Kidney Transplant Care Research Articles

Translation of evidence into kidney transplant clinical practice: managing drug-lab interactions by a context-aware clinical decision support system

BackgroundDrug-laboratory (lab) interactions (DLIs) are a common source of preventable medication errors. Clinical decision support systems (CDSSs) are promising tools to decrease such errors by improving prescription quality in terms of lab values. However, alert fatigue counteracts their impact. We aimed to develop a novel user-friendly, evidence-based, clinical context-aware CDSS to alert nephrologists about DLIs clinically important lab values in prescriptions of kidney recipients.MethodsFor the most frequently prescribed medications identified by a prospective cross-sectional study in a kidney transplant clinic, DLI-rules were extracted using main pharmacology references and clinical inputs from clinicians. A CDSS was then developed linking a computerized prescription system and lab records. The system performance was tested using data of both fictitious and real patients. The “Questionnaire for User Interface Satisfaction” was used to measure user satisfaction of the human-computer interface.ResultsAmong 27 study medications, 17 needed adjustments regarding renal function, 15 required considerations based on hepatic function, 8 had drug-pregnancy interactions, and 13 required baselines or follow-up lab monitoring. Using IF & THEN rules and the contents of associated alert, a DLI-alerting CDSS was designed. To avoid alert fatigue, the alert appearance was considered as interruptive only when medications with serious risks were contraindicated or needed to be discontinued or adjusted. Other alerts appeared in a non-interruptive mode with visual clues on the prescription window for easy, intuitive notice. When the system was used for real 100 patients, it correctly detected 260 DLIs and displayed 249 monitoring, seven hepatic, four pregnancy, and none renal alerts. The system delivered patient-specific recommendations based on individual lab values in real-time. Clinicians were highly satisfied with the usability of the system.ConclusionsTo our knowledge, this is the first study of a comprehensive DLI-CDSS for kidney transplant care. By alerting on considerations in renal and hepatic dysfunctions, maternal and fetal toxicity, or required lab monitoring, this system can potentially improve medication safety in kidney recipients. Our experience provides a strong foundation for designing specialized systems to promote individualized transplant follow-up care.

The Role of Telemedicine in Kidney Transplantation: Opportunities and Challenges.

Kidney transplantation is the treatment of choice for patients with advanced kidney disease who are medically and surgically fit to undergo the procedure and have reasonable life expectancy. It provides improved survival and quality of life for recipients and overall cost savings to the health care system (1,2). The process of undergoing kidney transplantation involves several phases of care including pretransplant referral and evaluation, waitlist management, and follow-up. In all phases of care, transplant centers interface with candidates and recipients who live across a wide geographic range, with many patients traveling significant distances to a transplant center (3). In the United States, 41,077 candidates were added to the waiting list in 2019 and 23,401 received a transplant. There are approximately 220,000 prevalent kidney transplant recipients and 250 centers actively performing kidney transplants (4). With this continually growing patient population and a limited number of transplant providers, transplant centers are in need of innovative models of health care delivery that ( 1 ) allow them to reach and monitor candidates and recipients, particularly those that live far away; and ( 2 ) improve utilization of transplant center resources. Telemedicine, the practice of medicine using technology to deliver care at a distance, represents an opportunity to do both. The technology used may include telehealth videoconferencing (TVC), the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communication (5). Although telemedicine has been successfully used by numerous specialties, its utilization in the field of kidney transplantation has been lagging. Telemedicine has the potential to affect and improve the delivery of kidney transplant care through the following: ( 1 ) replacing or supplementing in-person visits with virtual visits through TVC, ( 2 ) electronic consultation, and ( 3 ) remote monitoring and provision of education through mobile technology (6). Here we focus on TVC and highlight opportunities for its use …

Pediatric Kidney Transplant Experience in Ontario: A Review of Division of the Surgical and Medical Management Across Local Tertiary Care Institutions.

