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Weiner DE, Delgado C, Flythe JE, Forfang DL, Manley T, McGonigal LJ, McNamara E, Murphy H, Roach JL, Watnick SG, Weinhandl E, Willis K, Berns JS. Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024; 83:636-647. [PMID: 37972814 DOI: 10.1053/j.ajkd.2023.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/08/2023] [Accepted: 09/15/2023] [Indexed: 11/19/2023]
Abstract
Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.
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Affiliation(s)
| | - Cynthia Delgado
- San Francisco Veterans Affairs Health Care System and the University of California, San Francisco, CA
| | | | | | | | | | | | | | | | - Suzanne G Watnick
- Northwest Kidney Centers, Seattle, WA; University of Washington, Seattle, WA; Puget Sound VA, Seattle, WA
| | - Eric Weinhandl
- University of Minnesota, Minneapolis, MN; Satellite Healthcare, San Jose, CA
| | | | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Berns JS. What Is the Role of Daprodustat in Treatment of Anemia in People on Maintenance Dialysis? Clin J Am Soc Nephrol 2023; 18:1497-1499. [PMID: 37116458 PMCID: PMC10637450 DOI: 10.2215/cjn.0000000000000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Rosner MH, Manley CR, Hickey EV, Berns JS. Stakeholder Theory and For-Profit Dialysis: A Call for Greater Accountability. Clin J Am Soc Nephrol 2023; 18:1225-1227. [PMID: 36800521 PMCID: PMC10564339 DOI: 10.2215/cjn.0000000000000126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/08/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Mitchell H. Rosner
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia
| | - Charles R. Manley
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia
| | | | - Jeffrey S. Berns
- Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Reddy YN, Berns JS, Bansal S, Simon JF, Murray R, Jacob M, Perl J, Gould E. Home Dialysis Training Needs for Fellows: A Survey of Nephrology Program Directors and Division Chiefs in the United States. Kidney Med 2023; 5:100629. [DOI: 10.1016/j.xkme.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
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Lin E, McCoy MS, Liu M, Lung KI, Rapista D, Berns JS, Kanter GP. Association Between Nephrologist Ownership of Dialysis Facilities and Clinical Outcomes. JAMA Intern Med 2022; 182:1267-1276. [PMID: 36342723 PMCID: PMC9641593 DOI: 10.1001/jamainternmed.2022.5002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine of the University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Matthew S. McCoy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Manqing Liu
- Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts
| | - Khristina I. Lung
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Derick Rapista
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Jeffrey S. Berns
- Department of Medicine, Renal Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Genevieve P. Kanter
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Butler PD, Fowler JC, Meer E, Rosen IM, Reyes IM, Berns JS. A Blueprint for Increasing Ethnic and Racial Diversity in U.S. Residency Training Programs. Acad Med 2022; 97:1632-1636. [PMID: 35857407 DOI: 10.1097/acm.0000000000004847] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PROBLEM People who identify as African Americans, Latinos, or from indigenous backgrounds, are dramatically underrepresented in the U.S. physician workforce. It is critical for academic health centers to recognize racial and ethnic diversity at the residency level and implement changes to enhance diversity among trainees. APPROACH The Office of Graduate Medical Education (GME) at the University of Pennsylvania Health System (UPHS) developed a multipronged approach to enhance diversity and inclusion (D&I) among residency trainees. The approach included the development of an underrepresented in medicine (UIM) professional network; UIM-focused visiting clerkship programs; holistic review implementation by selection committees; and targeted outreach to UIM candidates, overseen by an associate designated institutional official for UIM Affairs. The authors reported demographic data on residency applicants invited for interviews and matching for all programs at UPHS from 2014-2015 (baseline) to 2020-2021. They also reported data on maximum ranking number programs reached to fill their positions and the average United States Medical License Examination (USMLE) Step 1 scores of matched candidates. Finally, they discussed the implications for leaders who wish to enhance D&I at academic health centers. OUTCOMES During the baseline year (2014-2015), UIMs represented 12.1% of interviewees and 8.7% of all matched candidates into UPHS residency programs. Over the successive 6 years after incremental implementation of the approach, UIM representation steadily increased. In 2020-2021, UIMs represented 23.2% of interviewees and 26.4% of matched candidates. Programs' maximum rank number to fill and USMLE Step 1 scores of matched candidates remained relatively unchanged. NEXT STEPS The UPHS Office of GME incorporated a purposeful approach to enhance the D&I of its residents. Across 6 years of implementation, UIM representation among resident matches tripled while quantitative program and candidate metrics remained unchanged. Similar efforts should be given further consideration for implementation and evaluation nationwide.
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Affiliation(s)
- Paris D Butler
- P.D. Butler is associate professor, Department of Surgery, and vice chair, Diversity, Equity, and Inclusion, Yale University School of Medicine, New Haven, Connecticut
| | - Jessica C Fowler
- J.C. Fowler is assistant professor, Department of Anesthesiology and Critical Care Medicine, and associate designated institutional official, Diversity and Inclusion, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elana Meer
- E. Meer is a resident physician, Department of Ophthalmology, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Ilene M Rosen
- I.M. Rosen is associate professor, Department of Internal Medicine, and assistant dean, Graduate Medical Education, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Iris M Reyes
- I.M. Reyes is professor, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- J.S. Berns is professor, Department of Internal Medicine, and vice president and associate dean, Graduate Medical Education, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Shulman R, Geara AS, Berns JS. Pamidronate versus zoledronic acid for the treatment of multiple myeloma–related hypercalcemia. Kidney Int 2022; 101:1086. [DOI: 10.1016/j.kint.2021.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 12/15/2021] [Indexed: 10/18/2022]
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Berns JS, Weng W, Jaar BG, Lipner RS, Brossman BG, McDonald FS. Analysis of Performance Trends from 2010-2019 on the American Board of Internal Medicine Nephrology Certifying Exam. J Am Soc Nephrol 2021; 32:2714-2723. [PMID: 34706969 PMCID: PMC8806090 DOI: 10.1681/asn.2021020160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/05/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. METHODS This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. RESULTS Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. CONCLUSIONS Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.
