Education in Nephrology Fellowship: A Survey-Based Needs Assessment

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Peritoneal dialysis in the Arabian Gulf countries: Challenges and opportunities

The Gulf Cooperation Council (GCC) is a regional organisation, consisting of six Arab countries that share common objectives and cultural identities, with a total population of 57.3 million. The prevalence of patients requiring dialysis in GCC countries is increasing, with a current mean prevalence of 551 per million population. Despite the several patient-level and healthcare system benefits of peritoneal dialysis (PD) compared to in-centre haemodialysis, the growth in PD utilisation has been limited. This is related to several factors, including deficiencies in modality education for chronic kidney disease patients, nephrology training and governmental policies advocating for this dialysis modality. Establishing a detailed PD registry in GCC countries is an important step towards understanding our patients' characteristics, outcomes, current PD practices and challenges in order to increase the use of PD and to facilitate future initiatives aimed at optimising the management of PD patients in this part of the world. This article reviews common challenges around PD practices and utilisation in GCC countries and provides possible solutions to overcome these challenges. It should be noted that the literature on PD patients, outcomes and treatment practices in GCC countries is limited, and as a result, many of our recommendations and discussion are based on clinical observations, experience and data when available.

American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis, which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review

End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.

Reimagining Nephrology Fellowship Education to Meet the Future Needs of Nephrology: A Report of the American Society of Nephrology Task Force on the Future of Nephrology

The American Society of Nephrology (ASN) Task Force on the Future of Nephrology was established in April 2022 in response to requests from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education regarding training requirements in nephrology. Given recent changes in kidney care, ASN also charged the task force with reconsidering all aspects of the specialty's future to ensure that nephrologists are prepared to provide high-quality care for people with kidney diseases. The task force engaged multiple stakeholders to develop 10 recommendations focused on strategies needed to promote: ( 1 ) just, equitable, and high-quality care for people living with kidney diseases; ( 2 ) the value of nephrology as a specialty to nephrologists, the future nephrology workforce, the health care system, the public, and government; and ( 3 ) innovation and personalization of nephrology education across the scope of medical training. This report reviews the process, rationale, and details (the "why" and the "what") of these recommendations. In the future, ASN will summarize the "how" of implementing the final report and its 10 recommendations.

Engagement in Free Open Access Medical Education by US Nephrology Fellows

BACKGROUND

As free open access medical education (FOAMed) use increases, it is important to characterize how and why learners are using this educational material in nephrology. We describe the frequency, purpose, and type of FOAMed usage across US nephrology fellows.

METHODS

In this cross-sectional survey, items were emailed to all US adult and pediatric nephrology fellows via the American Society of Nephrology (ASN) Fellow Survey in May 2022. The eight-item survey, developed to measure FOAMed engagement, had previously undergone instrument validation. The results were analyzed by descriptive statistics.

RESULTS

In total, 43% (359/842) adult nephrology fellows and 51% (45/88) pediatric nephrology fellows completed the survey. Seventy-four percent (300/404) of fellows reported using FOAMed, and 72% (215/300) started using FOAMed within the past 2 years. Of FOAMed users, 41% (122/300) reported viewing FOAMed and 33% (99/300) reported applying knowledge gained from these resources daily or weekly. Common purposes for FOAMed engagement included searching Twitter to learn about others' opinions in the field (43%; 130/300), reading blogs to answer clinical questions (35%; 105/300), and listening to podcasts for the most up-to-date information (39%; 116/300). Compared with traditional educational resources, fellows preferred using FOAMed for staying up to date on nephrology topics (75%) and answering clinical questions (37%). Among all fellows, the greatest barriers to FOAMed use were unfamiliarity with FOAMed (27%; 111/404), validity concerns (22%; 90/404), and a lack of a local community of FOAMed users (22%; 87/404).

CONCLUSIONS

Seventy-four percent of nephrology fellows used FOAMed resources in a variety of ways, and of them, 33% of fellows clinically applied knowledge gained from these resources. Reasons for engaging with FOAMed varied across resources.

Clinical Experience Is Not a Proxy for Competence: Comparing Fellow and Medical Student Performance in a Breaking Bad News Simulation-Based Mastery Learning Curriculum

BACKGROUND

It is unknown whether traditional medical education ensures competence among fellows in the key skill of breaking bad news (BBN). While simulation-based mastery learning (SBML) has been used to train fourth-year medical students (M4s) in BBN, it is unclear if it adds similar value for fellows.

OBJECTIVE

We examined the effect of traditional medical training on BBN skills by comparing baseline fellow and M4 skills and confidence and assessed the impact of a BBN SBML curriculum for fellows.