Background:Our institution is the largest pediatric kidney transplantation (KT) center in Canada and the referral center for pediatric KT in Ontario. Pediatric KT recipients are referred to our center for KT and transferred back to their local tertiary care institutions for post-transplant care. This investigation assesses whether the current system of transferring patients back to their local tertiary care institutions following KT allows decreased burden and distribution of resources from a single centralized surgical center.Methods:A retrospective review of KT performed at our institution between 2000 and 2015 was performed. Patients were divided into those who began their chronic kidney disease (CKD) care at our institution and those who began their care elsewhere. Readmission to our institution within 1 year of KT for surgical and nonsurgical complications was compared. The geographical proximity of patients to our institution and institution of initial CKD care was assessed quantitatively and mapped visually.Results:Of 324 patients who underwent KT, 244 (75.3%) began their CKD care at our institution. Those who began their CKD care at other institutions had shorter initial admissions to our institution (17 [14-24] vs 14 [12-17], P < .0001) and were less likely to be readmitted to our institution for nonsurgical concerns at <6 months after transplant (P < .0001) and 6 to 12 months after transplant (P < .0001). There were similar readmissions for complications requiring surgical management. The relationship between the center of CKD initiation and readmission remained significant on multivariate analysis. There was a significant difference in distance (km) to our institution between the 2 groups (46 [interquartile range = 24-109] vs 203 [117-406], P < .0001).Conclusion:Patients who are geographically distanced from our institution began their CKD care at their closest institution and were managed effectively at those institutions following initial discharge/transfer of care, suggesting that there is an effective distribution of health care resources with regard to CKD and KT care.

Management of Pediatric Kidney Transplant Patients During the COVID-19 Pandemic: Guidance From the Canadian Society of Transplantation Pediatric Group.

Purpose of the program:To provide guidance on the management of pediatric kidney transplant patients during the COVID-19 pandemic.Sources of information:Program-specific documents, preexisting, and related to COVID-19; documents from provincial, national, and international kidney transplant societies/agencies and organ procurement agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature.Methods:Challenges in the care of pediatric kidney transplant patients during the COVID-19 pandemic were highlighted within the Canadian Society of Transplantation (CST) Pediatric Group. It identified pediatric kidney transplant nephrologists (including a pediatric nephrologist ethicist) across the country and formed a workgroup. The initial guidance document was drafted and members of the workgroup reviewed and discussed all suggestions in detail via e-mail and virtual meetings. Disagreements were resolved by consensus. The document was reviewed by the CST Kidney Transplant Working Group, by the Canadian Society of Nephrology (CSN) COVID-19 Rapid Response Team (RRT), and an infectious disease expert. The suggestions were presented at an interactive webinar sponsored by CSN in collaboration with the CST and Canadian Association of Pediatric Nephrologists (CAPN), and attended by pediatric kidney health care professionals for further peer input. Final revisions were made based on feedback received. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity.Key findings:We identified 8 key areas of pediatric kidney transplant care that may be affected by the COVID-19 pandemic: (1) transplant activity, (2) outpatient clinic activity, (3) monitoring, (4) multidisciplinary care, (5) medications (immunosuppression and others), (6) patient/family education/support, (7) school and employment, and (8) management of pediatric kidney transplant patients who are COVID-19 positive. We make specific suggestions for each of these areas.Limitations:A full systematic review of available literature was not undertaken for the sake of expediency in development of this guideline. There is a paucity of literature to support evidence-based recommendations at this time. Instead, these guidelines were formulated based on expert opinion derived from available knowledge/experience and are subject to the biases associated with this level of evidence. The parallel review process that was created to expedite the publication of this work may not be as robust as standard arms’ length peer review processes.Implications:These recommendations are meant to serve as a guide to pediatric kidney transplant directors, clinicians, and administrators for providing the best patient care in the context of limited resources while protecting patients and health care providers wherever possible by limiting exposure to COVID-19. We recognize that recommendations may not be applicable to all provincial/local health authority practices and that they may not be delivered to all patients given the time and resource constraints affecting the individual provincial/local health jurisdiction.

Perspectives on Quality of Care in Kidney Transplantation: A Semistructured Interview Study.