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Affiliation(s)
- Jeffrey S. Berns
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Renal, Electrolyte, and Hypertension Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Weifeng Weng
- American Board of Internal Medicine, Philadelphia, Pennsylvania
| | - Bernard G. Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland,Nephrology Center of Maryland, Baltimore, Maryland
| | | | | | - Furman S. McDonald
- American Board of Internal Medicine, Philadelphia, Pennsylvania,J. Edwin Wood Clinic of the Pennsylvania Hospital, Department of Medicine, Philadelphia, Pennsylvania
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Owei L, Luks VL, Brooks KD, Kelz RR, Berns JS, Aarons CB. Smart-phone Based Geofencing: A Novel Approach to Monitoring Clinical Work Hours in Surgery Residency. J Surg Educ 2021; 78:e210-e217. [PMID: 34294568 DOI: 10.1016/j.jsurg.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The Accreditation Council for Graduate Medical Education specifies strict requirements for clinical work hours during residency training, with serious consequences for violations. Self-reporting of work hours by trainees can be inaccurate due to recall bias, giving program directors limited data to influence change. We aimed to assess the impact of a smart-phone based geofencing application on submission rates for work hours and reported violations in a general surgery residency program at a university-based medical center. We also examined resident perceptions surrounding implementation and use of the application. METHODS We compared clinical work hours submitted and violations reported during the pilot period (October-November 2019) with the months prior to the launch of the application (July-August 2019). PGY1 and PGY2 residents were eligible to use the application during and after this pilot period. Semi-structured interviews were used to assess resident perceptions. A retrospective review was conducted to compare reporting during the same time period from the prior academic year (2018-2019) for historical reference. Paired t-tests were used to analyze the data. RESULTS Twenty-six residents (15 PGY1, 11 PGY2) were eligible for the intervention and 23 residents (88%) used the application. The mean number of violations reported decreased significantly during the pilot period compared with the months prior to the intervention (4.5 vs. 11, p = 0.04). The total rate of submissions was not significantly different after the intervention (85% vs. 82%, p = 0.42). The PGY1 mean submission rate decreased during the pilot period (91%-75%, p = 0.21) while the PGY2 submission rate increased (77%-91%, p = 0.07). Compared with historical data, there was an increase in overall total submission rates between academic years 2018/2019 and 2019/2020 (74% vs. 79%, p = 0.047) and an associated decrease in the mean number of monthly violations (14 vs. 6.25, p = 0.004). Thirteen (50%) residents (8 PGY1, 5 PGY2) volunteered for semi-structured interviews. Most participants found the application useful for recording and reporting clinical work hours. They noted an ease in the administrative burden as well as more accurate reporting associated with automated logging. Use of the application was not perceived to limit engagement with patient care; however, there were privacy concerns and some technical barriers were identified. The messaging regarding the application's use was identified as critical for implementation. CONCLUSIONS The "real-time" data provided by a geofencing application in our program helped to reduce the number of work-hour violations reported and did not diminish resident engagement with patient care. Decreasing the administrative burden of recording work hours coupled with improving transparency and accuracy of submissions may be important mechanisms.
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Affiliation(s)
- Lily Owei
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Valerie L Luks
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kendall D Brooks
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Department of Medicine, Division of Nephrology, and Office of Graduate Medical Education, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cary B Aarons
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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Feldman HI, Berns JS, Dember LM, Dorman NM. Celebrating 4 Decades of AJKD. Am J Kidney Dis 2021; 78:1-2. [PMID: 34167669 DOI: 10.1053/j.ajkd.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Harold I Feldman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Renal Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jeffrey S Berns
- Renal Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Laura M Dember
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Renal Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nijsje M Dorman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Wish JB, Eckardt KU, Kovesdy CP, Fishbane S, Spinowitz BS, Berns JS. Hypoxia-Inducible Factor Stabilization as an Emerging Therapy for CKD-Related Anemia: Report From a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2021; 78:709-718. [PMID: 34332007 DOI: 10.1053/j.ajkd.2021.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
The National Kidney Foundation convened an interdisciplinary international workshop in March 2019 to discuss the potential role of a new class of agents for the treatment of anemia in patients with chronic kidney disease (CKD): the hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). International experts with expertise in physiology, biochemistry, structural chemistry, translational medicine and clinical management of anemia participated. Participants reviewed the unmet needs of current anemia treatment, the biology of hypoxia-inducible factor, the pharmacology of prolyl hydroxylase inhibitors, and the results of phase 2 clinical trials of HIF-PHIs among patients with both non-dialysis dependent and dialysis-dependent CKD. The results of key phase 3 clinical trials of HIF-PHIs in the public domain as of this writing are also presented in this article although they appeared after the workshop was completed. Participants in the workshop developed a number of recommendations for further examination of HIF-PHIs which are summarized in this article and include long-term safety issues, potential benefits, and practical considerations for implementation including patient and provider education.
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Affiliation(s)
- Jay B Wish
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Csaba P Kovesdy
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Bruce S Spinowitz
- Department of Medicine, New York Hospital Queens, Cornell University Medical Center, Queens, NY, USA
| | - Jeffrey S Berns
- Department of Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Ziemba JB, Berns JS, Huzinec JG, Bammer D, Salva C, Valentine E, Myers JS. The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment. Acad Med 2021; 96:997-1001. [PMID: 33735131 DOI: 10.1097/acm.0000000000004064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PROBLEM The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania. APPROACH The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process. OUTCOMES A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation. NEXT STEPS The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.
