Table 3. Comparing patient-centered individualized vs. disease-oriented approaches in individual patients.

	CASE 3
	76 year old woman with hypertension, diabetes and severe osteoarthritis. She is independent in all instrumental and basic activities of living. She has a stable GFR of 25-30 ml/min/1.73 m2 and 2+ proteinuria. On exam, her blood pressure is 140/90 mm Hg, she has no edema, and has substantial difficulty rising from the chair at the end of the visit. She has grandchildren who live close by and would love to be more involved in their daily lives, but her arthritis pain limits her mobility outside the home. She asks you whether it would be acceptable to take a non-steroidal agent (NSAID) because other pain medications are either ineffective or have intolerable side effects.
	Disease-oriented approach	Individualized patient-centered approach
Clinical Decision Making	History and Exam – elicit signs and symptoms relevant to CKD (e.g., presence of edema, blood pressure). Work-up – assess severity of kidney function, proteinuria, estimate progression.	History and Exam – elicit symptoms that are bothersome and treatable, ascertain treatment preferences, estimate life expectancy and other risks (e.g., worsening renal function). Work-up – tailor evaluation to match patient concerns, e.g., evaluation of mobility and gait (stand from seated position, walk 10 feet and return to chair).
Underlying conceptualization of disease	Use of NSAIDS will likely have an adverse effect on kidney function and blood pressure. High blood pressure may result in progression of underlying kidney disease and also confers an increased risk of death and cardiovascular events.	Competing and conflicting treatment priorities may exist in the setting of more than one treatable co-morbid condition. While NS AIDs will likely have an undesirable effect on CKD and hypertension, they may represent the best approach toward treating arthritis pain.
Treatment	Advise the patient to minimize or avoid NSAIDS. Recommend addition of an ACE inhibitor to lower blood pressure, slow progression of kidney disease and reduce cardiovascular risk in this patient with poorly controlled hypertension, diabetes and proteinuria.	Discuss the benefits and harms of NSAIDs with the patient who may consider trading off worsening renal function and blood pressure for better pain control. Target symptoms and limitations that matter to the patient, in this case pain management and mobility impairment (e.g., physical therapy, occupational therapy, assistive devices) CKD-based treatment might involve identifying ways to treat blood pressure that do not increase the risk associated with NSAID administration (e.g., use of diltiazem instead of an ACE inhibitor) and to monitor the impact of the NSAID on blood pressure and renal function (e.g., closer monitoring of renal function, more attention to salt intake, further incremental changes to anti-hypertensive regimen)
Approach to symptoms	The patient’s joint pain is unlikely to be related to CKD.	Treatment targeted at what matters most to the patient, recognizing that symptoms may take precedence over disease-based abnormalities even if these cannot be ascribed to an underlying disease process.
Goals of treatment	Clinical outcomes include preserving renal function, decreasing proteinuria, and reducing cardiovascular risk.	Clinical outcomes are those that matter to the patient and can be modified, and may include both traditional disease-based and non-disease based outcomes. Improved pain control might be more important for this patient than preserving renal function or optimizing blood pressure .

	CASE 4
	72 year old man with hypertension, diabetes, moderate dementia complicated by an increasing frequency of behavioral symptoms, episodes of urinary incontinence, and recurrent falls. His blood pressure is elevated at 190/80 mm Hg and he has 1-2+ lower extremity edema. He lives at home with his wife and requires 24 hour supervision. He has a stable GFR of 25-30 ml/min/1.73 m2 and an albumin-to-creatinine ratio of 400 mg/mg. An ultrasound several years ago showed 12 cm kidneys and no hydronephrosis. His wife asks you whether he really needs to keep coming to see you in renal clinic.
	Disease-oriented approach	Individualized patient-centered approach
Clinical Decision Making	History and Exam – elicit signs and symptoms relevant to CKD (e.g., presence of edema, blood pressure). Work-up – assess severity of kidney disease, proteinuria, progression, evaluation renal conditions that might contribute to patient’s presentation (e.g., UTI)	History and Exam – elicit symptoms that are bothersome to the patient and treatable, ascertain patient and family treatment preferences, evaluate caregiver stress. Work-up – evaluation for factors contributing to geriatric syndromes (e.g., evaluation for orthostatic hypotension, UTI, new medications, constipation).
Underlying conceptualization of disease	Nephrology referral is recommended for patients with advanced kidney disease in order to optimize management of disease complications and progression, and to prepare for ESRD. Lowering blood pressure will reduce risk of progressive kidney disease, mortality and vascular events, and may also reduce risk of cognitive dysfunction.	While the patient may benefit from specialized nephrology care, he and his wife are dealing with several competing concerns that may be of higher priority. The patient has worsening functional impairment/geriatric syndromes that should probably be prioritized although un. The wife may be experiencing caregiver burnout
Treatment	Recommend continued visits to nephrology and explore whether less frequent visits or phone follow-up might be possible. Recommend addition of an ACE inhibitor or ARB to manage hypertension in the setting of proteinuria and diabetes. Recommend a diuretic for edema and additional blood pressure control.	Discuss the benefits and harms of nephrology visits from the point of view of the patient and caregiver, explore alternative approaches to providing care (e.g. co-management with a primary care physician, delayed follow-up after acute issues have resolved). Explore resources available to support the caregiver. Treat underlying precipitants of evolving geriatric syndromes (e.g., UTI, constipation). Remove precipitating factors for falls and incontinence (e.g. avoid rising rapidly from sitting position, treat UTI). Limit effects of predisposing factors for falls and incontinence (e.g., more assistance during high risk activities, use cane or walker). Discontinue or change the dose or dosing schedule of medications that may be contributing to geriatric syndromes and avoid medications that could worsen these with consideration of overall pill burden (e.g., diuretic may worsen incontinence, ACE inhibitor will require a follow-up laboratory test, limiting the number of new medications) Some aspects of CKD-based treatment might be appropriate if likely to prevent outcomes that would interfere with patient and family goals. Optimal blood pressure control may prevent further cognitive decline but choice of agents might be tailored to simultaneously address other priorities.
Approach to symptoms	The patient does not have symptoms that are clearly due to his underlying CKD. It might be important to rule out a UTI as a cause for his deterioration.	Symptoms are likely multi-factorial and if modifiable and bothersome to the patient and caregiver, should be targeted using multi-faceted interventions (e.g., identification precipitants, caregiver education, increasing social support and non-pharmocologic approaches.)
Goals of treatment	Clinical outcomes include preserving renal function, decreasing proteinuria, reducing cardiovascular risk and identification of possible renal factors that might be contibuting to patient’s presentation.	Clinical outcomes matter to the patient and caregiver and that can be modified. For example, addressing and decreasing caregiver burden, managing geriatric symptoms and ensuring appropriate level of care might be priorities in this patient.

GFR = glomerular filtration rate, CKD = chronic kidney disease, NSAID = non-steroidal anti-inflammatory drug, ACE = angiotensin converting enzyme, UTI = urinary tract infection