one specific component of KSC	active medical management without dialysis
Gelfand, Samantha L et al. ([6],6)	Comprehensive CKD Care	Continue CKD care without dialysis, maximize quality and quantity of life	Comprehensive CKD Care is a necessary component of KSC	active medical management
Gelfand, Samantha L et al. ([6],6)	Kidney Supportive Care	symptom management, shared decision-making, advance care planning, comprehensive conservative treatment, and end-of-life care		Conservative kidney management, comprehensive conservative care, or simply conservative care
Summary	These terms are fundamentally interconnected and mutually reinforcing. As substantiated by the literature, KSC represents the quintessential synthesis and conceptual culmination of this terminological spectrum.

This study demonstrates KSC’s transformative potential as an innovative framework in nephrology care. KSC demonstrates multidimensional clinical advantages consistent with established evidence [33, 34].Tavares et al. conceptualize KSC as an enhanced palliative care framework for renal patients [10], emphasizing patient-centered strategies through shared decision-making and advance care planning to ensure therapeutic congruence with patient values and goals. This study validates clinicians’ acknowledgment of KSC’s clinical utility, rooted in its patient-centered paradigm that integrates individualized care with holistic assessment and symptom modulation, a detailed exposition of this phenomenon is presented in Theme 5 of our findings.Therefore, advancing the translational implementation of KSC necessitates strategic emphasis on harnessing its tailored therapeutic protocols and optimizing patient-specific outcomes. Alvin et al. incorporated KSC best practices within clinical nephrology practice, implementing structured needs evaluation and establishing targeted care coordination during patients’ progression to end-of-life stages [35]. Their findings operationalized KSC guidelines in nephrology care through standardized needs assessment and coordinated intervention protocols during end-stage renal disease transitions.The included research reports indicate that the widespread implementation of KSC in clinical practice encounters various challenges. Our analysis delineates implementation barriers spanning role ambiguity, multidisciplinary decision-making, interprofessional communication gaps, healthcare system constraints, and bioethical dilemmas.

Recent clinical discourse demonstrates progressive prioritization of conservative care paradigms [25, 36], reflecting evolving imperatives to optimize non-invasive therapeutic approaches. As delineated in our first major theme, clinicians’ role evolution constitutes the predominant barrier, emerging as the central analytical construct in our investigation. Clinicians implementing KSC navigate multifaceted role integration spanning clinical care delivery, patient advocacy, interprofessional consultation, and care coordination [37]. Such professional role reconfiguration may induce responsibility diffusion, workload intensification, and clinician distress. Clinical practice thus necessitates structured multidisciplinary team integration. This necessitates optimized team configuration and multidimensional support frameworks for KSC operationalization. Sustained development of interprofessional clinical care pathways remains imperative. Such pathways must deliver integrated support spanning biomedical, psychosocial, and nursing interventions for patients electing KSC therapeutic approaches [30]. KSC implementation requires iterative clinical decision-making aligned with disease trajectory, encompassing goal-setting, pharmacotherapy optimization, and therapeutic modality selection [38, 39]. To implement KSC within diverse healthcare systems, context-specific strategies must address country-specific barriers to implementation. For multidisciplinary team integration, Western systems (e.g., Europe and North America) should adopt role-specific EHR templates coupled with financial incentives to enhance compliance, whereas Asian contexts necessitate culturally tailored family mediation roles and integration of traditional medicine.For multidisciplinary team integration, clinician roles should be community-integrated, reinforcing and reorienting physician value propositions grounded in grassroots family-centered care, while developing corresponding legal frameworks to enhance and refine healthcare team support models.

Our analysis demonstrates treatment decision-making complexity arises from multifactorial determinants.For ESRD patients in particular, the uncertainties they face and the complexity of medical decision-making escalate significantly.Engagement with hospice care may precipitate mortality anxiety, particularly within Asian contexts where death discourse taboos persist. This anxiety predisposes toward non-curative care choices, disrupting triadic clinician-patient-family communication dynamics. Advancing KSC integration necessitates prioritized development of clinician communication and shared decision-making competencies. This enhances clinicians’ capacity to articulate disease-related uncertainties and prognostic implications within renal care contexts. KSC operationalization should incorporate dissemination of disease-specific educational materials and decision-support instruments. These interventions facilitate optimized patient communication strategies for nephrologists navigating multifaceted clinical demands [15]. For multidisciplinary team integration, we advocate a two-phase approach to enhance patient-centered communication within disease management For multidisciplinary team integration, addressing pre-implementation cognitive-ethical conflicts requires clinicians to cultivate cultural humility through standardized, disease-specific progression family conference protocols that sustain active patient-family engagement while respecting regional norms - ensuring KSC principles are implemented with appropriate cultural sensitivity rather than rigid enforcement or excessive dilution. However, addressing post-decisional operational barriers as patients progress to end-stage disease requires shifting communication focus to system-level interventions: institutional accreditation aligned with KSC quality metrics, sustainable funding models for integrated renal-palliative care teams, and time-efficient training programs supporting overburdened clinicians in maintaining value-congruent care.

