Advancing American Kidney Health Initiative Research Articles

Should Transplant Nephrology Pursue Recognition from the Accreditation Council for Graduate Medical Education (ACGME)?

Kidney transplant is not only the best treatment for patients with advanced kidney disease but it also reduces health care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with perioperative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative, passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the past decade, there has been a decline in the Nephrology-as well Transplant Nephrology-workforce due to a multitude of reasons. The American Society of Transplantation Kidney Pancreas Community of Practice created a workgroup to discuss the Transplant Nephrology workforce shortage. In this article, we discuss the scope of the problem and how the Accreditation Council for Graduate Medical Education recognition of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work force crisis.

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

The Advancing American Kidney Health Initiative aims to increase rates of utilization of peritoneal dialysis (PD) in the United States. One of the first steps to PD is successful catheter placement, which can be performed by surgeons, interventional radiologists, or nephrologists. We examined the association between operator subspecialty and risk of needing a follow-up procedure in the first 90 days after initial PD catheter implantation. Overall, we found that 15.5% of catheters required revision, removal, or a second catheter placement within 90 days. The odds of requiring a follow-up procedure was 36% higher for interventional radiologists and 86% higher for interventional nephrologists compared with general surgeons. Further research is needed to understand how to optimize the function of catheters across different operator types. The US government has implemented incentives to increase the use of PD. Successful placement of PD catheters is an important step to increasing PD utilization rates. Our objective was to compare initial outcomes after PD catheter placement by different types of operators. We included PD-naïve patients insured by Medicare who had a PD catheter inserted between 2010 and 2019. We examined the association between specialty of the operator (general surgeon, vascular surgeon, interventional radiologist, or interventional nephrologist) and odds of needing a follow-up procedure, which we defined as catheter removal, replacement, or revision within 90 days of the initial procedure. Mixed logistic regression models clustered by operator were used to examine the association between operator type and outcomes. We included 46,973 patients treated by 5205 operators (71.1% general surgeons, 17.2% vascular surgeons, 9.7% interventional radiologists, 2.0% interventional nephrologists). 15.5% of patients required a follow-up procedure within 90 days of the initial insertion, of whom 2.9% had a second PD catheter implanted, 6.6% underwent PD catheter removal, and 5.9% had a PD catheter revision within 90 days of the initial insertion. In models adjusted for patient and operator characteristics, the odds of requiring a follow-up procedure within 90 days were highest for interventional nephrologists (HR, 1.86; 95% confidence interval [CI], 1.56 to 2.22) and interventional radiologists (odds ratio, 1.36; 95% CI, 1.17 to 1.58) followed by vascular surgeons (odds ratio, 1.06; 95% CI, 0.97 to 1.14) compared with general surgeons. The probability of needing a follow-up procedure after initial PD catheter placement varied by operator specialty and was higher for interventionalists and lowest for general surgeons.

Advances in hemodialysis therapy.

End-stage renal disease (ESRD) continues to be a disease process with a high rate of hospitalization and mortality. There has been little innovation in nephrology over the last few decades compared to revolutionary high-tech advancements in other areas like oncology and cardiovascular medicine. Kidney transplantation, the only available alternative to renal replacement therapy, is limited in its availability. It is essential to have advances in this field to improve the efficiency of currently available treatments and devise new therapies. The current description of renal replacement therapy is inappropriate as it only replaces the filtration function of the failed kidney without addressing its other vital metabolic, endocrinologic, and immunologic roles and portability. Hence, it is critical to have newer therapies focusing on total replacement and portability, not just clearance. This review will address the developments in hemodialysis therapy. Advances in hemodialysis therapy include hemodiafiltration, portable machines, wearable artificial kidneys, and bioartificial kidneys. Although promising, newer technologies in this direction are still far from clinical application. Several organizations and enterprises including the Kidney Health Initiative and Kidney X: The Kidney Innovation Accelerator, as well as The Advancing American Kidney Health Initiative, are working in tandem to develop new therapies that could customize the treatment of ESRD.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Addressing kidney health disparities with new national policy: the time is now.