There is currently no agreement as to what constitutes quality transplant care, and there is a lack of consistency in the approach to assessing transplantation quality. We aimed to ascertain the views of patients, clinicians, and program administrators about quality care for kidney transplant patients. Semistructured qualitative interviews were conducted with 20 patients, 17 physicians, and 11 program administrators. Transcripts were analyzed using inductive thematic analysis. We identified 8 themes: access to treatment (standardized transplant referral, lengthy transplant evaluation process, lengthy living donor evaluation); accessibility of services (alternative access options, flexible appointment availability, appropriate amount of follow-up, barriers for accessing care); program resources (comprehensive multidisciplinary care, knowledgeable staff, peer support groups, educational resources, patient navigators/ advocates); communication of information (taking time to answer questions, clear communication about treatment, communication tailored to patients, health promotion and illness prevention); attitude of care providers (positive and supportive attitude, patient centered care); health outcomes (freedom from dialysis, Long-term health, short-term health, fear of infections); patient satisfaction (returning to normal life, patient satisfaction with care); and safety (reducing infection risk, quick response to complications, patient health status on the waitlist). There is a need to move beyond basic clinical outcomes and focus on increasing ease of access, the patient-provider relationship, and outcomes that are most important to the patients.

Postoperative Care in Kidney Transplantation: A Comparison Between Controlled and Uncontrolled Donation After Circulatory Death

Recent research in kidney transplantation has revealed differences in the evolution of renal function among patients transplanted from 2 alternative programs for donation after circulatory death (DCD). A retrospective, observational, single-center study was carried out from 2013 to 2016 at a level III hospital intensive care unit (ICU) to assess the progression of kidney recipients after transplants from uncontrolled DCD (uDCD) or controlled DCD (cDCD). The following variables were collected for data analysis: demographics, comorbidities, type of donation, lactate, hemoglobin and glucose levels at ICU admission, creatinine concentration at ICU admission, at-hospital ward transfer, at-hospital discharge, radioisotope imaging results, ICU and in-hospital length of stay, and mortality. There were 87 patients eligible for analysis, 42.5% of which were uDCD recipients. Improvement in kidney function was significantly delayed after uDCD compared with cDCD. A multivariate analysis showed that both uDCD and lactate levels at ICU admission increase the risk of poor outcome after renal transplantation. No deaths were registered in either patient group. Our results suggest that kidney transplantation recipients from uDCD recover renal function at a slower rate than patients transplanted from cDCD, a factor that does not affect mortality.

Case Mix, Patterns of Care, and Inpatient Outcomes Among Ontario Kidney Transplant Centers: A Population-Based Study.

Background:Significant variation in both patient case mix and the structure of care in kidney transplantation has been previously described in the United States.Objective:The objective of our study was to characterize patient case mix, patterns of care, and inpatient outcomes across 5 kidney transplant centers in the province of Ontario, Canada.Design:This was a retrospective population-based cohort study using health care administrative databases.Setting:The setting is Ontario, Canada.Patients:We included adult (≥18 years) transplant recipients who received a primary, solitary kidney between January 1, 2000, and December 31, 2013 (N = 5037).Methods:Using linked administrative health care databases, we characterized kidney transplant recipient and donor factors, center characteristics, provider characteristics, and inpatient outcomes across transplant centers in Ontario. To compare case mix–adjusted differences in length of stay across centers, multivariable Cox proportional hazards regression was used to obtain hazard ratios (HRs) for each center relative to the average across all centers. Center volume and provider characteristics were added to the models to examine whether these factors explain differences in length of stay across centers.Results:We noted significant differences across transplant centers in patient race, cause of end-stage renal disease, body mass index, comorbidities, time on dialysis, and donor type. Mean annual transplant center volumes during the study period ranged between 51.5 (9.3) and 101.7 (23.9) transplants/year across centers (P < .0001). Physician specialty most responsible for in-hospital transplant care varied significantly across centers with the most common combination being nephrologist and urologist. Less than 31 deaths occurred in hospital during the index transplant admission but mortality risk did not differ significantly between centers. Overall, 25.1% of recipients required dialysis in hospital post transplantation (range across centers 18.3%-33.5%, P < .0001) and 24.7% of recipients spent time in the intensive care unit (ICU; range across centers: 5.7%-58.0%, P < .0001). The proportion of participants requiring dialysis did not change with time (P = .12), whereas the proportion staying in the ICU increased steadily over time (P < .0001). The median length of stay in hospital after transplantation ranged from 7 to 9 days across centers (P < .0001) and decreased significantly over time. After adjusting for patient case mix as well as center and provider factors, HRs for length of stay censored at the time of death ranged between 0.75 (95% confidence interval [CI]: 0.69-0.82) and 1.29 (95% CI: 1.20-1.38) across centers. Center volume and provider experience were not independently associated with length of hospital stay.Limitations:Data were missing (0.8%-18.4%) for certain covariates of interest.Conclusions:This study found significant heterogeneity across kidney transplant centers in case mix, practice patterns, and inpatient outcomes. Future studies are needed to examine the influence of length of stay and practice patterns on long-term outcomes such as patient/graft survival and quality of life.

