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Background. Chronic kidney disease (CKD) is associated with an elevated risk of all-cause mortality, with cardiovascular death being extensively investigated. However, non-cardiovascular mortality represents the biggest percentage, showing an evident increase in recent years. Klotho is a gene highly expressed in the kidney, with a clear influence on lifespan. Low levels of Klotho have been linked to CKD progression and adverse outcomes. Single nucleotide polymorphisms (SNPs) of the Klotho gene have been associated with several diseases, but studies investigating the association of Klotho SNPs with noncardiovascular death in CKD populations are lacking. Methods. The main aim of this study was to assess whether 11 Klotho SNPs were associated with non-cardiovascular death in a subpopulation of the National Observatory of Atherosclerosis in Nephrology (NEFRONA) study (n ¼ 2185 CKD patients). Results. After 48 months of follow-up, 62 cardiovascular deaths and 108 non-cardiovascular deaths were recorded. We identified a high non-cardiovascular death risk combination of SNPs corresponding to individuals carrying the most frequent allele (G) at rs562020, the rare allele (C) at rs2283368 and homozygotes for the rare allele (G) at rs2320762 (rs562020 GG/AG þ rs2283368 CC/CT þ rs2320762 GG). Among the patients with the three SNPs genotyped (n ¼ 1016), 75 (7.4%) showed this combination. Furthermore, 95 (9.3%) patients showed a low-risk combination carrying all the opposite genotypes (rs562020 AA þ rs2283368 TT þ rs2320762 GT/TT). All the other combinations [n ¼ 846 (83.3%)] were considered as normal risk. Using competing risk regression analysis, we confirmed that the proposed combinations are independently associated with a higher fhazard ratio [HR] 3.28 [confidence interval (CI) 1.51-7.12]g and lower [HR 6 × 10-6 (95% CI 3.3 × 10-7-1.1 × 10-5)] risk of suffering a non-cardiovascular death in the CKD population of the NEFRONA cohort compared with patients with the normal-risk combination. Conclusions. Determination of three SNPs of the Klotho gene could help in the prediction of non-cardiovascular death in CKD. © The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

La implantación del proceso de planificación anticipada de cuidados y del documento de voluntades anticipadas (DVA) es escasa en España. Por este motivo, el Grupo de Ética y Nefrología de la Sociedad Española de Nefrología (S.E.N.) elaboró una encuesta para conocer la opinión de los pacientes en programa de diálisis sobre el DVA y otras situaciones relacionadas con el fin de la vida. Los pacientes recibieron documentación explicativa sobre la naturaleza y significado del DVA y un cuestionario sobre su conocimiento y aceptación. Se recogió su punto de vista sobre diversos aspectos relacionados con el fin de la vida. La encuesta se realizó en siete unidades de diálisis hospitalarias con un total de 416 pacientes en diálisis en activo. El cuestionario se entregó a 265 pacientes, 154 contestaron la encuesta, el 69,2% respondió sin ayuda. El grado de implantación del DVA era muy bajo (7,9%) y también la designación de representante (6,6%). Los pacientes tenían una idea muy clara sobre sus deseos ante situaciones como coma irresoluble, estado vegetativo, demencia irreversible y enfermedad grave no tratable y más de un 65% no deseaban que se les aplicaran ventilación mecánica, alimentación por sonda, diálisis o maniobras de resucitación en caso de parada cardiorrespiratoria. Muchos opinaron que el DVA podría hacerse antes de comenzar el tratamiento de diálisis, pero la mayoría consideró que sólo debería ofrecerse a aquellas personas que lo pidieran (el 65 frente al 34%). En conclusión, los pacientes en diálisis tienen una postura bastante definida ante diversas situaciones asociadas con el fin de la vida, sin embargo esta voluntad no está reflejada documentalmente debido a la escasa implantación de los DVA. Advance care planning (ACP) and the subsequent advance directive document (ADD), previously known as "living wills", have not been widely used in Spain. The Ethics Group from the Spanish Society of Nephrology has developed a survey in order to investigate the opinion of dialysis patients regarding the ADD and end-of-life care. Patients received documentation explaining ACP and filled out a survey about their familiarity with and approval of the ADD. Seven hospital dialysis centres participated in the study for a total of 416 active dialysis patients. Questionnaires were distributed to 263 patients, 154 of which answered (69.2% completed them without assistance). The rates for ADD implementation (7.9%) and designation of a representative person (6.6%) were very low. Most of the patients clearly expressed their wishes about irreversible coma, vegetative state, dementia and untreatable disease. More than 65% did not want mechanical ventilation, chronic dialysis, tube feeding or resuscitation if cardiorespiratory arrest occurred. They reported that an ADD could be done before starting dialysis but most thought that it should be offered only to those who requested it (65% vs 34%). In conclusion, patients have clear wishes about end-of-life care, although these desires had not been documented due to the very low implementation of the ADD.