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Affiliation(s)
- Justin B Ziemba
- J.B. Ziemba is assistant professor and assistant program director, Division of Urology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: http://orcid.org/0000-0002-0962-2055
| | - Jeffrey S Berns
- J.S. Berns is associate dean for graduate medical education and professor, Division of Renal-Electrolyte and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jill G Huzinec
- J.G. Huzinec is former director of patient safety, Department of Clinical Effectiveness and Quality Improvement, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Dina Bammer
- D. Bammer is nursing professional development specialist, Department of Nursing Professional Development, Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Catherine Salva
- C. Salva is associate professor and program director, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Valentine
- E. Valentine is associate professor and patient safety officer, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Myers
- J.S. Myers is professor, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Toto R, Petersen J, Berns JS, Lewis EF, Tran Q, Weir MR. A Randomized Trial of Strategies Using Darbepoetin Alfa To Avoid Transfusions in CKD. J Am Soc Nephrol 2021; 32:469-478. [PMID: 33288629 PMCID: PMC8054895 DOI: 10.1681/asn.2020050556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Exposure to high doses or a high cumulative dose of erythropoiesis-stimulating agents (ESAs) may contribute to cardiovascular events in patients with CKD and anemia. Whether using a low fixed ESA dose versus dosing based on a hemoglobin-based, titration-dose algorithm in such patients might reduce risks associated with high ESA doses and decrease the cumulative exposure-while reducing the need for red blood cell transfusions-is unknown. METHODS In this phase-3, randomized trial involving 756 adults with stage-3 to -5 CKD and anemia, we evaluated incidence of red blood cell transfusions for participants randomized to receive darbepoetin given as a fixed dose (0.45 µg/kg every 4 weeks) versus administered according to a hemoglobin-based, titration-dose algorithm, for up to 2 years. Participants received transfusions as deemed necessary by the treating physician. RESULTS There were 379 patients randomized to the fixed-dose group, and 377 to the titration-dose group. The percentage of participants transfused did not differ (24.1% and 24.4% for the fixed-dose and titration-dose group, respectively), with similar time to first transfusion. The titration-dose group achieved significantly higher median hemoglobin (9.9 g/dl) compared with the fixed-dose group (9.4 g/dl). The fixed-dose group had a significantly lower median cumulative dose of darbepoetin (median monthly dose of 30.9 µg) compared with the titration-dose group (53.6 µg median monthly dose). The FD and TD group received a median (Q1, Q3) cumulative dose per 4 weeks of darbepoetin of 30.9 (21.8, 40.0) µg and 53.6 (31.1, 89.9) µg, respectively; the median of the difference between treatment groups was -22.1 (95% CI, -26.1 to -18.1) µg. CONCLUSIONS These findings indicate no evidence of difference in incidence of red blood cell transfusion for a titration-dose strategy versus a fixed-dose strategy for darbepoetin. This suggests that a low fixed dose of darbepoetin may be used as an alternative to a dose-titration approach to minimize transfusions, with less cumulative dosing.
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Affiliation(s)
- Robert Toto
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Jeffrey S. Berns
- Perelman School of Medicine at the University of Pennsylvania and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Qui Tran
- Amgen Inc., Thousand Oaks, California
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Affiliation(s)
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Clarence H Braddock
- David Geffen School of Medicine at the University of California, Los Angeles
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15
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Berns JS, Brennan PJ. Helping Medical Trainees Understand the Financial Health of Training Institutions. Acad Med 2020; 95:1630. [PMID: 33109968 DOI: 10.1097/acm.0000000000003664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Jeffrey S Berns
- Associate dean for graduate medical education and designated institutional official, University of Pennsylvania Health System, Philadelphia, Pennsylvania;
| | - Patrick J Brennan
- Chief medical officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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16
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Potluri VS, Sawinski D, Tam V, Shults J, Cohen JB, Wiebe DJ, Shah SP, Berns JS, Reese PP. Effect of Neighborhood Food Environment and Socioeconomic Status on Serum Phosphorus Level for Patients on Chronic Dialysis. J Am Soc Nephrol 2020; 31:2622-2630. [PMID: 32917783 DOI: 10.1681/asn.2020030290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/20/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Elevated blood phosphorus levels are common and associated with a greater risk of death for patients receiving chronic dialysis. Phosphorus-rich foods are prevalent in the American diet, and low-phosphorus foods, including fruits and vegetables, are often less available in areas with more poverty. The relative contributions of neighborhood food availability and socioeconomic status to phosphorus control in patients receiving dialysis are unknown. METHODS Using longitudinal data from a national dialysis provider, we constructed hierarchical, linear mixed-effects models to evaluate the relationships between neighborhood food environment or socioeconomic status and serum phosphorus level among patients receiving incident dialysis. RESULTS Our cohort included 258,510 patients receiving chronic hemodialysis in 2005-2013. Median age at dialysis initiation was 64 years, 45% were female, 32% were Black, and 15% were Hispanic. Within their residential zip code, patients had a median of 25 "less-healthy" food outlets (interquartile range, 11-40) available to them compared with a median of four "healthy" food outlets (interquartile range, 2-6). Living in a neighborhood with better availability of healthy food was not associated with a lower phosphorus level. Neighborhood income also was not associated with differences in phosphorus. Patient age, race, cause of ESKD, and mean monthly dialysis duration were most closely associated with phosphorus level. CONCLUSIONS Neither neighborhood availability of healthy food options nor neighborhood income was associated with phosphorus levels in patients receiving chronic dialysis. Modifying factors, such as nutrition literacy, individual-level financial resources, and adherence to diet restrictions and medications, may be more powerful contributors than food environment to elevated phosphorus.