Our analysis identifies structural healthcare system deficiencies constraining KSC operationalization. Existing evidence demonstrates insufficient organizational infrastructure and inadequate advance care planning training predispose clinicians to bioethical conflicts [40]. Our synthesis delineates system-level constraints spanning resource allocation deficits, workflow fragmentation, administrative governance barriers, and reimbursement model limitations. Such constraints compromise care teams’ capacity to deliver evidence-based KSC, exacerbating clinical decision-making complexity in multifaceted scenarios [41]. Global KSC implementation challenges necessitate a coordinated strategy integrating education, guideline standardization, resource optimization, stakeholder engagement, research innovation, and policy reform [42]. To operationalize standardized guidelines, a “KSC Operational Manual” will be developed, detailing key decision points, alongside flowcharts and checklists for clinical application [43]. A Guideline Committee will be established to review emerging evidence quarterly, ensuring alignment with current best practices. A structured training curriculum will be developed, comprising phased modules on end-of-life communication skills, pain management, and ethical decision-making frameworks [44]. An structured online learning platform will be developed, incorporating video case libraries, interactive quizzes, and AI-powered feedback systems to improve learning outcomes. A KSC Quality Indicator Database will be established to monitor and improve implementation, tracking metrics such as advance directive completion rates and symptom control effectiveness [45]. Furthermore, visual decision aids (such as Visual guides and interactive tools) will be developed to support shared decision-making between patients and clinicians, thereby facilitating KSC adoption.

Conclusion

This systematic review integrates qualitative evidence on clinician perspectives regarding KSC, highlighting critical implications for advancing nephrology practice innovation. KSC represents an emerging global therapeutic approach focused on improving quality of life through comprehensive symptom management and personalized care strategies. Prioritizing patient-centered care through shared decision-making and advance care planning ensures treatment alignment with patients’ values, preferences, and clinical objectives. KSC improves end-of-life care experiences by proactively managing critical illness transitions, reducing distress for patients and families through coordinated support. Persistent implementation barriers remain, rooted in healthcare system deficiencies and clinician ethical challenges. Targeted support systems are essential to optimize complex decision-making pathways. 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.

Limitations

Despite a comprehensive search of qualitative studies, only eight records met the eligibility criteria. While this facilitated in-depth analysis, the small sample size constrains the generalizability of findings, particularly due to the global diversity of healthcare systems. Sensitivity analyses excluding lower-quality studies demonstrated the robustness of core themes, thereby partially addressing methodological constraints.Notably, the included studies were predominantly conducted in high-income Western settings, with a notable underrepresentation of research from low- and middle-income countries, including China. This geographic bias raises concerns regarding the transferability of findings to non-Western healthcare contexts, where cultural, ethical, and structural factors may vary significantly.

A key limitation stems from the restriction to English-language publications. Searches in Chinese databases (e.g., CNKI, Wanfangdata) produced no non-English publications, indicating a potential linguistic and publication bias that may exclude relevant perspectives from non-Anglophone regions. This omission may bias the synthesis toward Western-centric interpretations of KSC implementation.

Furthermore, the inherent biases embedded in the primary studies were not systematically assessed. For instance, some included studies may have relied on clinician self-reports, which might overestimate adherence to KSC principles, or excluded marginalized patient populations, thereby limiting the diversity of perspectives captured. Future KSC research should prioritize multi-regional, multilingual, and multi-method investigations, such as gray literature and non-English sources, to enhance validity, reduce bias, and improve global applicability.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

XL and WJ: conception, design of the work, formal analysis, the acquisition, analysis, and have drafted the work. DW and YX and XY Z and SY L: the acquisition, analysis, and interpretation of data; and the creation of new software used in the work.

Funding

This work was supported by the Beijing Municipal Administration of Hospitals Incubating Program (PX2022001), the Capital’s Funds for Health Improvement and Research (CHF 2024-4G-2029).

Data availability

Data is provided within the supplementary information files.

Declarations

Ethical approval

There is no ethical statement for this trial.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.