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Andrei Javier, MD and colleagues article published in American Journal of Kidney Disease

July 21st 2017

Dr Javier works along Dr. Abdel-Kader in his clinical trials.Here is a brief description of the research that interests Dr. Abdel-Kader

Dr. Abdel-Kader's research interests include quality of life in chronic kidney disease (CKD), quality of care in non-dialysis dependent CKD, health information technology including electronic health records (EHR) and clinical decision support systems (CDSS). His prior work includes assessing patient centered outcomes in CKD, characterizing quality of CKD care in the primary care setting, and examining interventions to improve CKD care delivery. He's received federal and foundational grants to fund this research including an ongoing career development award from the NIH. His publications have included manuscripts in the American Journal of Kidney Diseases, Clinical Journal of the American Society of Nephrology, and the Journal of Hypertension among others.

Title:  Reliability and Utility of the Surprise Question in CKD Stages 4 to 5.

Published in the American Journal of Kidney Disease

Javier AD1, Figueroa R2, Siew ED1, Salat H1, Morse J3, Stewart TG3, Malhotra R4, Jhamb M5, Schell JO6, Cardona CY7, Maxwell CA8, Ikizler TA1, Abdel-Kader K9.



Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown.


Observational study.


388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic.


Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.


Mortality, test-retest reliability, and blinded inter-rater reliability.


Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin).


Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary).


Single center, small number of deaths.


The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.

Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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