ExPAND Project

Expanding and Promoting Alternative Care and Knowledge in Decision-making (ExPAND) Trial

The ExPAND project, led by Drs. Dale Lupu and Alvin Moss, aims to compare two health system-based approaches for providing kidney failure treatment options to older patients with kidney failure. The goal is to ensure that these patients are actively involved in a shared decision-making (SDM) process covering a full range of choices. This way, they will have meaningful access to the full range of choices available to them.

Annually, over 130,000 patients with kidney failure start dialysis, and older patients constitute the fastest-growing segment. Unfortunately, frail patients or those who have other serious medical conditions may not live longer with dialysis than without it. U.S. healthcare policy has created a powerful "dialysis default," where virtually all patients with kidney failure who do not receive a transplant are treated with a standard dialysis regimen in a dialysis center, regardless of whether it will help them live any longer or better. 

It is important to note that about 20% of patients regret the decision to start dialysis, yet non-dialysis alternatives are rarely offered to them. Most patients report being unaware that they had a choice about kidney failure treatment. Older patients with kidney disease often value independence over staying alive longer, but most nephrologists are not aware of their patients' values and do not offer alternatives to standard dialysis, such as active medical management without dialysis (AMMWD), a time-limited trial of dialysis (TLT), palliative dialysis, or deciding not to decide (DND) until a later date.

Shared decision-making is recognized as the preferred approach to implementing patient-centered care and ensuring that patients receive treatment that matches their goals. There is an urgent need for strategies to increase the adoption and implementation of SDM in nephrology practices and elsewhere in healthcare systems where CKD patients receive care.


The ExPAND project is a collaboration between the GW School of Nursing, West Virginia University School of Medicine, the University of Bristol, the Coalition for the Supportive Care of Kidney Patients (CSCKP), and nine nephrology practices: