The "Advancing American Kidney Health" Executive Order: Challenges and Opportunities for the Large Dialysis Organizations

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial)

BACKGROUND

Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients.

METHODS

An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients).

DISCUSSION

Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance

The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.

Capacity for the management of kidney failure in the International Society of Nephrology North America and the Caribbean region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

The International Society of Nephrology Global Kidney Health Atlas charts the availability and capacity of kidney care globally. In the North America and the Caribbean region, the Atlas can identify opportunities for kidney care improvement, particularly in Caribbean countries where structures for systematic data collection are lacking. In this third iteration, respondents from 12 of 18 countries from the region reported a 2-fold higher than global median prevalence of dialysis and transplantation, and a 3-fold higher than global median prevalence of dialysis centers. The peritoneal dialysis prevalence was lower than the global median, and transplantation data were missing from 6 of the 10 Caribbean countries. Government-funded payments predominated for dialysis modalities, with greater heterogeneity in transplantation payor mix. Services for chronic kidney disease, such as monitoring of anemia and blood pressure, and diagnostic capability relying on serum creatinine and urinalyses were universally available. Notable exceptions in Caribbean countries included non-calcium-based phosphate binders and kidney biopsy services. Personnel shortages were reported across the region. Kidney failure was identified as a governmental priority more commonly than was chronic kidney disease or acute kidney injury. In this generally affluent region, patients have better access to kidney replacement therapy and chronic kidney disease-related services than in much of the world. Yet clear heterogeneity exists, especially among the Caribbean countries struggling with dialysis and personnel capacity. Important steps to improve kidney care in the region include increased emphasis on preventive care, a focus on home-based modalities and transplantation, and solutions to train and retain specialized allied health professionals.

Pregnancies in Women With Kidney Failure on Home Dialysis in the United States

Introduction

Women with kidney failure have impaired fertility and are at a higher risk of maternal and fetal morbidity and mortality. Little is known about pregnancies in women receiving maintenance home dialysis in the United States.

Methods

Using data from the United States Renal Data System (USRDS), a cohort of 26,387 women aged 15 to 49 years with kidney failure receiving maintenance home dialysis from 2005 to 2018 was examined. We calculated pregnancy rates and identified factors, including the modality associated with pregnancy receiving home dialysis.

Results

Overall, 437 pregnancies were identified in 26,837 women on home dialysis. The unadjusted pregnancy rate was 8.6 per 1000 person-years (PTPY). The unadjusted pregnancy rate was higher on home hemodialysis (16.0 vs. 7.5 PTPY) than on peritoneal dialysis. Women receiving home hemodialysis had a higher adjusted likelihood of pregnancy than women receiving peritoneal dialysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.79-3.05). Compared with women aged 20 to 24 years, the likelihood of pregnancy was lower in women aged 30 to 34 years (HR, 0.64; 95% CI, 0.43-0.96), 35 to 39 years (HR, 0.53; 95% CI, 0.35-0.79), 40 to 44 years (HR, 0.32; 95% CI, 0.21-0.49), and 45 to 49 years (HR, 0.21; 95% CI, 0.13-0.33). Whereas Black women had a higher likelihood of pregnancy (HR, 1.40; 95% CI, 1.07-1.83), there was no difference in likelihood of pregnancy in Asian, Hispanic, and Native Americans as compared to Whites. Body mass index, cause of kidney failure, socioeconomic status, rurality, predialysis nephrology care, or dialysis vintage were not significantly associated with pregnancy on home dialysis.

Conclusion

The pregnancy rate in women with kidney failure undergoing home dialysis is higher with home hemodialysis than with peritoneal dialysis. Younger age and Black race or ethnicity are associated with a higher likelihood of pregnancy among women receiving home dialysis. This information can guide clinicians in preconception counselling and making informed treatment decisions for pregnant women on home dialysis.