METHODS

Fellows training in six programs at Northwestern University from November 2018 to May 2019 were eligible for inclusion. Fellows completed a BBN SBML curriculum including a pretest, individualized feedback using a previously published assessment tool, and ongoing deliberate practice until all achieved a minimum passing standard (MPS). The primary outcomes were checklist and scaled item scores on the assessment tool. Fellow performance was compared to a historical M4 cohort.

RESULTS

Twenty-eight of 38 eligible fellows completed the curriculum and were included for analysis. Fellows reported significantly more experience and confidence in BBN compared to M4s, yet their pre-training performance was significantly worse on checklist (57.1% vs 65.0%, P = .02) and scaled items; only 4% reached the MPS. After training, fellow performance significantly improved on checklist (57.1% to 92.6%, SD = 5.2%, P < .001) and scaled items; all reached the MPS.

CONCLUSIONS

Despite higher confidence and BBN clinical experience, fellows performed worse than untrained M4s, confirming that experience is not a proxy for skill. Programs must develop competency-based assessments to ensure entrustment of communication skills.

Peritoneal Dialysis in Critically Ill Patients: Time for a Critical Reevaluation?

Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led to widespread decline in the use of PD for AKI across high-income countries. The lack of familiarity and comfort with the use of PD in critical care settings has also led to lack of use even among those receiving maintenance PD. Many critical care units reflexively convert patients receiving maintenance PD to alternative dialysis therapies at admission. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries. In high-income countries, the coronavirus disease 2019 (COVID-19) pandemic, saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight advantages and disadvantages of PD in critical care settings and indications and contraindications for its use. We provide an overview of literature to support both PD treatment during AKI and its continuation as a maintenance therapy during critical illness. For AKI therapy, we further discuss establishment of PD access, PD prescription management, and complication monitoring and treatment. Finally, we discuss expansion in the use of PD for AKI therapy extending beyond its role during times of resource constraints.

Point-of-Care Ultrasound Use in Nephrology: A Survey of Nephrology Program Directors, Fellows, and Fellowship Graduates

Rationale & Objective

Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use.

Study Design

Anonymous, online survey.

Setting & Participants

All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program.

Analytical Approach

Descriptive.

Results

46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation.

Limitations

Loss of respondents as program directors and fellows progressed through the survey.

Conclusions

Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.

Teaching Conservative Kidney Management and Other Palliative Care Skills in Nephrology Fellowships

Offering and providing effective conservative kidney management (CKM) for patients with end-stage kidney disease who do not want dialysis is a foundational skill that all nephrology fellows should learn during fellowship training. However, the current educational landscape in fellowship training programs is sparse and is not recognized currently as a skill within the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Moreover, there is no standardized curriculum, methods of assessment of this learning objective, and no structure for implementation within general and subspecialty nephrology training programs. In this article, we discuss the current educational resources available for fellowship training programs, including interactive communication skills workshops such as NephroTalk, that address core concepts of CKM and assess communication skills and attitudes of trainees. Additional assessment tools should be prioritized when developing a CKM curriculum, including assessment of symptom management and medical knowledge acquisition. We propose that the ACGME nephrology milestones specifically highlight CKM as an important component within the ACGME nephrology milestones, thus ensuring that trainees understand how and when to offer CKM (knowledge), implement it effectively (skills), and conceptualize it as an appropriate course for patients in a number of varied situations (attitudes). We also outline a subspecialty pathway for palliative nephrology, to align with the recent American Society of Nephrology Task Force Recommendation to provide subspecialty training beyond core competencies, for those interested in pursuit of advanced training that ultimately can shape the CKM landscape in education and policy making.

Point-of-care ultrasonography in nephrology comes of age

The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology.

Current Trends and Challenges in Nephrology Fellowship Training: Expansion of Education in Home Dialysis, Palliative Care, and Point-of-Care Ultrasound

Nephrology education has changed significantly since the first nephrology fellowship programs were established in the United States in the 1950s and 1960s. The past several years have seen increased opportunities for subspecialization in areas such as interventional nephrology, onconephrology, and glomerular disease. Notable trends in fellowship curricula include the expansion of education in home dialysis and palliative care, driven by policy changes and focus on patient-centered care. In addition, point-of-care ultrasound has garnered significant interest due to its potential to provide diagnostic information that improves patient care. An important area that remains largely unaddressed appears to be education about the business and administrative aspects of nephrology. Meanwhile, the importance of training in hemodialysis catheter placement and kidney biopsy has come into question due to the small proportion of nephrologists performing these procedures today. Nephrology fellowship programs should strive to tailor their curriculum to meet the interests and needs of individual fellows.