Changing Paradigms in the Management of Rejection in Kidney Transplantation: Evolving From Protocol-Based Care to the Era of P4 Medicine.

Purpose of review:P4 medicine denotes an evolving field of medicine encompassing predictive, preventive, personalized, and participatory medicine. Using the example of kidney allograft rejection because of donor-recipient incompatibility in human leukocyte antigens, this review outlines P4 medicine’s relevance to the various stages of the kidney transplant cycle.Sources of information:A search for English articles was conducted in Medline via OvidSP (up to August 18, 2016) using a combination of subject headings (MeSH) and free text in titles, abstracts, and author keywords for the concepts kidney transplantation and P4 medicine. The electronic database search was expanded further on particular subject headings.Findings:Available histocompatibility methods exemplify current applications of the predictive and preventive domains of P4 medicine in kidney transplant recipients’ care. Pharmacogenomics are discussed as means to facilitate personalized immunosuppression regimens and promotion of active patient participation as a means to improve adherence.Limitations:For simplicity, this review focuses on rejection. P4 medicine, however, should more broadly address health concerns in kidney transplant recipients, including competing outcomes such as infections, malignancies, and cardiovascular disease. This review highlights how biomarkers to evaluate these competing outcomes warrant validation and standardization prior to their incorporation into clinical practice.Implications:Consideration of all 4 domains of the P4 medicine framework when caring for and/or studying kidney transplant recipients has the potential of increasing therapeutic efficiency, minimizing adverse effects, decreasing health care costs, and maximizing wellness. Technologies to gauge immune competency, immunosuppression requirements, and early/reversible immune-mediated injuries are required to optimize kidney transplant care.

Care and outcomes of end-stage kidney disease patients in times of armed conflict: recommendations for action.

Conflicts can lead to significant disruption in the care of endstage kidney disease (ESKD) patients. The purpose of this paper is to review the available literature on the care of ESKD patients in times of armed conflict and make recommendations for action. A review of all PubMed-published reports between 1965 and 2015 about the care of ESKD patients at the time of conflict. We excluded articles that reported on acute kidney injury and natural disasters. We found a total of 12 reports on dialysis care and/or kidney transplant care from five armed conflicts and resulting refugee crises. These conflicts led to significant shortage of staff and resources and caused several obstacles in providing adequate dialysis to ESKD patients. In one study, the mortality rate of patients on automated peritoneal dialysis was as high as 95%. The kidney transplantation rate decreased in all but one of the reports about kidney transplant care and patients had difficulties securing their immunosuppressive medications. ESKD patients, especially dialysis patients, comprise a severely vulnerable population during conflicts. Their care can be disrupted and altered leading to a substantial increase in their mortality rate. Efforts to improve their care during conflicts are needed.

Variation in structure and delivery of care between kidney transplant centers in the United States.

Although the United States possesses one of the most comprehensive transplant registries in the world, nationally representative data on how transplant care is structured and delivered is lacking. Therefore, we surveyed all 208 adult kidney transplant centers in the United States, excluding 37 pediatric and 58 inactive adult centers. Respondents were asked about the characteristics of their kidney transplant programs (25 items), the structure and process of care (18 items), coordination of care (10 items), and the characteristics of transplant physicians and surgeons (9 items). The survey was completed by directors of 156 transplant centers (75% response). The results demonstrated significant variation between centers in several domains. Sixty-five percent of transplant centers do not have a dedicated transplant pharmacist in outpatient care. Two thirds of transplant centers do not see the kidney transplant recipients at least monthly during the first year. Less than 30% of centers perform joint sit-down or walking rounds between nephrology and transplant surgery. There was significant variation in the structure and process of care in kidney transplantation. This implies variation in the use of resources at the transplant centers. This variation should be studied to determine best practices associated with optimal kidney allograft and patient survival.