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Affiliation(s)
- Vishnu S Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deirdre Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Siddharth P Shah
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania .,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Lin E, Ginsburg PB, Chertow GM, Berns JS. The "Advancing American Kidney Health" Executive Order: Challenges and Opportunities for the Large Dialysis Organizations. Am J Kidney Dis 2020; 76:731-734. [PMID: 32763259 DOI: 10.1053/j.ajkd.2020.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine, University of Southern California, Los Angeles, CA; Leonard D Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA; University Kidney Research Organization, Kidney Research Center, Los Angeles, CA.
| | - Paul B Ginsburg
- Leonard D Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA; Brookings Institution, Washington, DC
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey S Berns
- Division of Nephrology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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18
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Berns JS, Rapalino O, Fenves AZ, El Khoury JB, Klepeis VE, Anahtar MN. Case 11-2020: A 37-Year-Old Man with Facial Droop, Dysarthria, and Kidney Failure. N Engl J Med 2020; 382:1457-1466. [PMID: 32268031 DOI: 10.1056/nejmcpc1916252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jeffrey S Berns
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Otto Rapalino
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Joseph B El Khoury
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Veronica E Klepeis
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Melis N Anahtar
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
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19
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Berns JS, Coull S, Paskin D, Spevetz A, Boyer WC. Reflections on a Crisis in Graduate Medical Education: The Closure of Hahnemann University Hospital. Acad Med 2020; 95:499-502. [PMID: 31972677 DOI: 10.1097/acm.0000000000003156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In June 2019, Hahnemann University Hospital (HUH) in Philadelphia became the largest U.S. teaching hospital to announce its closure and the closure of all of its graduate medical education (GME) programs, which displaced more than 550 residents, fellows, and other trainees. In addition to the displaced trainees, the HUH closure involved many stakeholders at both the closing hospital and hospitals willing to accept transferred residents and fellows-program directors and coordinators, designated institutional officials (DIOs), and hospital executives-as well as the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services, the National Resident Matching Program, and other organizations. Given the rarity of such events, those involved had little experience or expertise in dealing with the closure of so many GME programs at one time. In this Invited Commentary, the DIOs of HUH and 4 other area teaching hospitals detail their experiences working to find new training opportunities for the displaced residents and fellows, discussing lessons learned and providing recommendations to prepare for any future teaching hospital closures. Stakeholder organizations should work together to develop a "playbook" for use during future closures so that the chaos that occurred this time can be avoided.
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Affiliation(s)
- Jeffrey S Berns
- J.S. Berns is associate dean for graduate medical education, Perelman School of Medicine, University of Pennsylvania, and designated institutional official, University of Pennsylvania Health System, Philadelphia, Pennsylvania. S. Coull is designated institutional official, Temple University Health System, vice president for medical education, Temple University Hospital, and assistant dean for graduate medical education and undergraduate medical education, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania. D. Paskin is vice dean, Sidney Kimmel Medical College, Thomas Jefferson University, and designated institutional official, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. A. Spevetz is designated institution official, Cooper University Health and Cooper Medical School of Rowan University, Camden, New Jersey. W.C. Boyer was chief academic officer and designated institutional official, Hahnemann University Hospital, Philadelphia, Pennsylvania. The author is currently chief academic officer/designated institutional official, Crozer-Keystone Health System, Upland, Pennsylvania
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Abstract
Conflicts of interest involving physicians are commonplace in the US, occurring across many different specialties and subspecialties in a variety of clinical settings. In nephrology, two important scenarios in which conflicts of interest arise are dialysis facility joint venture (JV) arrangements and financial participation in End-stage Kidney Disease Seamless Care Organizations (ESCOs). Whether conflicts of interest occurring in either of these settings influence decision-making or patient care outcomes is not known due to a lack of transparent, publicly available information, and opportunities to conduct independent study. We discuss possible benefits and risks of nephrologist's financial participation in JVs and ESCOs and possible mechanisms for disclosure and reporting of such arrangements as well as risk mitigation.
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Affiliation(s)
- Aaron Glickman
- Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.,Leonard D Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA.,Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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21
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Rodby R, Perazella MA, Berns JS. The changing of the guard. Semin Dial 2019; 32:482-484. [PMID: 31633841 DOI: 10.1111/sdi.12843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Roger Rodby
- Rush University Medical Center, Chicago, IL, USA
| | | | - Jeffrey S Berns
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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22
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Clapp JT, Diraviam SP, Lane-Fall MB, Szymczak JE, Muralidharan M, Chung JJ, Gutsche JT, Curley MAQ, Berns JS, Fleisher LA. Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration. Am J Kidney Dis 2019; 75:61-71. [PMID: 31492489 DOI: 10.1053/j.ajkd.2019.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE Collaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today's ICUs. Although there is considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the 2 parties remain poorly understood. This article describes interactions between nephrology consultants and ICU teams in the academic medical setting. STUDY DESIGN Focused ethnography using semi-structured interviews and participant observation. SETTING & PARTICIPANTS Purposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation. ANALYTICAL APPROACH Interview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach. RESULTS Nephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care. LIMITATIONS Aspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined. CONCLUSIONS Differences in approach between internal medicine-trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.