Point-of-Care Ultrasound Training during Nephrology Fellowship: A National Survey of Fellows and Program Directors

BACKGROUND AND OBJECTIVES

Point-of-care ultrasound (POCUS)-performed by a clinician during a patient encounter and used in patient assessment and care planning-has many potential applications in nephrology. Yet, US nephrologists have been slow to adopt POCUS, which may affect the training of nephrology fellows. This study sought to identify the current state of POCUS training and implementation in nephrology fellowships.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Concise survey instruments measuring attitudes toward POCUS, its current use, fellow competence, and POCUS curricula were disseminated to (1) 912 US nephrology fellows taking the 2021 Nephrology In-Training Examination and (2) 229 nephrology training program directors and associate program directors. Fisher exact, chi-squared, and Wilcoxon rank sum tests were used to compare the frequencies of responses and the average responses between fellows and training program directors/associate program directors when possible.

RESULTS

Fellow and training program directors/associate program directors response rates were 69% and 37%, respectively. Only 38% of fellows (240 respondents) reported receiving POCUS education during their fellowship, and just 33% of those who did receive POCUS training reported feeling competent to use POCUS independently. Similarly, just 23% of training program directors/associate program directors indicated that they had a POCUS curriculum in place, although 74% of training program directors and associate program directors indicated that a program was in development or that there was interest in creating a POCUS curriculum. Most fellow and faculty respondents rated commonly covered POCUS topics-including dialysis access imaging and kidney biopsy-as "important" or "very important," with the greatest interest in diagnostic kidney ultrasound. Guided scanning with an instructor was the highest-rated teaching strategy. The most frequently reported barrier to POCUS program development was the lack of available instructors.

CONCLUSIONS

Despite high trainee and faculty interest in POCUS, the majority of current nephrology fellows are not receiving POCUS training. Hands-on training guided by an instructor is highly valued, yet availability of adequately trained instructors remains a barrier to program development.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_09_21_CJN01850222.mp3.

Regional variations in nephrology trainee confidence with clinical skills may relate to the availability of local training opportunities in the UK: results from a national survey

Background

The United Kingdom offers a standardised training program for nephrology fellows. However, local training opportunities vary resulting in mismatches between trainee interests and accessible opportunities. This may impact trainee confidence, satisfaction, and future service provision.

Methods

A survey assessing confidence with key procedures and sub-specialities was disseminated. Associations with region of training were probed using Chi square tests, with significance set at p < 0.0008 following a Bonferroni correction. Results were compared to trainee views on available opportunities for development.

Results

139 responses were received (32% response rate, demographics representative of the UK nephrology trainee cohort). Procedural independence varied from 98% for temporary femoral vascular catheters to 5% for peritoneal dialysis catheters (PDIs). Independence with inserting tunnelled vascular catheters varied with region (p < 0.0001). Trainees expressed a desire for formal training in kidney ultrasound scanning and PDIs, corresponding with procedures they had least opportunity to become independent with. Trainees felt least confident managing kidney disease in pregnancy. Suggestions for improving training included protected time for garnering sub-speciality knowledge, developing procedural skills and for experiencing practice in other nephrology units.

Conclusions

A mismatch between trainee interests and professional development opportunities exists, which may threaten trainee autonomy and impact patient care particularly with regards to peritoneal dialysis. Provisions to facilitate trainee directed development need to be made while balancing the rigors of service provision. Such measures could prove critical to promoting trainee well-being and preventing attrition within the nephrology workforce.

Urgent Start Peritoneal Dialysis: A Population-Based Cohort Study,

Rationale & Objective

It is a common practice to start patients in urgent need of dialysis on hemodialysis via a central venous catheter. Because central venous catheter use is associated with increased risk of infections, hospitalizations, and mortality, urgent start peritoneal dialysis (PD) increasingly represents a viable alternative. This study aimed to examine clinical outcomes, complications, mortality, and modality retention in patients who initiated urgent start PD.

Study Design

Retrospective cohort study.

Setting and Participants

Eighty-four adult members of a large integrated health care system who initiated urgent start PD between January 1, 2011, and December 31, 2014.

Exposure

Urgent start PD.

Outcomes

Retention rates at 30, 90, and 365 days; time to the development of noninfectious and infectious complications, modality failure, and all-cause mortality.

Analytical Approach

Cumulative incidence of all-cause mortality was estimated using the Kaplan-Meier method. Retention rates for PD were computed using binomial proportions.

Results

Occurrence of major complications was less than 5%. Catheter malfunction occurred in 6% of cases; of those, catheter patency could be established in 80%. Infectious complications occurred in 20% of patients who initiated PD and included peritonitis and exit site infections. At 365 days after initiation, the cumulative incidence of all-cause mortality was 9.7% (95% CI, 4.7%-19.4%). PD retention rates were 98.8%, 91.3%, and 80.0% at 30 days, 90 days, and 1 year, respectively.