End-stage kidney disease (ESKD) affects over 780,000 Americans and is associated with excess morbidity and premature death. Kidney disease health disparities are well-recognized, manifesting as ESKD overburden among racial and ethnic minority populations. Specifically, Black and Hispanic individuals have a 3.4-fold and 1.3-fold greater life risk of developing ESKD than their white counterparts. There is compelling evidence that communities of color have less opportunity to benefit from kidney-specific care throughout the course of their disease, from pre-ESKD, to ESKD home therapies and kidney transplantation. These healthcare inequities have the combined devastating impact of worse outcomes and quality of life for patients and families at a significant financial cost on the healthcare system. In the last three years, across two presidential administrations, bold, broad initiatives have been outlined that, together could lead to significant transformation in kidney health. The Advancing American Kidney Health (AAKH) initiative was established as a national framework to revolutionize kidney care but did not address health equity. More recently, the Advancing Racial Equity executive order was announced, outlining initiatives to promote equity for historically underserved communities. Building from these presidential directives, we outline strategies to address the complex issue of kidney health disparities, focusing on patient awareness, care delivery, scientific advancement, and workforce initiatives. An equity-focused framework will guide policy advancements to reduce the kidney disease burden in susceptible populations and positively impact the health and well-being of all Americans.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Keys to Driving Implementation of the New Kidney Care Models.

Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative's framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.

Utilization of Peritoneal Dialysis in the United States: Progress in Tackling Obstacles to Expansion.

To facilitate the desired increase in home dialysis utilization in the United States, multiple factors need to be taken into consideration in order to achieve this complex task. Through policy-level facilitators such as the Advancing American Kidney Health Initiative and the expansion of telehealth utilization, adjustments to the existing payment models, providing health equity incentives, increasing number of provider education materials on home therapies, and allaying patient fears with the expansion of home dialysis education nationwide, we have taken several steps in the right direction. There is still a long way to go, and further improvements can be made while utilizing lessons learned from some of our international peers who have been successful in their implementation of large-scale home dialysis programs.

Education Standards for Pharmacists Providing Comprehensive Medication Management in Outpatient Nephrology Settings

Chronic kidney disease is a public health problem that has generated renewed interest due to poor patient outcomes and high cost. The Advancing American Kidney Health initiative aimed to transform kidney care with goals of decreasing the incidence of kidney failure and increasing the number of patients receiving home dialysis or a kidney transplant. New value-based models of kidney care that specify inclusion of pharmacists as part of the kidney care team were developed to help achieve these goals. To support this Advancing American Kidney Health-catalyzed opportunity for pharmacist engagement, the pharmacy workforce must have a fundamental knowledge of the core principles needed to provide comprehensive medication management to address chronic kidney disease and the common comorbid conditions and secondary complications. The Advancing Kidney Health through Optimal Medication Management initiative was created by nephrology pharmacists with the vision that every person with kidney disease receives optimal medication management through team-based care that includes a pharmacist to ensure medications are safe, effective, and convenient. Here, we propose education standards for pharmacists providing care for individuals with kidney disease in the outpatient setting to complement proposed practice standards.

Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States

The United States Department of Health and Human Services launched the Advancing American Kidney Health Initiative in 2019, which included a goal of transforming dialysis care from an in-center to a largely home-based dialysis program. A substantial motivator for this transition is the potential to reduce costs of ESKD care with peritoneal dialysis. Studies demonstrating that peritoneal dialysis is less costly than in-center hemodialysis have often focused on the perspective of the payer, whereas less consideration has been given to the costs of those who are more directly involved in treatment decision making, including patients, caregivers, physicians, and dialysis facilities. We review comparisons of peritoneal dialysis and in-center hemodialysis costs, focusing on costs incurred by the people and organizations making decisions about dialysis modality, to highlight the financial barriers toward increased adoption of peritoneal dialysis. We specifically address misaligned economic incentives, underappreciated costs for key stakeholders involved in peritoneal dialysis delivery, differences in provider costs, and transition costs. We conclude by offering policy suggestions that include improving data collection to better understand costs in peritoneal dialysis, and sharing potential savings among all stakeholders, to incentivize a transition to peritoneal dialysis.