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Affiliation(s)
- Justin T Clapp
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Sushmitha P Diraviam
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meghan B Lane-Fall
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Julia E Szymczak
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Madhavi Muralidharan
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jamison J Chung
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Martha A Q Curley
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey S Berns
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Akizawa T, Macdougall IC, Berns JS, Yamamoto H, Taguchi M, Iekushi K, Bernhardt T. Iron Regulation by Molidustat, a Daily Oral Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor, in Patients with Chronic Kidney Disease. Nephron Clin Pract 2019; 143:243-254. [PMID: 31387097 PMCID: PMC6979436 DOI: 10.1159/000502012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND/AIMS The current treatment for anemia associated with chronic kidney disease (CKD) includes the administration of erythropoiesis stimulating agents (ESAs) combined with iron supplementation. Molidustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, has potential to treat anemia associated with CKD through increased erythropoietin production and improved iron availability. Here, we report the effect of molidustat on iron metabolism. METHOD Parameters of iron metabolism were monitored in three 16-week, randomized, controlled, phase 2 studies assessing the safety and efficacy of molidustat in the treatment of anemia associated with CKD in different populations: treatment-naïve and previously ESA-treated patients not on dialysis, and previously ESA-treated patients on hemodialysis. Iron supplementation was left at the discretion of the investigator. RESULTS In treatment-naïve patients not on dialysis, transferrin saturation (TSAT), hepcidin, ferritin, and iron concentrations decreased with molidustat, whereas total iron binding capacity (TIBC) increased. Similar results were observed in previously ESA-treated patients not on dialysis, although changes in those parameters were larger in treatment-naïve than in previously ESA-treated patients. In previously ESA-treated patients receiving hemodialysis, hepcidin concentration and TIBC remained stable with molidustat, whereas TSAT and ferritin and iron concentrations increased. Generally, similar trends were observed in secondary analyses of subgroups of patients not receiving iron supplementation. CONCLUSIONS Molidustat is a potential alternative to standard treatment of anemia associated with CKD, with a different mechanism of action. In patients not receiving dialysis, molidustat increases iron availability. In patients receiving hemodialysis, further investigation is required to understand fully the mechanisms underlying iron mobilization associated with molidustat.
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Affiliation(s)
- Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan,
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Gelfand SL, Eneanya ND, Leonberg-Yoo AK, Berns JS. CPR for OHCA Is Rarely Successful, and What Is “Success” Anyway? J Am Soc Nephrol 2019; 30:1137. [DOI: 10.1681/asn.2019020149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Akizawa T, Macdougall IC, Berns JS, Bernhardt T, Staedtler G, Taguchi M, Iekushi K, Krueger T. Long-Term Efficacy and Safety of Molidustat for Anemia in Chronic Kidney Disease: DIALOGUE Extension Studies. Am J Nephrol 2019; 49:271-280. [PMID: 30852574 DOI: 10.1159/000499111] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/06/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Molidustat, a novel hypoxia-inducible factor-prolyl hydroxylase inhibitor, is being investigated for the treatment of anemia associated with chronic kidney disease (CKD). The efficacy and safety of molidustat were recently evaluated in three 16-week phase 2b studies. Here, we report the results of two long-term extension studies of molidustat. METHODS Both studies were parallel-group, open-label, multicenter studies of ≤36 months' duration, in patients with anemia due to CKD, and included an erythropoiesis-stimulating agent as active control. One study enrolled patients not receiving dialysis (n = 164), and the other enrolled patients receiving hemodialysis (n = 88). The primary efficacy variable for both studies was change in blood hemoglobin (Hb) level from baseline to each post-baseline visit, and safety outcomes included adverse events (AEs). RESULTS In patients not on dialysis, the mean ± SD Hb concentrations at baseline were 11.28 ± 0.55 g/dL for molidustat and 11.08 ± 0.51 g/dL for darbepoetin. The mean ± SD blood Hb concentrations throughout the study (defined as mean of each patient's overall study Hb levels) were 11.10 ± 0.508 and 10.98 ± 0.571 g/dL in patients treated with molidustat and darbepoetin, respectively. Similar proportions of patients reported at least one AE in the molidustat (85.6%) and darbepoetin (85.7%) groups. In patients on dialysis, mean ± SD Hb levels at baseline were 10.40 ± 0.70 and 10.52 ± 0.53 g/dL in the molidustat and epoetin groups, respectively. The mean ± SD blood Hb concentrations during the study were 10.37 ± 0.56 g/dL in the molidustat group and 10.52 ± 0.47 g/dL in the epoetin group. Proportions of patients who reported at least one AE were 91.2% in the molidustat group and 93.3% in the epoetin group. CONCLUSIONS Molidustat was well tolerated for up to 36 months and appears to be an effective alternative to darbepoetin and epoetin in the long-term management of anemia associated with CKD.
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Affiliation(s)
- Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan,
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas Bernhardt
- Research & Development, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Gerald Staedtler
- Research & Development, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Megumi Taguchi
- Medical Affairs, Pulmonology & Cardiology, Bayer Yakuhin Ltd., Osaka, Japan
| | - Kazuma Iekushi
- Medical Affairs, Pulmonology & Cardiology, Bayer Yakuhin Ltd., Osaka, Japan
| | - Thilo Krueger
- Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
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Macdougall IC, Akizawa T, Berns JS, Bernhardt T, Krueger T. Effects of Molidustat in the Treatment of Anemia in CKD. Clin J Am Soc Nephrol 2018; 14:28-39. [PMID: 30559105 PMCID: PMC6364546 DOI: 10.2215/cjn.02510218] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 10/12/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES The efficacy and safety of molidustat, a hypoxia-inducible factor-prolyl hydroxylase inhibitor, have been evaluated in three 16-week, phase 2b studies in patients with CKD and anemia who are not on dialysis (DaIly orAL treatment increasing endOGenoUs Erythropoietin [DIALOGUE] 1 and 2) and in those who are on dialysis (DIALOGUE 4). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS DIALOGUE 1 was a placebo-controlled, fixed-dose trial (25, 50, and 75 mg once daily; 25 and 50 mg twice daily). DIALOGUE 2 and 4 were open-label, variable-dose trials, in which treatment was switched from darbepoetin (DIAGLOGUE 2) or epoetin (DIALOGUE 4) to molidustat or continued with the original agents. Starting molidustat ranged between 25-75 and 25-150 mg daily in DIAGLOGUE 2 and 4, respectively, and could be titrated to maintain hemoglobin levels within predefined target ranges. The primary end point was the change in hemoglobin level between baseline and the mean value from the last 4 weeks of the treatment period. RESULTS In DIAGLOGUE 1 (n=121), molidustat treatment was associated with estimated increases in mean hemoglobin levels of 1.4-2.0 g/dl. In DIAGLOGUE 2 (n=124), hemoglobin levels were maintained within the target range after switching to molidustat, with an estimated difference in mean change in hemoglobin levels between molidustat and darbepoetin treatments of up to 0.6 g/dl. In DIAGLOGUE 4 (n=199), hemoglobin levels were maintained within the target range after switching to molidustat 75 and 150 mg, with estimated differences in mean change between molidustat and epoetin treatment of -0.1 and 0.4 g/dl. Molidustat was generally well tolerated, and most adverse events were mild or moderate in severity. CONCLUSIONS The overall phase 2 efficacy and safety profile of molidustat in patients with CKD and anemia enables the progression of its development into phase 3.