Limitations

Retrospective cohort design, a well-matched comparable group of urgent start hemodialysis patients could not be identified, small number of patients in a single integrated health care system, uncertain or limited generalizability of findings to other health care systems.

Conclusions

At 1 year after initiation, patients who initiated urgent start PD had high survival and modality retention rates. In unplanned initiation of dialysis, urgent start PD is a viable and sustainable option and should be considered in selected patients to optimize care.

Nephrology Fellowship Clinician-Performed Ultrasound Curriculum

Fluid overload (FO) contributes significantly to the development of cardiovascular disease among patients with end-stage kidney disease (ESKD) on hemodialysis (HD), yet remains underappreciated due to limitations of the physical exam [1]. Lung ultrasound (US) is an established tool for quantification of FO [2]. Previous validation of quantitative lung US among nephrology attendings using a remote web-based lung ultrasound training has been demonstrated [3]. Interest in ultrasound education among nephrology fellows is high [4]. Clinician-performed ultrasound curricula for nephrology fellows have been described previously, however fellows’ competency in quantitative lung US has not been described [5]. In the present study we aimed to assess the current level of knowledge among nephrology fellows as well as the efficacy of a brief training course in quantitative lung US.

Nuts and Bolts of a POCUN Program

For those that have experienced how much point of care ultrasound can positively impact patient care, the potential of an organized point of care ultrasound program is moderated by the reality of building such a program from scratch. We have watched novice and intermediate users ride the roller coaster of ambition and reality checks at each of the hands-on skills sessions across the nation. The first climb occurs on the morning of Day 1. Anticipation grows over how hard it might be to learn this skill, then peaks and dips into the exhilaration of seeing success with what feels like minimal guidance. A comprehension of attainability takes over, and after each hands-on session, confidence climbs fast. Day 2 begins with the courage of some experience, and the anticipation of more success.

The Kidney Diet Challenge: An Experiential Educational Experience

Background

Health care providers who care for patients with CKD must be able to provide effective counseling about a kidney-friendly diet. Nutrition is underemphasized in medical curricula, and the kidney diet is one of the most challenging diets. We hypothesized that participation in an experiential educational program in kidney diet would result in improved knowledge of the underlying principles behind it and provide concrete examples of how to explain this diet to patients.

Methods

The first part of this study was a knowledge assessment administered to all US nephrology fellows during the 2020 National Board of Medical Examiners Nephrology In-Training Examination. We later opened the assessment to a broader, global audience via social media. Respondents included trainees, practicing nephrologists, dieticians, and other health professionals. Participants self-identified willingness to participate in the second part of the study, the Kidney Diet Challenge (KDC). The 5-day challenge included daily webinars by experts in nutrition. Daily surveys captured self-reported adherence to the diet. Social media was used to engage with participants. All participants received a follow-up knowledge assessment.

Results

Among the nephrology fellows (n=317), the median pretest score was 2 out of 5 (40%) questions correct, and results did not differ by year of training (P=0.31). Of the participants (n=70) who completed the 5-day challenge and responded to the post-challenge survey, the distribution of the number of correct answers improved after the KDC (median [25th, 75th percentile]: 3 [2, 3] versus 3 [2, 4]; P<0.001). Statistics from our official hashtag for this study (#kidneydietchallenge) showed that we achieved 406,241 reaches and 1,004,799 impressions, with a total of 974 posts using this hashtag.

Conclusions

The KDC is an immersive, experiential educational tool that enabled a global population to learn how to counsel their patients better about adherence to a complex kidney diet.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at the bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice, including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum, including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, is needed before POCUS training is universally incorporated across nephrology fellowship programs.

Evolving outcomes of peritoneal dialysis: secular trends at a single large center over three decades

Background

Peritoneal dialysis (PD) is improving as a renal replacement therapy for end-stage renal disease (ESRD) patients. We analyzed the main outcomes of PD over the last three decades at a single large-scale PD center with an established high-quality care system.

Methods

As a retrospective cohort study, we included participants (n = 1,203) who began PD between 1990 and 2019. Major PD-related outcomes were compared among the three 10-year cohorts.

