**5. Shared decision-making in patients with chronic kidney disease**

SDM in nephrology settings is a challenging issue because of the complexity of chronic kidney disease and the preference-sensitive choice to be made [19]. When chronic kidney disease progresses toward end-stage kidney disease (ESKD), patients need to make decisions for different renal replacement therapies to be survived [1]. They must continue receiving one of the RRT treatments for the rest of their lives. Therefore, it is important for patients to select the treatment option that is the most suitable and acceptable treatment based on the preference and values of patients [20].

To help patients for making timely treatment modality decisions, international guidelines in nephrology suggest shared decision-making (SDM), where the treatment is selected based on patient's values and preferences [21]. SDM in nephrology engage the patients in decisions that best suit patients' preferences and their living and medical situations [22]. In the SDM process for renal replacement therapies, both healthcare providers and patients choose the best treatment option together after assessing the evidence and discussing the pros and cons of all available options (including kidney transplantation, hemodialysis, and peritoneal dialysis), individual preferences, and the circumstances of the patient. During the SDM process, outcomes from weighing the clinical guidelines are weighed against personal beliefs and preferences [22].

#### **5.1 Shared decision-making for the selection of renal replacement therapies**

Patients suffering from advanced chronic kidney disease should make complex decisions for selection of all possible renal replacement therapies [1]. Each option of RRT could impact their everyday life. The selection of RRT is a usual situation for 'informed shared decision-making' (iSDM). Van Dulmen et al. [23] proposed four essential elements for iSDM in RRT: (a) at least two persons are engaged in decisions, (b) both share information according to the evidence-based care, and (c) building an agreement on the preferred choice, and where (d) a consensus is made on the treatment option with joint responsibility.

#### **5.2 Time of shared decision-making for selection of RRT**

Because kidney function of patients with chronic kidney disease usually declines progressively, the healthcare providers especially the nephrologists and nurses have multiple opportunities to discuss all available options of renal replacement therapy.

There are when shared decision-making for a patient with CKD is important at least three times: when the patient enters stage 4 (estimated glomerular filtration rate [eGFR] < 30 ml/min/1.73 m2 ), when the patient is going to start RRT in the near time (eGFR <15 ml/min/1.73 m2 ), or when the healthcare provider find no evidence that further treatment will prolong life (age ≥ 75 years and multiple comorbidities, or eGFR <5 ml/min/1.73 m2 ). In this stage, a nephrologist should discuss all available options for renal replacement therapy with the patient and family and support the patient in the selection of a suitable lifesaving treatment based on the patient's preferences and the best evidence [24].