Deceased Donor Kidney Transplant: Organ Donation and Utilization in Ethnic Minorities. Review of The SRTR Annual Report.

Background: Previous studies have shown that minorities and vulnerable populations experience a suboptimal access to kidney transplantation due to cultural, educational and geografic barriers, with discrepancies between potential and actual donation in minorities. We analyzed differences in deceased kidney donation and utilization between different ethnic groups, as surrogate of access to kidney transplantation for adult pts. Material and Methods: Analysis of the SRTR annual data report (public data). Over the analyzed decade (2000/01-2010/11) the overall deceased kidney donation rate ( / 1,000 deaths) has increased from 16.4 to 19.6 with variations between ethnic groups. Donation has remained unchanged for Caucasians (C) from 18 to 19, almost doubled for African Americans (AA) from 9.2 to 17.9, increased from 20.6 to 28 for Hispanic (H), from 3.1 to 5.3 in other/unknown (O/U) ethnicities, unchanged for Asians (A), 6.8 vs 6.3. The overall % of organs discarded has also increased from 12.68 to 17.93, with a trend to higher discard in AA (7.69) and O/U (6.6) compared to C (4.99) and H (4.11). In the same period of time the overall number of active listed patient has increased from 39,564 to 54,001. The percentage of total distribution of pts waiting for kidney transplant shows a decline for C (45.5 to 40.3) overall stability for AA (34.5 to 33.5) and O/U (1.3 to 1.3) and increase for H (12.8 to 17.7) and A (6 to 7.3). Similar trend for newly listed patients in these ethnic groups: C 50.9 to 46.5, AA 29.3 and 29.3, other 1.2 to 1.3, H 13 to 16.5. Even though the total annual number of kidney transplant has increased in all ethnic groups, since 2006 (2006 vs 2011), it has decreased in C (9,005 to 8,388) and O/U (219 to 188) and increased in AA (3,991 to 4,174), H (2,143 to 2,340) and A (843 to 965). Conclusions: These data suggest that the rate of kidney donation/transplantation has increased in minorities and may reflect a possible improvement in kidney transplant care access in these populations. The increase in deceased kidney donation seems to be more pronounced in AA and H. The increased kidney discard may reflects a more aggressive approach in provisional organ acceptance and not necessarily related to a specific ethnic group. Study limitation: data review not capturing multifactorial barriers for different ethnic groups. Patient education remains a key factor to improve access to transplantation for minorities and all other pts.

Optimal use of corticosteroids in nephrology

Abstract The usage of corticosteroids is widespread in nephrology both in the treatment of patients with native kidney diseases and of patients who have received a kidney transplant. In glomerular diseases, steroids are part of most immunosuppressive regimens applied nowadays, and only few steroid-free immunosuppressive regimens have been reported on. It is my hope that - with the introduction of more targeted therapies - corticosteroid dosage can be reduced or eliminated completely in the future. Although corticosteroids have been the mainstay in the immunosuppressive treatment of patients who received a kidney transplant, there has been a long-standing interest in steroid avoidance and withdrawal (SAW). However, there is an ongoing debate whether SAW can be considered to be the standard of care in kidney transplantation at this moment.

Genetic determinants of renal transplant outcome: where do we stand?

Kidney transplantation has become the preferred method of renal replacement. However, the rate of long term allograft survival has not changed over the last decade. Donor and recipient genetic interplay influences kidney transplant outcome but our knowledge of these complex interactions is limited. Until recently, investigations have been limited to small candidate gene studies, usually restricted to allograft recipients. Genome-wide association studies have been slow to emerge in transplantation but the first has recently been reported and will be reviewed here. Much larger studies involving donor and recipients pairs are ongoing. We are now entering the era of epigenetics and whole genome sequencing which will hopefully provide a more in-depth knowledge of the genetic influences on renal transplant outcome. This may lead to a more accurate assessment of post-transplant risk, potentially allowing for the development of risk predication models leading to a more personalized approach to kidney transplant care. In this article, we examine the current and emerging literature in the field and discuss the limitations of current studies and technologies.