Results

The 1,203 participants were 58.3% male with a mean age of 47.9 ± 13.8 years. The median PD treatment duration was 45 months (interquartile range, 19–77 months); 362 patients (30.1%) transferred to hemodialysis, 289 (24.0%) received kidney transplants, and 224 (18.6%) died. Overall, the 5- and 8-year adjust patient survival rates were 64% and 49%, respectively. Common causes of death included infection (n = 55), cardiac (n = 38), and cerebrovascular (n = 17) events. The 5- and 8-year technique survival rates were 77% and 62%, respectively, with common causes of technique failure being infection (42.3%) and solute/water clearance problems (22.7%). The 5-year patient survival significantly improved over time (64% for the 1990–1999 cohort vs. 93% for the 2010–2019 cohort). The peritonitis rate also substantially decreased over time, from 0.278 episodes/patient-year (2000–2004) to 0.162 episodes/patient-year (2015–2019).

Conclusion

PD is an effective treatment option for ESRD patients. There was a substantial improvement in the patient survival and peritonitis rates over time. Establishing adequate infrastructure and an effective system for high-quality PD therapy may be warranted to improve PD outcomes.

Developing the subspecialty of cardio-nephrology: The time has come. A position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology

Patients with the dual burden of chronic kidney disease (CKD) and cardiovascular disease (CVD) experience unacceptably high rates of morbidity and mortality, which also entail unfavorable effects on healthcare systems. Currently, concerted efforts to identify, prevent and treat CVD in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this position paper endorse the need for a dedicated interdisciplinary team of subspecialists in cardio-nephrology that manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for training programs, guidelines and best clinical practice models, and research funding from nephrology, cardiology and other professional societies, to support the development of the subspecialty of cardio-nephrology. This position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology (S.E.N.) is intended to be the starting point to develop the subspecialty of cardio-nephrology within the S.E.N.. The implementation of the subspecialty in day-to-day nephrological practice will help to diagnose, treat, and prevent CVD in CKD patients in a precise, clinically effective, and health cost-favorable manner.

An Introduction to Point-of-Care Ultrasound: Laennec to Lichtenstein

Point-of-care ultrasonography (POCUS) is rapidly evolving as a noninvasive adjunct to physical examination among various specialties. POCUS increases the sensitivity of conventional physical examination by providing the answers to simple clinical questions at the bedside. As such, it can reduce fragmentation of care and expedite management. In addition, using bedside ultrasound as the first-line investigation may eliminate unnecessary radiation and contrast exposure. The advent of highly portable and affordable ultrasound devices has made the use of POCUS more practical and user-friendly, making it the stethoscope of the 21st century. This review will provide an overview of the rationale for integrating POCUS into nephrology practice. We also discuss the current scope of POCUS practice and state of training.

Building and Maintaining an Ultrasound Program: It Takes a Village

Building and maintaining a successful point-of-care ultrasound program is a complex process that involves establishing an ecosystem between three unique but overlapping domains: ultrasound equipment, ultrasound users, and the health care system. By highlighting the different areas of focus and each of the key stakeholders and components, a group can ensure adequate attention is paid to all aspects of point-of-care ultrasound program development in nephrology.

Developing the subspecialty of cardio-nephrology: The time has come. A position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology

Patients with the dual burden of chronic kidney disease (CKD) and cardiovascular disease (CVD) experience unacceptably high rates of morbidity and mortality, which also entail unfavorable effects on healthcare systems. Currently, concerted efforts to identify, prevent and treat CVD in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this position paper endorse the need for a dedicated interdisciplinary team of subspecialists in cardio-nephrology that manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for training programs, guidelines and best clinical practice models, and research funding from nephrology, cardiology and other professional societies, to support the development of the subspecialty of cardio-nephrology. This position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology (S.E.N.) is intended to be the starting point to develop the subspecialty of cardio-nephrology within the S.E.N.. The implementation of the subspecialty in day-to-day nephrological practice will help to diagnose, treat, and prevent CVD in CKD patients in a precise, clinically effective, and health cost-favorable manner.

The peritoneal dialysis orders objective structured clinical examination (OSCE): A formative assessment for nephrology fellows

Background:

Peritoneal dialysis (PD) management is a fundamental nephrology skill, especially with the recent emphasis on home dialysis. We report a prospective multicentre cohort study of a formative objective structured clinical examination (OSCE) assessing competence in managing PD-associated bacterial peritonitis, using the unified model of construct validity.

Methods:

The OSCE was developed by the principal investigators and reviewed by two subject matter experts. The test committee (eight nephrologists and one PD nurse) assessed test item difficulty/relevance and determined passing score. There were 22 test items (7 evidence-based/standard-of-care questions). Passing score was 16/22 (73%). No item had median relevance less than ‘important’, and all were easy to medium difficulty. Content validity index was 0.91. Preliminary validation (16 board-certified volunteers): mean score was 19 ± 2, with 94% (15/16) passing. Kappa = 0.85 [95% confidence interval (CI) 0.77–0.94]. Cronbach’s α = 0.70.