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Affiliation(s)
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas Bernhardt
- Departments of Pharmaceutials Development, and TA Cardiology and Nephrology, Bayer AG, Berlin, Germany; and
| | - Thilo Krueger
- Departments of Research and Development, and Pharmaceuticals, Bayer AG, Wuppertal, Germany
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Affiliation(s)
- Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;
| | | | - Eugene Lin
- Division of Nephrology and Hypertension, University Kidney Research Organization Kidney Research Center, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
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Affiliation(s)
- Jeffrey S Berns
- From the Perelman School of Medicine at the University of Pennsylvania (J.S.B., A.G., M.S.M.), and the Hospital of the University of Pennsylvania (J.S.B.) - both in Philadelphia
| | - Aaron Glickman
- From the Perelman School of Medicine at the University of Pennsylvania (J.S.B., A.G., M.S.M.), and the Hospital of the University of Pennsylvania (J.S.B.) - both in Philadelphia
| | - Matthew S McCoy
- From the Perelman School of Medicine at the University of Pennsylvania (J.S.B., A.G., M.S.M.), and the Hospital of the University of Pennsylvania (J.S.B.) - both in Philadelphia
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Berns JS. Kidney Tattoos. Am J Kidney Dis 2018; 73:A13-A14. [PMID: 30219592 DOI: 10.1053/j.ajkd.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 08/14/2018] [Indexed: 11/11/2022]
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Berns JS. Training Nephrology Fellows in Temporary Hemodialysis Catheter Placement and Kidney Biopsies is Needed and Should be Required. Clin J Am Soc Nephrol 2018; 13:1099-1101. [PMID: 29907618 PMCID: PMC6032578 DOI: 10.2215/cjn.00040118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Akizawa T, Macdougall IC, Berns JS, Bernhardt T, Taguchi M, Ogura E, Lekushi K. SP334IRON REGULATION BY MOLIDUSTAT, BAY 85-3934, A DAILY ORAL HYPOXIA-INDUCIBLE FACTOR PROLYL HYDROXYLASE INHIBITOR IN PATIENTS WITH CHRONIC KIDNEY DISEASE. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.sp334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tadao Akizawa
- Division of Nephrology, Showa Univ School of Medicine, Tokyo, Japan
| | | | - Jeffrey S Berns
- Nephrology, Hospital of the Univ of Pennsylvania, Philadelphia, PA, United States
| | | | | | - Eriko Ogura
- Product Development, Bayer Yakuhin Ltd, Osaka, Japan
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Schrauben SJ, Negoianu D, Costa C, Cohen RM, Goldfarb S, Fuchs BD, Berns JS. Accuracy of Acid-Base Diagnoses Using the Central Venous Blood Gas in the Medical Intensive Care Unit. Nephron Clin Pract 2018; 139:293-298. [PMID: 29649820 DOI: 10.1159/000488501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/15/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acid-base disturbances are frequent in critically ill patients. Arterial blood gas (ABG) is the gold standard in the diagnosis of these disturbances, but it is invasive with potential hazards. For patients with a central venous catheter, venous blood gas (VBG) sampling may be an alternative, less-invasive diagnostic tool. However, the accuracy of a central VBG-based acid-base disorder diagnosis compared to an ABG is unknown. The primary objective of this study was to assess the accuracy of a central VBG-based acid-base disorder diagnosis compared to the "gold standard" ABG in critically ill patients. METHODS This was a study of adult patients in a medical intensive care unit that had simultaneously drawn ABG and central VBG samples. Expert acid-base diagnosticians, all nephrologists, diagnosed the acid-base disorder(s) in each blood gas sample. The central VBG diagnostic accuracy was assessed with percent agreement, sensitivity, and specificity compared to the ABG-based diagnosis. RESULTS The study involved 23 participants. Overall, the central VBG had 100% sensitivity for metabolic acidosis, metabolic alkalosis, and respiratory acidosis, and lower sensitivity (71%) for respiratory alkalosis, and high percent agreement, ranging from 75 to 94%. VBG-based diagnoses in vasopressor-dependent patients (n = 13, 56.5%) performed similarly to the entire sample. CONCLUSIONS In critically ill adult patients, central VBG may be used to detect and diagnose acid-base disturbances with reasonable diagnostic accuracy, even in shock states, compared to the ABG. This study supports the use of central VBG for diagnosis of acid-base disturbances in critically ill patients.
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Affiliation(s)
- Sarah J Schrauben
- Renal, Electrolyte and Hypertension Division of the Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dan Negoianu
- Renal, Electrolyte and Hypertension Division of the Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cristiana Costa
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Raphael M Cohen
- Renal, Electrolyte and Hypertension Division of the Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stanley Goldfarb
- Renal, Electrolyte and Hypertension Division of the Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Barry D Fuchs
- Division of Pulmonary, Allergy, and Critical Care of the Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Berns
- Renal, Electrolyte and Hypertension Division of the Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jeffrey S. Berns
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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34
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Affiliation(s)
- T. Alp Ikizler
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeffrey S. Berns
- Renal-Electrolyte and Hypertension Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Berns JS, Ghosn M, Altamirano RR. International Medical Graduates in Nephrology: Roles, Rules, and Future Risks. Am J Kidney Dis 2017; 72:113-117. [PMID: 29221624 DOI: 10.1053/j.ajkd.2017.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/13/2017] [Indexed: 11/11/2022]
Abstract
International medical graduates (IMGs) have become an increasingly essential part of many residency and fellowship programs in the United States. IMGs, who may be of either US or non-US citizenship, contribute significantly to the physician workforce across this country, particularly in underserved areas, as well as in their home countries on their return after training. Approximately 65% of nephrology fellows are IMGs, with most of these being non-US citizens. Non-US IMG applications for nephrology fellowship have been declining, exacerbating an ongoing shortage of nephrology trainees. IMGs face visa status restrictions and immigration policy concerns, limitations on federally funded research support, and difficulty finding desirable jobs in both private practices and academia after fellowship. We review training, examination, and licensure requirements, as well as visa status rules for IMGs. We also discuss the potential negative impact of recent immigration policies limiting the entry of non-US IMGs on the medical community in general and in nephrology in particular.