Complementing donor-specific antibody testing

New data suggest that among kidney transplant recipients, those whose serum contains donor-specific antibodies that bind C1q fare the worst. Although these findings are intriguing, several unanswered questions remain and changing practice to include a C1q binding assay as standard of care in kidney transplantation would be premature.

The Quality of Health Insurance Service Delivery for Kidney Transplant Recipients: A Patient Perspective

Increased attention has been devoted to improving quality care in kidney transplantation. The discourse on quality care has focused on transplant center metrics and other clinical parameters. However, there has been little discussion on the quality of health insurance service delivery, which may be critical to kidney recipients' access to transplantation and immunosuppression. This paper describes and provides a framework for characterizing kidney transplant recipients' positive and negative interactions with their insurers. A consecutive cohort of kidney recipients (n = 87) participated in semistructured interviews on their interactions with insurance agencies. Patients reported negative (37%) and/or neutral or positive (79%) interactions with their insurer (a subset [16%] reported both). Perceived negative experiences included: poor service, logistical difficulties with confusing and time-consuming paperwork, poor communication, rude behavior and concerns about adequate coverage. Positive experiences related to: having good coverage, a simple application process, straightforward transactions and helpful communication. Findings suggest that even when patients have insurance coverage, difficult interactions with insurers and limited skills in navigating insurance options may limit their access to needed medications and health services. Future research is needed to test this hypothesis in a larger population.

Effects of a clinical pathway on quality of care in kidney transplantation: a non-randomized clinical trial

Standardization of care is essential for improving outcome of kidney transplantation (KT). Clinical pathways (CPs) are known to standardize and improve perioperative care for a number of interventions. In transplantation medicine, however, pertinent evidence is very limited. This study evaluates effects of a CP on quality of care in KT. Consecutive patients (n=32) undergoing KT between July 2006 and August 2007 who were treated with a CP were compared to patients (n=44) treated without CP between January 2005 and June 2006. Several quality indicators regarding process and outcome were compared between groups. Quality of care was significantly higher in the CP group for the following indicators: timely removal of central venous catheters, wound drains, and Foley catheters and control of cyclosporine levels, respiratory exercising, and pain control. Median stay decreased non-significantly from 21.4 to 18.3 days. There was significantly less delayed graft function in the CP group. All other outcome indicators showed no significant differences. Implementation of a CP for KT improves the quality of perioperative treatment by standardizing care. Regarding effects on outcome, no clear conclusion can be drawn. We recommend that large randomized studies are conducted to evaluate the latter issue.

Effects of self‐efficacy, self‐care behaviours on depressive symptom of Taiwanese kidney transplant recipients

The aim of this study was to examine the effect of self-efficacy on depression and to consider the mediating effect of self-care behaviour. Depression is a problem for kidney transplant recipients and can compromise their quality of life. From other studies on chronic illnesses, self-efficacy and self-care behaviour have been considered to be potential determinants for depressive symptoms. However, none of these previous studies have investigated the relationships among these variables in kidney transplantation recipients. A cross-sectional survey employing correlation design and purposive sampling was used. One hundred and seventy-seven persons who had received a kidney transplant participated. A self-administrated questionnaire and a medical record audit were used to collect data. The data were analysed using correlation and hierarchical linear regression methods. The average score of depressive symptoms was 8.61 SD 7.64. Among the participants in the study, 32.8% had scores of depressive symptoms higher than 11 (indicating mild to severe symptoms of depression). Self-efficacy and self-care behaviour had direct negative effects on depressive symptoms. Self-care behaviour had partial mediating effect on the relationship between self-efficacy and depression. Total variance explained was 23%. Depressive symptoms are still a problem that need to be addressed among kidney transplantation patients. Patients who have higher self-efficacy and higher self-care behaviour will have lower depressive symptoms. Our results support that self-efficacy is the significant predictor of depressive symptoms. Self-efficacy is a powerful and modifiable determinant of depressive symptoms. We should design interventions that focus not only on the skill aspects of self-care behaviour but also on those that have a strong connection with self-efficacy. We could incorporate the self-efficacy-enhanced strategies as proposed by social cognitive theory into the kidney transplantation care programme.

