• Andrei D Javier, Rocio Figueroa, Edward D Siew, Huzaifah Salat, Jennifer Morse, Thomas G Stewart, Rakesh Malhotra, Manisha Jhamb, Jane O Schell, Cesar Y Cardona, Cathy A Maxwell, T Alp Ikizler, and Khaled Abdel-Kader.
• Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
• Am. J. Kidney Dis. 2017 Jul 1; 70 (1): 93-101.

BackgroundPrognostic 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.Study DesignObservational study.Setting & Participants388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic.PredictorTrinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.OutcomesMortality, test-retest reliability, and blinded inter-rater reliability.MeasurementsBaseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin).ResultsMedian 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).LimitationsSingle center, small number of deaths.ConclusionsThe 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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