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Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania and the Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Muriel Ghosn
- Division of Nephrology and Hypertension, Ain Wazein Medical Village, El Chouf, Lebanon
| | - Rodolfo R Altamirano
- International Student and Scholar Services, University of Pennsylvania, Philadelphia, PA
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Berns JS. Interpretation of the Kidney Disease: Improving Global Outcomes guidelines for iron therapy: commentary and emerging evidence. Clin Kidney J 2017; 10:i3-i8. [PMID: 29225817 PMCID: PMC5716187 DOI: 10.1093/ckj/sfx042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/05/2017] [Indexed: 12/12/2022] Open
Abstract
The ‘Kidney Disease: Improving Global Outcomes’ (KDIGO) Clinical Practice Guideline for Anaemia in Chronic Kidney Disease includes detailed recommendations for the use of iron therapy in a variety of clinical circumstances. However, the evidence base regarding the use of iron therapy in patients with chronic kidney disease was relatively incomplete at the time the guideline was developed. As a result, there has been significant debate as to the appropriate use of iron therapy in this population. In this article, the KDIGO guidelines are discussed in the context of recently published commentary pieces and additional research to provide a richer context in which to interpret and understand the guidelines.
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Affiliation(s)
- Jeffrey S Berns
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Sedrak MS, Myers JS, Small DS, Nachamkin I, Ziemba JB, Murray D, Kurtzman GW, Zhu J, Wang W, Mincarelli D, Danoski D, Wells BP, Berns JS, Brennan PJ, Hanson CW, Dine CJ, Patel MS. Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial. JAMA Intern Med 2017; 177:939-945. [PMID: 28430829 PMCID: PMC5543323 DOI: 10.1001/jamainternmed.2017.1144] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration. OBJECTIVE To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions. INTERVENTIONS Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. MAIN OUTCOMES AND MEASURES Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. RESULTS The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001). CONCLUSIONS AND RELEVANCE Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02355496.
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Affiliation(s)
- Mina S Sedrak
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer S Myers
- Center for Healthcare Improvement & Patient Safety, University of Pennsylvania Health System, Philadelphia3University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S Small
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Irving Nachamkin
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Justin B Ziemba
- Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dana Murray
- University of Pennsylvania Health System, Philadelphia
| | - Gregory W Kurtzman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia 7The Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia
| | - Jingsan Zhu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Wenli Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Brian P Wells
- University of Pennsylvania Health System, Philadelphia
| | - Jeffrey S Berns
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick J Brennan
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - C William Hanson
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - C Jessica Dine
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mitesh S Patel
- University of Pennsylvania Health System, Philadelphia4Perelman School of Medicine, University of Pennsylvania, Philadelphia 5The Wharton School, University of Pennsylvania, Philadelphia 7The Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia 8Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Berns JS, Glickman JD, Reese PP. Dialysis Payment Model Reform: Managing Conflicts Between Profits and Patient Goals of Care Decision Making. Am J Kidney Dis 2017; 71:133-136. [PMID: 28663064 DOI: 10.1053/j.ajkd.2017.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/26/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania and the Hospital of the University of Pennsylvania; Philadelphia, PA.
| | - Joel D Glickman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, Philadelphia, PA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, Philadelphia, PA
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Uhlig K, Berns JS, Carville S, Chan W, Cheung M, Guyatt GH, Hart A, Lewis SZ, Tonelli M, Webster AC, Wilt TJ, Kasiske BL. Recommendations for kidney disease guideline updating: a report by the KDIGO Methods Committee. Kidney Int 2017; 89:753-60. [PMID: 26994574 DOI: 10.1016/j.kint.2015.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 10/21/2015] [Accepted: 11/12/2015] [Indexed: 12/27/2022]
Abstract
Updating rather than de novo guideline development now accounts for the majority of guideline activities for many guideline development organizations, including Kidney Disease: Improving Global Outcomes (KDIGO), an international kidney disease guideline development entity that has produced guidelines on kidney diseases since 2008. Increasingly, guideline developers are moving away from updating at fixed intervals in favor of more flexible approaches that use periodic expert assessment of guideline currency (with or without an updated systematic review) to determine the need for updating. Determining the need for guideline updating in an efficient, transparent, and timely manner is challenging, and updating of systematic reviews and guidelines is labor intensive. Ideally, guidelines should be updated dynamically when new evidence indicates a need for a substantive change in the guideline based on a priori criteria. This dynamic updating (sometimes referred to as a living guideline model) can be facilitated with the use of integrated electronic platforms that allow updating of specific recommendations. This report summarizes consensus-based recommendations from a panel of guideline methodology professionals on how to keep KDIGO guidelines up to date.
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Affiliation(s)
- Katrin Uhlig
- Tufts Medical Center, Boston, Massachusetts, USA.