Results:

Eighty-seven fellows (16 programmes) were tested; 67% passed. Fellows scored significantly less than validators: 17 ± 3 versus 19 ± 2, p < 0.001 [95% CI 1.2–3.6]. Eighty-six per cent of evidence-based/standard-of-care questions were answered correctly by validators versus 54% by fellows; p < 0.001. Ninety-three per cent of fellows recognized that sufficient criteria were present to diagnose peritonitis, but only 17% correctly indicated all three. Seventy-seven per cent recognized peritonitis-associated ultrafiltration failure, but only 17% prescribed 21 days of antibiotic treatment for gram-negative peritonitis. Eighty-five per cent of fellows surveyed agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Second-year in-training examination and OSCE scores were positively correlated (Pearson’s r = 0.57, p < 0.00).

Conclusions:

The OSCE may be used to formatively assess fellow proficiency in managing PD-associated peritonitis.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

Challenges and Opportunities in Expanding Home Hemodialysis for 2025

The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.

The use of virtual physician mentoring to enhance home dialysis knowledge and uptake

Home dialysis therapies are flexible kidney replacement strategies with documented clinical benefits. While the incidence of end-stage kidney disease continues to increase globally, the use of home dialysis remains low in most developed countries. Multiple barriers to providing home dialysis have been noted in the published literature. Among known challenges, gaps in clinician knowledge are potentially addressable with a focused education strategy. Recent national surveys in the United States and Australia have highlighted the need for enhanced home dialysis knowledge especially among nephrologists who have recently completed training. Traditional in-person continuing professional educational programmes have had modest success in promoting home dialysis and are limited by scale and the present global COVID-19 pandemic. We hypothesize that the use of a 'Hub and Spoke' model of virtual home dialysis mentorship for nephrologists based on project ECHO would support home dialysis growth. We review the home dialysis literature, known educational gaps and plausible educational interventions to address current limitations in physician education.

A hemodialysis curriculum for nephrology fellows using a blended learning approach: best of both worlds?

A comprehensive, hands-on hemodialysis curriculum during nephrology training is necessary for effective learning and optimal patient care. Traditional instructive approaches are unable to fully meet the needs of the digitally inclined learner and are limited by time constraints and increasing clinical workload. Internet based learning (E-learning) is becoming increasingly popular in medical education and nephrology and gaining even greater relevance in the COVID era. However, it presents technical challenges and may create an environment of social isolation. A ‘blended learning approach’ combines E-learning with traditional methods of teaching and offers advantages over either approach alone. We have designed and implemented a formalized hemodialysis curriculum at our institution that is based on blended learning, utilizing faculty-created E-learning tools combined with traditional pedagogical methods (bed-side and classroom). The web-based tools discuss hemodialysis adequacy, principles of urea transport, hemodialysis access examination and access complications. These tools are open access and structured around the science of cognitive learning using animation, interactivity, self-assessment and immediate feedback features. They have been viewed by a wide audience of nephrologists, dialysis nurses as well as medicine house-staff and have received strong validation in a post-test survey. The online tools have supported a ‘flipped classroom’ instructive model and our blended curriculum has been successfully used for nephrology fellow training at our institution. Incorporating faculty designed/approved E-learning tools to create a ‘blended’ nephrology curriculum for trainees at various levels of medical education, can help streamline active and time-efficient learning, with the goal of improving learner engagement, knowledge acquisition and academic curiosity in the field.

'I hear and I forget. I see and I remember. I do and I understand.'- incorporating high-fidelity medical simulation into the undergraduate nephrology course

Background

Medical simulation is a teaching method, which enables the development of clinical skills by implementing a simulation scenario in a true-to-life environment, but without exposing patients to any risk. So far, there has been no information on the use of high-fidelity simulation in undergraduate clinical nephrology teaching. Aim of this study was to analyze students' opinions and reactions to the simulation module in nephrology.

Methods

The survey consisting of the Satisfaction with Simulation Experience Scale (SSES) and open-ended question concerning the overall impression of classes was conducted among 103 5^th year medical students, who took part in the simulation training in nephrology. SSES consisted of three parts (debriefing, reasoning, education). Statements from the open-ended question were interpreted by means of the Atlas.ti software for qualitative data analysis.

Results

The overall score for simulation classes was 4.39 ± 0.69 points. Students rated debriefing, reasoning and education at 4.43 ± 0.78, 4.32 ± 0.7 and 4.39 ± 0.73 points, respectively. 87.4% and 84.5% of participants agreed that simulation developed their 'clinical reasoning' and 'decision-making' skills in nephrology, respectively.