Message from the Chairperson

Dietetics, as we have been accustomed to, recently has changed dramatically with the legislative passage of the Beneficiary Improvement & Protection Act of 2000. Prospectively, the profession of dietetics will go down in history with the implementation of the Medicare Medical Nutrition Therapy (MNT) Act of 2001. For the first time, the Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Finance Administration, now covers MNT education to specific outpatient Medicare beneficiaries. This coverage falls under Medicare Part B for clients having a diagnosis of diabetes and/or chronic kidney disease. For ease of definition, Medicare will reimburse qualified dietitians and nutrition professionals who enroll in the Medicare program regardless of whether they provide MNT services in an independent practice setting or hospital outpatient department. Reimbursement for these MNT services does not include hospital inpatients, skilled nursing facility residents, or hospice patients. CMS has defined renal disease as chronic renal insufficiency for patients with a glomerular filtration rate between 13 to 50 mL/min and for post–kidney transplant care after hospital discharge. The final rule on Medicare MNT was issued on November 1, 2001. CMS clarified and expanded the definition for renal disease coverage that includes end-stage renal disease beneficiaries who are not receiving dialysis. In addition, it has extended the time period for which MNT would be covered for post–kidney transplant beneficiaries from 6 months to 36 months. To become a qualified provider, CMS will allow persons who are credentialed as “registered dietitians” with the American Dietetic Association (ADA) Commission on Dietetic Registration to use those credentials for proof of education and required professional experience. After completing the necessary enrollment forms, additional documents that may need to be submitted besides verification of “registered” status include a copy of state licensure or certification, if applicable, and a diploma indicating completion of a minimum of a bachelor's degree. A signed statement verifying completion of a supervised practice and/or internship program may also be needed. If practicing in more than 1 state, separate enrollment forms for each state and separate state licensure certification must be submitted. If a decision is made to pursue nutrition education reimbursement for the diabetic and/or chronic kidney disease client, which has been lack there of from Medicare in the past, be certain to investigate the options closely and carefully to become a Medicare MNT provider. The provider enrollment form can be accessed at the CMS Web site, which is http://www.hcfa.gov/Medicare/enrollment. Additional information can also be obtained through the ADA's Web site, which is http://www.eatright.org/gov/reimbursement.html. Another closely associated announcement recently has transpired in February 2002. The National Kidney Foundation (NKF) published the release of the Kidney/Disease Outcomes Quality Initiatives (K/DOQI) for chronic kidney disease. Details of these clinical practice guidelines can be found in the American Journal of Kidney Diseases and/or at the NKF Web site, which is http://www.kidney.org. The close connection between the Medicare MNT bill for chronic kidney disease and the K/DOQI clinical practice guidelines is paramount. Become informed and determine which reimbursement option is the most beneficial to you, the nutrition professional expert. It is now time for me to “switch hats” for the final time as the CRN/Clinical Nephrology Meetings (CNM) 2001-2002 Program Chair. I am grateful and very thankful for having the opportunity to work with 2 excellent and supportive Program Planning Committees and the NKF staff since the spring of 2000. They have assisted me with the detail planning and implementation of the successful 2001 CNM that was in Orlando, FL, last April and the April 2002 CNM in Chicago, IL. I am pleased and honored to hand over the reigns of the CRN/CNM Program Chair position to my successor, Cathi J. Martin, RD, CSR, LD, for CNM 2003-2004. She was my Co-Chair for CNM 2002 and also served on the CNM 2001 Program Planning Committee. Cathi is a Nephrology Research Coordinator at Vanderbilt University in Nashville, TN. She is also the CRN, Region II Alternate Representative and is currently the ADA-Renal Practice Group's Renal Nutrition Forum Newsletter Managing Editor. I have great confidence in her as she begins to “design” the CRN tracks for CNM 2003, which will be held in Dallas, TX, next April. Cathi welcomes your comments, suggestions, and ideas for CNM 2003 and can be reached via e-mail at [email protected] . In closing, I would like to share with you some words of wisdom. We are in the age of new opportunities for dietetics as MNT practitioners. Always remember that change is good and that we need to keep moving forward to face the new challenges that will occur. We also need to reflect back on where we have been to appreciate where we are going!