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Serena Carville
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
| | - Wiley Chan
- Northwest Kaiser Permanente, Portland, Oregon, USA
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Allyson Hart
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Angela C Webster
- Cochrane Kidney and Transplant and Centre for Kidney Research, Westmead Hospital, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy J Wilt
- Center for Chronic Diseases Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA; University of Minnesota, Department of Medicine, Minneapolis, Minnesota, USA
| | - Bertram L Kasiske
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
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Berns JS. Honoring Patient Preferences: The 2016 National Kidney Foundation Presidential Address. Am J Kidney Dis 2016; 68:661-664. [PMID: 27555104 DOI: 10.1053/j.ajkd.2016.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Besharatian BD, Berns JS. More May be Less; Yet Another Way which More Intense Renal Replacement Therapy May Not be Better. Semin Dial 2016; 29:515-517. [PMID: 27726171 DOI: 10.1111/sdi.12556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Behdad D Besharatian
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Kramer H, Yee J, Weiner DE, Bansal V, Choi MJ, Brereton L, Berns JS, Samaniego-Picota M, Scheel P, Rocco M. Ultrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report. Am J Kidney Dis 2016; 68:522-532. [PMID: 27449697 DOI: 10.1053/j.ajkd.2016.06.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/02/2016] [Indexed: 11/11/2022]
Abstract
High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which is governed by patients' interdialytic weight gain, body weight, and dialysis treatment time. We also examine the potential benefits and pitfalls of adopting a UFR threshold as a clinical performance measure and outline several aspects of UFR thresholds that require further research.
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Affiliation(s)
- Holly Kramer
- Division of Nephrology, Department of Medicine, Loyola University Chicago, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL.
| | - Jerry Yee
- Division of Nephrology, Department of Medicine, Henry Ford Medical Center, Detroit, MI
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Vinod Bansal
- Division of Nephrology, Department of Medicine, Loyola University Chicago, Maywood, IL
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Paul Scheel
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Rocco
- Division of Nephrology, Department of Medicine, Wake Forest University, Winston-Salem, NC
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Lin J, Fernandez H, Shashaty MGS, Negoianu D, Testani JM, Berns JS, Parikh CR, Wilson FP. False-Positive Rate of AKI Using Consensus Creatinine-Based Criteria. Clin J Am Soc Nephrol 2015; 10:1723-31. [PMID: 26336912 DOI: 10.2215/cjn.02430315] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/22/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false-positive rates because of inherent laboratory and biologic variabilities of creatinine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false-positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient's true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria. RESULTS Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false-positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%-8.1%), whereas patients with true serum creatinine ≥1.5 mg/dl (representing 21% of the clinical cohort) had a false-positive AKI diagnosis rate of 30.5% (interquartile range =30.1%-30.9%) versus 2.0% (interquartile range =1.9%-2.1%) in patients with true serum creatinine values <1.5 mg/dl (P<0.001). CONCLUSIONS Use of small serum creatinine changes to diagnose AKI is limited by high false-positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies.
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Affiliation(s)
- Jennie Lin
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Hilda Fernandez
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; and
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | | | - Jeffrey S Berns
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Chirag R Parikh
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - F Perry Wilson
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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44
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Abstract
The kidney biopsy is the gold standard in the diagnosis and management of many diseases. Since its introduction in the 1950s, advancements have been made in biopsy technique to improve diagnostic yield while minimizing complications. Here, we review kidney biopsy indications, techniques, and complications in the modern era. We also discuss patient populations in whom special consideration must be given when considering a kidney biopsy and the important role that the kidney biopsy plays in nephrology training. These data are presented to develop best practice strategies for this essential procedure.
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Affiliation(s)
- Jonathan J Hogan
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michaela Mocanu
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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45
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Berns JS. Improving Care of Patients With CKD: The 2015 National Kidney Foundation Presidential Address. Am J Kidney Dis 2015; 66:547-51. [PMID: 26243584 DOI: 10.1053/j.ajkd.2015.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/15/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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46
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Perry Wilson F, Nolin TD, Berns JS. Drugs, Dialysis, Decisions, and Data: A Walk through the Minefield of Nephropharmacology. Semin Dial 2015; 28:323-4. [DOI: 10.1111/sdi.12390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Thomas D. Nolin
- University of Pittsburgh School of Pharmacy; Pittsburgh Pennsylvania
| | - Jeffrey S. Berns
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
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47
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Berns JS, Ikizler TA. Quality training, quality board examinations, quality nephrologists. Am J Kidney Dis 2015; 66:7-8. [PMID: 26111903 DOI: 10.1053/j.ajkd.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 05/12/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - T Alp Ikizler
- Vanderbilt University Medical Center, Nashville, Tennessee
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48
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49
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Abstract
Epilepsy is a disorder with an approximate worldwide prevalence of 1%. Due to complexities of metabolism, protein-binding, renal elimination, and other pharmacokinetic parameters, the dosing of antiepileptic drugs (AEDs) in patients with chronic kidney disease (CKD) or end stage renal disease (ESRD) deserves special attention. This is a review of the most commonly prescribed AEDs with special focus on their indication, pharmacokinetics, and unique considerations for use in patients with CKD and ESRD. A review of their renal toxicities is also included.
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Affiliation(s)
- Amar D Bansal
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chloe E Hill
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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50
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Abstract
The development and widespread use of serum creatinine concentration-based prediction equations to calculate eGFR have been major advances for detection of patients with CKD and the epidemiologic study of CKD and its outcomes. However, these equations as well as those that also incorporate serum cystatin C concentration provide GFR estimates that, although reasonably precise on average, can differ markedly and in clinically important ways from actual GFR. Thus, it is important that clinicians who use these equations for clinical decision-making be familiar with their strengths and weaknesses and have an appreciation of their potential for error. More precise knowledge of actual GFR is important in certain clinical circumstances, including, as presented in this Attending Rounds, patients with stage 5 CKD, in whom decisions regarding dialysis initiation are necessary. Nephrologists should have the ability to accurately determine GFR when needed if clinical circumstances suggest inaccuracy of the calculated eGFR reported by the clinical laboratory.
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Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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