Thematic analysis revealed that students evaluated the module as 'interesting', 'useful' and 'informative', but they found number of classes significantly insufficient. Students pointed out that due to the small emphasis placed on practical aspects in the existing curriculum e.g. routes of drug administration and conversion of doses, they could not fully benefit from simulation.

Conclusion

Medical simulation is a valuable constituent of the nephrology course. Putting greater emphasis on practical aspects from the beginning of training may enable students to benefit more from simulation modules.

A Night Float System in Nephrology Fellowship: A Mixed Methods Evaluation

BACKGROUND

Johns Hopkins was an early adopter of an in-house nephrology fellowship night float to improve work-life balance. Our study aimed to elucidate attitudes to guide fellowship structuring.

METHODS

We performed a mixed-methods study surveying Johns Hopkins fellows, alumni, and faculty and conducting one focus group of current fellows. Surveys were developed through literature review, queried on a five-point Likert scale, and analyzed with t and ANOVA tests. The focus group transcript was analyzed by two independent reviewers.

RESULTS

Survey response rates were 14 (100%) fellows, 32 (91%) alumni, and 17 (94%) faculty. All groups felt quality of patient care was good to excellent with no significant differences among groups (range of means [SD], 4.1 [0.7]-4.6 [0.7]; P=0.12), although fellows had a statistically significantly more positive view than faculty on autonomy (4.6 [0.5] versus 4.1 [0.3]; P=0.006). Fellows perceived a positive effect across all domains of night float on the day team experience (range, 4.2 [0.8]-4.6 [0.6]; P<0.001 compared with neutral effect). Focus group themes included patient care, care continuity, professional development, wellness, and structural components. One fellow said, "…my bias is that every program would switch to a night float system if they could." All groups were satisfied with night float with 4.7 [0.5], 4.2 [0.8], and 4.0 [0.9] for fellows, faculty, and alumni, respectively; fellows were most enthusiastic (P=0.03). All three groups preferred night float, and fellows did so unanimously.

CONCLUSIONS

Night float was well liked and enhanced the perceived daytime fellow experience. Alumni and faculty were positive about night float, although less so, possibly due to concerns for adequate preparation to handle overnight calls after graduation. Night float implementation at other nephrology programs should be considered based on program resources; such changes should be assessed by similar methods.

Opportunities for Subspecialization in Nephrology

The interface between nephrology and other fields of medicine continues to expand. With the advent of novel therapies in cancer, diagnostics and therapeutics in lithology, novel devices in cardiology, advances in women's health issues, novel diagnostics and therapies in glomerular diseases, and the national priority in home-based dialysis, several subspecialties in nephrology have emerged. This article will discuss the subspecialties of onconephrology, cardionephrology, obstetric nephrology, uronephrology, glomerular disease specialization, and home-based dialysis in nephrology. We discuss the current state of each subspecialty, recommended educational content, length of training, available training opportunities, and potential career pathways for each.

The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

BACKGROUND AND OBJECTIVES

An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons.

RESULTS

Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias.

CONCLUSIONS

Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

Urgent start peritoneal dialysis: are we there yet?

The use of peritoneal dialysis (PD) has increased substantially in the United States (US) in the past decade. This was likely spurred in large part by the implementation of the expanded prospective payment system for the Medicare End Stage Renal Disease (ESRD) program in 2011. Over the same period, there has also been growing interest in urgent start PD, which is commonly defined as initiation of PD within 14 days of catheter insertion. Ye and colleagues recently reported their experience with urgent start PD in 2059 Chinese ESRD patients over a 9-year period. Rates of complications, including peri-catheter leaks and peritonitis, were very low despite initiation of PD immediately after open catheter placement via open laparotomy in nearly all patients. Long term technique survival was good, with only 75 patients developing catheter failure. This study provides further evidence to suggest that urgent start PD is feasible and effective, although the generalizability of these results to Western populations is unclear. Recent proposed changes to the payment models in the Medicare ESRD program, designed to incentivize use of kidney transplantation and home dialysis, are likely to further propel growth of PD and urgent start PD in the US. Further studies are needed to optimize use of urgent PD and patient outcomes.

[Amending of the 3rd cycle of medical studies in France: What the nephrologists stand for]

2017 was the year during which France has seen the amendment of the 3rd cycle of medical education. Three new steps have been uploaded: "basement", "in depth", and "liability". The latter has been particularly discussed as it is really close to the former post-graduate state. Nephrology has always been a very attractive discipline. While most others have been increased in terms of length in initial medical education, nephrology has been assigned to 4 years. Altogether, nephrologists whatever their generation have led a series of questionnaires we report here. From 3 of them, we had new data providing insights regarding both their feeling and knowledge about this amendment. Globally, they dissatisfy whatever the considered generation and they propose different modifications. The upcoming generation especially wants more options and tailored initial formation when older nephrologists are more prone to require one additional year for all. Whatever is chosen by state institutions, representative associations such as SNIN, CJN, and CUEN should act together as spokeperson to disseminate both nephrologists' wishes and information about what is coming.

