Shared Decision-Making and Decision Support in Advanced Chronic Kidney Disease: A Systematic Review of Models, Treatment Pathways, and Patient-Centered Outcomes

Abstract

Shared decision-making (SDM) is a crucial part of patient-centered care because advanced chronic kidney disease (CKD) requires complex treatment choices. This study systematically reviews models of SDM and decision-support interventions in advanced CKD, focusing on treatment pathways, modality selection, and patient-centered outcomes. We conducted a systematic review in accordance with accepted methodological guidelines. From the beginning to May 2026, we searched PubMed, Embase, the Cochrane Library, and Scopus. We included studies assessing SDM models, treatment routes, decision-support treatments, and patient-centered outcomes in advanced CKD. We used the Joanna Briggs Institute (JBI) critical appraisal tools for cross-sectional studies, the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool for nonrandomized studies, and the Risk-of-Bias Assessment Tool 2.0 (RoB 2.0) for randomized trials. We included seven studies involving 3,130 participants. The mean or median participant age ranged from 60.8 to 82 years, and female representation ranged from 38% to 50%. SDM quality was moderate (9-item Shared Decision-Making Questionnaire (SDM-Q-9): 52.5 ± 27.8/100) and improved with alternative education (β = 8.2; 95% CI: 0.7-15.7; p = 0.03). Treatment preference concordance was significant, with 68% choosing home-based dialysis and 83% starting their preferred modality. SDM was associated with lower odds of unscheduled dialysis initiation (33.3% vs. 66.7%; adjusted OR = 0.19; 95% CI: 0.07-0.47; p = 0.001) and increased peritoneal dialysis (PD) uptake (27.3% overall; 27.27% vs. 13.33% in conventional care). Decision-aid use increased patient-family agreement from κ = 0.25 to κ = 0.63. While knowledge of conservative kidney treatment was only 7% at baseline, supportive care knowledge rose from 2.02 ± 0.96 to 2.36 ± 0.93 (p < 0.01). Additionally, 76.2% of participants preferred early disclosure of kidney failure risk (p = 0.03). Frailty (HR = 6.42; p = 0.001) and BMI <25 kg/m² (HR = 2.84; p = 0.01) were associated with increased mortality. Intervention acceptability was high, with 98% satisfaction, 96% perceived usefulness, and 52.2% spending >20 minutes using decision-support tools. In advanced CKD, SDM and decision-support interventions may improve treatment alignment, patient understanding, involvement, and care planning, supporting their potential incorporation into standard nephrology practice.