Peritoneal Dialysis Catheter Complications after Insertion by Surgeons, Radiologists, or Nephrologists

SIGNIFICANCE STATEMENT

The Advancing American Kidney Health Initiative aims to increase rates of utilization of peritoneal dialysis (PD) in the United States. One of the first steps to PD is successful catheter placement, which can be performed by surgeons, interventional radiologists, or nephrologists. We examined the association between operator subspecialty and risk of needing a follow-up procedure in the first 90 days after initial PD catheter implantation. Overall, we found that 15.5% of catheters required revision, removal, or a second catheter placement within 90 days. The odds of requiring a follow-up procedure was 36% higher for interventional radiologists and 86% higher for interventional nephrologists compared with general surgeons. Further research is needed to understand how to optimize the function of catheters across different operator types.

BACKGROUND

The US government has implemented incentives to increase the use of PD. Successful placement of PD catheters is an important step to increasing PD utilization rates. Our objective was to compare initial outcomes after PD catheter placement by different types of operators.

METHODS

We included PD-naïve patients insured by Medicare who had a PD catheter inserted between 2010 and 2019. We examined the association between specialty of the operator (general surgeon, vascular surgeon, interventional radiologist, or interventional nephrologist) and odds of needing a follow-up procedure, which we defined as catheter removal, replacement, or revision within 90 days of the initial procedure. Mixed logistic regression models clustered by operator were used to examine the association between operator type and outcomes.

RESULTS

We included 46,973 patients treated by 5205 operators (71.1% general surgeons, 17.2% vascular surgeons, 9.7% interventional radiologists, 2.0% interventional nephrologists). 15.5% of patients required a follow-up procedure within 90 days of the initial insertion, of whom 2.9% had a second PD catheter implanted, 6.6% underwent PD catheter removal, and 5.9% had a PD catheter revision within 90 days of the initial insertion. In models adjusted for patient and operator characteristics, the odds of requiring a follow-up procedure within 90 days were highest for interventional nephrologists (HR, 1.86; 95% confidence interval [CI], 1.56 to 2.22) and interventional radiologists (odds ratio, 1.36; 95% CI, 1.17 to 1.58) followed by vascular surgeons (odds ratio, 1.06; 95% CI, 0.97 to 1.14) compared with general surgeons.

CONCLUSIONS

The probability of needing a follow-up procedure after initial PD catheter placement varied by operator specialty and was higher for interventionalists and lowest for general surgeons.

Evaluation of Curricula Content on Kidney Disease in US Doctor of Pharmacy Programs

Objective. Although pharmacists improve outcomes in the care of patients with kidney diseases and current guidelines advocate multidisciplinary care, pharmacist nephrology training is not well described. This study seeks to characterize required and elective coursework within US Doctor of Pharmacy curricula. This information will be valuable in identification and evaluation of educational gaps for pharmacists as best practices in the education and care of kidney diseases for pharmacists are established.Methods. This prospective, cross-sectional, descriptive study assessed current practices and trends in education on kidney diseases within Doctor of Pharmacy curricula at accredited programs in the United States through an electronic survey.Results. Forty-three percent (N=61) of all ACPE-accredited pharmacy institutions were represented in the survey. Content on kidney diseases was found to be taught in both required and elective coursework, and one-third of responding institutions offered advanced pharmacy practice experiences focused on kidney diseases. Variation was found in the amount of time allotted for the teaching of kidney diseases topics in pharmacy curricula and the types of experiential training offered. Six respondents reported offering postgraduate education that focused on kidney diseases. Most respondents were clinical faculty who had completed residency training and board certification.Conclusion. Given the complex interplay between kidney diseases and other health conditions, the increasing incidence and prevalence of kidney diseases, and the potential expansion of pharmacists' roles in the care of patients with kidney diseases, a review of current Doctor of Pharmacy curricula is necessary to guide any future optimization efforts to ensure practice-ready pharmacists.

Association Between Nephrologist Ownership of Dialysis Facilities and Clinical Outcomes

Importance

Ownership of US dialysis facilities presents a financial conflict of interest for nephrologists, who may change their clinical practice to improve facility profitability.

