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The benefits of kidney replacement therapy (KRT) are uncertain for many in this group. Supporting decisions between treatment options requires consideration of how people perceive chronic kidney disease and its treatments. This qualitative study aimed to explore how older patients and family members understand kidney function and failure, and how this impacts treatment decision-making.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Between September 2018 and July 2019, semi-structured interviews were conducted with older patients and family members recruited from three United Kingdom kidney units. Eligible patients had estimated glomerular filtration rate (eGFR)\u2009&lt;\u200915\u00a0ml\/min\/1.73m\n                      <jats:sup>2<\/jats:sup>\n                      , no previous KRT and were age\u2009\u2265\u200980 years, or \u2265\u200965 years with significant comorbidity. Interviews used a topic guide developed with patient input. Interview transcripts were analysed using inductive thematic analysis and constant comparative techniques.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Fifteen patients and 12 family members were interviewed. Three themes were identified: (i) Critical blood-cleaning organs, where kidney function was considered vital for survival; (ii) Unwitnessed function and failure, where kidney disease was experienced invisibly; and (iii) Quantifying and predicting kidney function, including conceptualisation of kidney function using numbers and graphs. Unwitnessed, intangible experiences of kidney failure appeared to accentuate reliance on clinicians for disease information. Numerical and graphical depictions of kidney function were central to formation of disease understanding. Concepts of treatment \u2018thresholds\u2019 appeared to affirm misperceptions of a binary choice between dialysis and death.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Unintended misunderstandings, including eGFR thresholds for dialysis initiation, arise from common clinical communication approaches and appear to impact upon informed decision-making. This is especially important for older patients with multiple conditions, for whom the benefits of dialysis are uncertain. Improved consultation approaches which enhance patient understanding are needed. Revising misleading terminology and shifting focus away from numerical disease metrics may help patients and families making individualised choices between treatments.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical trial number<\/jats:title>\n                    <jats:p>Not applicable.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12882-025-04541-1","type":"journal-article","created":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T10:32:35Z","timestamp":1762252355000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["How do older patients with advanced kidney disease, and their family members, understand kidney function and failure? 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All participants gave informed, written consent for participation in the study.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"All participants gave informed, written consent for their data (including quotation excerpts) to be published.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"FC is Chief Investigator, and LR and JC are co-investigators for the Prepare for Kidney Care Study, a randomised controlled trial comparing outcomes for older people preparing for kidney dialysis vs. CKM (https:\/\/www.hra.nhs.uk\/planning-and-improving-research\/application-summaries\/research-summaries\/prepare-for-kidney-care\/). LR is co-applicant of the NIHR Bristol Biomedical Research Centre (BRC). The authors have no other relationships\/activities\/interests related to the content of this manuscript to declare.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"613"}}