The Advancing American Kidney Health Initiative: The Challenge of Measuring Success.

CKD affects approximately 37 million of those in the United States and $114 billion were spent caring for this population in 2016, most of which was spent on RRT.[1][1],[2][2] Kidney transplantation has the best clinical outcomes at the lowest cost, but not everyone is eligible for a transplant. As

The Role of Peritoneal Dialysis in Different Phases of Kidney Transplantation.

The utilization of peritoneal dialysis (PD) has been increasing in the past decade owing to various government initiatives and recognition of benefits such as better preservation of residual renal function, quality of life, and lower cost. The Advancing American Kidney Health initiative aims to increase the utilization of home therapies such as PD and kidney transplantation to treat end stage kidney disease (ESKD). A natural consequence of this development is that more patients will receive PD, and many will eventually undergo kidney transplantation. Therefore, it is important to understand the effect of pretransplant PD on posttransplant outcomes such as delayed graft function (DGF), rejection, thrombosis, graft, and patient survival. Furthermore, some of these patients may develop DGF, which raises the question of the utility of PD during DGF and its risks. Although transplant is the best renal replacement therapy option, it is not everlasting, and many transplant recipients must go on dialysis after allograft failure. Can PD be a good option for these patients? This is another critical question. Furthermore, a significant proportion of nonrenal solid organ transplant recipients develop ESKD. Is PD feasible in this group? In this review, we try to address all of these questions in the light of available evidence.

Initial Home Dialysis Is Increased for Rural Patients by Accessing Urban Facilities.

The 240,000 rural patients with end stage kidney disease in the United States have less access to nephrology care and higher mortality than those in urban settings. The Advancing American Kidney Health initiative aims to increase the use of home renal replacement therapy. Little is known about how rural patients access home dialysis and the availability and quality of rural dialysis facilities. Incident dialysis patients in 2017 and their facilities were identified in the United States Renal Data System. Facility quality and service availability were analyzed with descriptive statistics. We assessed the availability of home dialysis methods, depending on rural versus urban counties, and then we used multivariate logistic regression to identify the likelihood of rural patients with home dialysis as their initial modality and the likelihood of rural patients changing to home dialysis within 90 days. Finally, we assessed mortality after dialysis initiation on the basis of patient home location. Of the 97,930 dialysis initiates, 15,310 (16%) were rural. Rural dialysis facilities were less likely to offer home dialysis (51% versus 54%, P<0.001). Although a greater proportion of rural patients (9% versus 8%, P<0.001) were on home dialysis, this was achieved by traveling to urban facilities to obtain home dialysis (OR=2.74, P<0.001). After adjusting for patient and facility factors, rural patients had a higher risk of mortality (HR=1.06, P=0.004). Despite having fewer facilities that offer home dialysis, rural patients were more often on home dialysis methods because they traveled to urban facilities, representing an access gap. Even if rural patients accessed home dialysis at urban facilities, rural patients still suffered worse mortality. Future dialysis policy should address this access gap to improve care and overall mortality for rural patients.