Objective

To investigate the association between nephrologist ownership of freestanding dialysis facilities and clinical outcomes.

Design, Setting, and Participants

This cross-sectional study was conducted using US Renal Data System data linked to a data set of freestanding nonpediatric dialysis facility owners. Participants were a sample of all adults with fee-for-service Medicare receiving dialysis for end-stage kidney disease from January 2017 to November 2017 at included facilities. Data were analyzed from April 2020 through August 2022.

Exposures

Outcomes associated with nephrologist ownership were assessed using a difference-in-differences analysis comparing the difference in outcomes between patients treated by nephrologist owners and patients treated by nonowners within facilities owned by nephrologists after accounting for differences in patient outcomes between nephrologist owners and nonowners in other facilities.

Main Outcomes and Measures

Outcomes plausibly associated with nephrologist ownership were evaluated: (1) treatment volumes (missed treatments and transplant waitlist status); (2) erythropoietin-stimulating agent (ESA) use and related outcomes (anemia, defined as hemoglobin level <10 g/dL, and blood transfusions), (3) quality metrics (mortality, hospitalizations, 30-day readmissions, hemodialysis adequacy, arteriovenous fistula use, and hemodialysis catheter use for ≥3 months), and (4) home dialysis use.

Results

A cohort of 251 651 patients (median [IQR] age, 66 [46-85] years; 112 054 [44.5%] women; 9765 Asian [3.9%], 86 837 Black [34.5%], and 148 617 White [59.1%]; 38 938 Hispanic [15.5%]) receiving dialysis for end-stage kidney disease were included. Patient treatment by nephrologist owners at their owned facilities was associated with a 2.4 percentage point (95% CI, 1.1-3.8 percentage points) higher probability of home dialysis, a 2.2 percentage point (95% CI, 3.6-0.7 percentage points) lower probability of receiving an ESA, and no significant difference in anemia or blood transfusions. Patient treatment by nephrologist owners at their owned facilities was not associated with differences in missed treatments, transplant waitlisting, mortality, hospitalizations, 30-day readmissions, hemodialysis adequacy, or fistula or long-term dialysis catheter use.

Conclusions and Relevance

This cross-sectional cohort study found that nephrologist ownership was associated with increased home dialysis use, decreased ESA use, and no change in anemia or blood transfusions.

Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients

Peritoneal dialysis (PD) patients are at high risk for peritonitis, an infection of the peritoneum that affects 13% of PD users annually. Relying on subjective peritonitis symptoms results in delayed treatment, leading to high hospitalisation costs, peritoneal scarring, and premature transition to haemodialysis. We have developed and tested a low-cost, easy-to-use technology that uses microscopy and image analysis to screen for peritonitis across the effluent drain tube. Compared to other technologies, our prototype is made from off-the-shelf, low-cost materials. It can be set up quickly and key stakeholders believe it can improve the overall PD experience. We demonstrate that our prototype classifies infection-indicating and healthy white blood cell levels in clinically collected patient effluent with 94% accuracy. Integration of our technology into PD setups as a screening tool for peritonitis would enable earlier physician notification, allowing for prompt diagnosis and treatment to prevent hospitalisations, reduce scarring, and increase PD longevity. Our findings demonstrate the versatility of microscopy and image analysis for infection screening and are a proof of principle for their future applications in health care.

Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings

Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.

The Knowledge Assessment of Renal Transplantation (KART) 2.0: Development and Validation of CKD and Transplant Knowledge Scales

BACKGROUND AND OBJECTIVES

Many individuals with kidney disease, particularly those belonging to racial and ethnic minority groups and whose primary language is not English, lack knowledge related to kidney disease symptoms, physiologic functions of the kidney, and benefits and risks of kidney transplantation. Valid instruments to assess patients' knowledge of CKD and kidney transplantation are needed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using a sample of 977 patients with stages 3-5 CKD in the Kaiser Permanente health system, we developed the Knowledge Assessment of Renal Transplantation (KART) 2.0 instrument. We conducted cognitive interviews followed by item response theory (IRT) to reduce 48 candidate items. Construct validity was tested by examining differences in scores between patients who spent <1 and ≥1 hour receiving CKD and transplant education.