Design, Dissemination, and Assessment of NephSIM: A Mobile-Optimized Nephrology Teaching Tool

BACKGROUND

Digital innovations have the potential to enhance current graduate medical education strategies.

OBJECTIVE

We assessed the scope, reach, and effectiveness of Nephrology Simulator (NephSIM), a free, mobile-optimized, nephrology educational tool designed to teach pathophysiology with a diagnostic approach using interactive cases.

METHODS

NephSIM, launched in June 2018, was designed as a mobile-optimized website with peer-reviewed content in WordPress. Content, including interactive cases with iterative feedback, infographics, and tutorials, was developed by nephrology fellows and attending nephrologists. The teaching tool was shared via an e-mail subscriber list and Twitter. Website usage data and Twitter analytics were reviewed. Case content was categorized, and the case completion rate was calculated. A self-report survey was sent to subscribers to assess their demographics and experience.

RESULTS

Thirty-four cases have been published to date and represent a variety of nephrology topics. There have been 100 745 page views between June 2018 and June 2019, representing 17 922 unique visitors from more than 100 countries. There are 1929 accounts that follow NephSIM on Twitter. Tweets received 124 200 impressions and a 3% engagement rate. Median case completion rate was 69% (interquartile range 64%-78%). Our survey response rate was 17% (76 of 445). Nearly all NephSIM users rated the platform highly in terms of satisfaction and usability, and planned to continue using in the future.

CONCLUSIONS

The development of a mobile-optimized, case-based teaching approach by nephrology fellows and faculty is feasible and has demonstrated global participation and high levels of learner satisfaction.

Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform

BACKGROUND AND OBJECTIVES

Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics.

RESULTS

Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; P<0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; P<0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; P<0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; P=0.004).

CONCLUSIONS

More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.

Trends Associated With Large-scale Expansion of Peritoneal Dialysis Within an Integrated Care Delivery Model

IMPORTANCE

Despite favorable national trends in the incidence of end-stage renal disease (ESRD) from 2008 to 2011, ESRD incidence has been increasing recently, and less than 10% of patients with ESRD start renal replacement therapy with peritoneal dialysis (PD) in the United States. Given known and potential advantages of PD over hemodialysis, the Kaiser Permanente Northern California integrated health care delivery system implemented a program to expand use of PD.

OBJECTIVES

To describe the system-level approach to expansion of PD use and temporal trends in initiation and persistence of PD and its associated mortality.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included adult members of a large integrated health care delivery system in Northern California who initiated chronic dialysis therapy from January 1, 2008, through December 31, 2018. Data were analyzed from March 1, 2018, through May 31, 2019.

EXPOSURE

From 2008 to 2018, Kaiser Permanente Northern California implemented a multidisciplinary, system-wide approach to increase use of PD that included patient and caregiver education, education and support tools for health care professionals, streamlined system-level processes, monitoring, and continuous quality improvement.

MAIN OUTCOMES AND MEASURES

Temporal trends in the proportion of patients starting chronic dialysis with PD vs hemodialysis compared with national trends. Secondary outcomes included persistence of PD at 1 year in those initiating it and standardized 1-year mortality rates in those initiating PD or hemodialysis.

RESULTS

Among 13 500 eligible health plan members in the study population (7840 men [58.1%] and 5660 women [41.9%]; mean [SD] age, 64.3 [14.4] years), initiation of PD increased from 165 of 1089 all new dialysis patients (15.2%) in 2008 to 486 of 1438 (33.8%) in 2018, which was substantially higher than national trends (6.1% in 2008 and 9.7% in 2016). Among the 2974 patients who initiated PD from 2008 to 2017, 2387 (80.3%) continued PD at 1 year after initiation, with a significant increase in age-, sex-, and race-standardized rates from 2008 (69.1%) to 2017 (84.2%). Age-, sex-, and race-standardized 1-year mortality for patients receiving PD and hemodialysis did not change significantly across this 10-year period (17.3% to 15.5% for hemodialysis, P = 0.89 for trend; and 5.5% to 7.3% for PD, P = 0.12 for trend).

CONCLUSIONS AND RELEVANCE

This study suggests that large-scale expansion of PD is feasible using a multidisciplinary, integrated, coordinated care approach; we believe these findings represent a national opportunity to improve outcomes for patients with advanced kidney disease.