Home hemodialysis

Heimhämodialyse (HHD) ist der Grundstein der Nierenersatztherapie in Deutschland. Sie ermöglichte ab 1969 das Überleben mit einer bis dahin tödlichen Diagnose. Mit dem Ausbau eines guten Netzes von Dialysezentren gingen das Wissen und die Erfahrung der HHD jedoch zunehmend verloren. In der Ausbildung kommt die HHD heute praktisch nicht mehr vor. Ungenügende Aufklärung und fehlendes Angebot der HHD sind die Folge. Aktuell werden in Deutschland weniger als 0,8 % der Patienten mit HHD behandelt. Die Industrie orientierte sich bei der Entwicklung von Dialysegeräten auf Standgeräte für die Zentren. Diese Form der Therapie behindert die Mobilität und schränkt die Aktivitäten von Patienten mit dialysepflichtiger Niereninsuffizienz ein. Ausgehend von der Advancing American Kidney Health Initiative hat sich eine erfreuliche Dynamik in der Entwicklung innovativer, tragbarer und implantierbarer künstlicher Nieren entwickelt. Damit kann die Lebensqualität verbessert und die Sterblichkeitsrate gesenkt werden. Auch in Deutschland und Europa sind erste Initiativen entstanden. Diese innovativen Geräte und der damit zusammenhängende Wandel in der Nierenersatztherapie werden viele Probleme der nephrologischen Community, wie Personalmangel oder den Mangel an Spenderorganen und Tod auf der Warteliste lösbar machen und den Patienten Unabhängigkeit und Mobilität schenken. Die Kostenbelastung der Gesundheitssysteme kann reduziert werden. Darüber hinaus werden der immense Wasser- und Stromverbrauch durch die regenerativen Techniken der neuen Geräte dramatisch verringert.

Realizing the Goals of the Advancing American Kidney Health Initiative: Toward a Better Future for Kidney Disease Research Funding.

The Executive Order on Advancing American Kidney Health aimed to slow the progression of kidney disease, increase access to kidney transplantation, and expand home dialysis. In order to support the kidney health strategy laid out by the Advancing American Kidney Health, the National Institutes of Health, the National Institute of Diabetes, and Digestive, and Kidney Diseases, as well as other funding agencies must dedicate robust research funding to kidney disease. Currently, federal research investment for kidney health is less than 1% of Medicare fee-for-service expenditures for Americans with kidney disease. To address disparities in federal research funding, nephrology organizations are working together to advocate for increased federal commitment to kidney disease research. Underfunding of kidney disease research impedes scientific opportunities and innovation and prevents the collaboration of young investigators with research faculty that can accelerate the exodus of talent within the nephrology research workforce. This review provides an overview of the current state of federal research funding for kidney disease within the United States. In addition, we discuss ongoing advocacy efforts and programs that aim to increase federal funding for kidney-related research and accelerate the development of new and better therapies.

Value-Based Care and Kidney Disease: Emergence and Future Opportunities.

The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

The Growing Demand for Home Dialysis Therapies: Challenges and Potential Solutions

The End-Stage Renal Disease Treatment (ETC) Model, an aspect of the Advancing American Kidney Health Initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in 2019, is designed to shift the predominant in-center hemodialysis dialysis model in the United States to a home dialysis model. This shift represents a monumental change in the treatment of end stage kidney failure and is occurring amid a strained nursing workforce. The CMS Conditions for Coverage for dialysis facilities mandate registered nurse responsibility for the conduct of patients' home dialysis training, and the current nursing shortage presents challenges because the need for nephrology nurses will increase to meet the growing demand for home dialysis during the ETC implementation period. As the ETC Model is implemented in randomly selected dialysis facilities across the United States, nephrology nurses must have leading roles as full partners with CMS and other stakeholders for the mutual determination of short- and long-term solutions for meeting the growing home dialysis training demands.

Consequences of Both Coxsackievirus B4 and Type 1 Diabetes on Female Non-Obese Diabetic Mouse Kidneys.

Despite the 2019 Executive Order on Advancing American Kidney Health Initiative, kidney disease has moved up in rank from the 9th to the 8th leading cause of death in the United States. A recent push in the field of nephrology has been to identify molecular markers and/or molecular profiles involved in kidney disease process or injury that can help identify the cause of injury and predict patient outcomes. While these studies have had moderate success, they have not yet considered that many of the health conditions that cause kidney disease (diabetes, hypertension, etc.) can also be caused by environmental factors (such as viruses), which in and of themselves can cause kidney disease. Thus, the goal of this study was to identify molecular and phenotypic profiles that can differentiate kidney injury caused by diabetes (a health condition resulting in kidney disease) and coxsackievirus B4 (CVB4) exposure (which can cause diabetes and/or kidney disease), both alone and together. Non-obese diabetic (NOD) mice were used for this study due to their susceptibility to both type 1 diabetes (T1D)- and CVB4-mediated kidney injury, in order to glean a better understanding of how hyperglycemia and viral exposure, when occurring on their own and in combination, may alter the kidneys’ molecular and phenotypic profiles. While no changes in kidney function were observed, molecular biomarkers of kidney injury were significantly up- and downregulated based on T1D and CVB4 exposure, both alone and together, but not in a predictable pattern. By combining individual biomarkers with function and phenotypic measurements (i.e., urinary albumin creatinine ratio, serum creatinine, kidney weight, and body weight), we were able to perform an unbiased separation of injury group based on the type of injury. This study provides evidence that unique kidney injury profiles within a kidney disease health condition are identifiable, and will help us to identify the causes of kidney injury in the future.