RESULTS

Cognitive interviews modified four items and omitted 11. IRT analyses resulted in two scales: the KART 2.0-Transplant Knowledge Scale (16 items; Cronbach's α=0.8) and the KART 2.0-CKD Knowledge Scale (nine items; Cronbach's α=0.79). Differential item functioning showed that the scales were unbiased to capture knowledge across self-identified race, primary language, CKD stage, and sex. Both scales distinguished patients who had spent <1 and ≥1 hour speaking with health professionals (effect size [ES]=0.33 [transplant], 0.54 [CKD]; P<0.001 for both), reading about kidney disease (ES=0.45 [transplant], 0.62 [CKD]; P<0.001), reading about kidney transplantation (ES=0.67 [transplant], 0.69 [CKD]; P<0.001), and reading about living donor kidney transplant (ES=0.76 [transplant], 0.62 [CKD]; P<0.001).

CONCLUSIONS

The KART 2.0 is a valid tool to assess patients' knowledge of CKD and kidney transplantation.

Hidden Costs Associated with Conversion from Peritoneal Dialysis to Hemodialysis

Background

Increasing use of peritoneal dialysis (PD) will likely lead to increasing numbers of patients transitioning from PD to hemodialysis (HD). We describe the characteristics of patients who discontinued PD and converted to HD, trajectories of acute-care encounter rates and the total cost of care both before and after PD discontinuation, and the incidence of modality-related outcomes after PD discontinuation.

Methods

We analyzed data in the United States Renal Data System to identify patients aged ≥12 years who were newly diagnosed with ESKD in 2001-2017, initiated PD during the first year of ESKD, and discontinued PD in 2009-2018. We estimated monthly rates of hospital admissions, observation stays, emergency department encounters, and Medicare Parts A and B costs during the 12 months before and after conversion from PD to HD, and the incidence of home HD initiation, death, and kidney transplantation after conversion to in-facility HD.

Results

Among 232,699 patients who initiated PD, there were 124,213 patients who discontinued PD. Among them, 68,743 (55%) converted to HD. In this subgroup, monthly rates of acute-care encounters and total costs of care to Medicare sharply increased during the 6 months preceding PD discontinuation, peaking at 96.2 acute-care encounters per 100 patient-months and $20,701 per patient in the last month of PD. After conversion, rates decreased, but remained higher than before conversion. Among patients who converted to in-facility HD, the cumulative incidence of home HD initiation, death, and kidney transplantation at 24 months was 3%, 25%, and 7%, respectively.

Conclusions

The transition from PD to HD is characterized by high rates of acute-care encounters and health-care expenditures. Quality improvement efforts should be aimed at improving transitions and encouraging both home HD and kidney transplantation after PD discontinuation.

Positive effect of home hemodialysis in a pregnant woman with chronic kidney failure during the COVID-19 pandemic: A case report

This report discusses the case of a 25-year-old pregnant woman from an underserved community, with two previous failed kidney transplants and a previous miscarriage. The patient required a progressive increase to 30 h a week of in-hospital hemodialysis during the COVID-19 pandemic lockdown. She delivered her baby while transitioning to home hemodialysis. Women with end-stage kidney disease who require hemodialysis and wish to become pregnant or who are pregnant have options to allow for a safe and healthy delivery. This can be achieved with vigorous hemodialysis, even at home.

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Women with end-stage kidney disease who require hemodialysis and attempting to become pregnant have options to allow for a safe and healthy delivery.

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A safe and healthy delivery can be achieved with vigorous hemodialysis, even at home.

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It may be possible for patients to transition to home hemodialysis from in-center hemodialysis.

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New types of healthcare barriers arose during the COVID-19 pandemic.