Racial/ethnic and prior willingness disparities in potential living kidney donors\u2019 self-assessed responses to advancing American kidney health regulation

BackgroundRacial/ethnic disparities in living donor kidney transplantation (LDKT) are large, and rates of LDKT may be limited by indirect costs of living donation. A 2019 Executive Order– Advancing American Kidney Health (AAKH)– sought to remove indirect costs through an expanded reimbursement program. We examine how potential living kidney donors in the U.S. believe regulation stemming from the AAKH initiative will impact their living donor evaluation likelihood, how these beliefs vary by minority race/ethnicity and prior willingness to be evaluated, and how differences are explained by ability to benefit or knowledge and attitudes.MethodsData from a 2019 online survey (Families of Renal Patients Survey) were used. Respondents are U.S. adult (> 18 years) members of the Qualtrics Survey Panel who reported having relatives with weak or failing kidneys (N = 590). Respondents’ likelihood to be evaluated for living kidney donation are measured by self-report. Prior willingness is measured by past donation-related actions and current attitudes. Ability to benefit is measured by self-reported labor force participation and financial strain. Transplant knowledge is measured by self-report and a knowledge test, and transplant-related attitudes are measured by self-report. Average marginal effects of minority race/ethnicity and prior willingness for response to each provision in fully-adjusted models were estimated. Formal tests of mediation were conducted using the Karlson, Holm, and Breen (KHB) mediation model. Stata/MP 14.2 was used to conduct all analyses.ResultsMajorities of all groups report favorable responses to the provisions stipulated in AAKH regulation. Responses to provisions are significantly associated with race/ethnicity and prior willingness, with racial/ethnic minorities and those not previously willing to be evaluated less likely to report favorable responses to these provisions. Prior willingness differences are partially explained by group differences in ability to benefit and transplant-related knowledge and attitudes, but racial/ethnic differences largely are not.ConclusionsRegulation stemming from the AAKH initiative is likely to effectively promote LDKT, but may also exacerbate racial/ethnic disparities. Therefore, the regulation may need to be supplemented by efforts to address non-financial obstacles to LDKT in racial/ethnic minority communities in order to ensure equitable increases in LDKT rates and living donor support.

Value-Based Care in Nephrology: The Kidney Care Choices Model and Other Reforms.

The Advancing American Kidney Health (AAKH) initiative has reinvigorated the focus on improving the care of patients with advanced CKD. Multiple interventions have been planned, focusing on education campaigns for both clinicians and patients, delaying the progression of kidney disease and improving utilization of home dialysis modalities and kidney transplantation. Value-based care models for patients with advanced kidney disease are being rolled out, with the ESKD treatment choices model starting in January 2021, and the Kidney Care Choices model planned to start in January 2022. There is increasing emphasis on the role of the nephrologist as the "captain of the ship," leading efforts in care coordination as physician leaders. The transplant reforms have focused on changes to organ procurement organizations aiming to increase availability of organs, and transplants performed, both deceased and living donor, and removing financial disincentives from live organ donation. The American Society of Nephrology (ASN) and the National Kidney Foundation (NKF) are partnering with the Department of Health and Human Services to develop educational material for clinicians and patients. In this review, we discuss these reforms, potential challenges that have arisen, and potential solutions, with emphasis on the Kidney Care Choices model.