End-stage Renal Disease Network Research Articles

Improving Access to Kidney Transplantation: Perspectives From Dialysis and Transplant Staff in the Southeastern United States

Rationale & ObjectiveThere are many barriers to meeting the goal of increasing kidney transplants in the United States. It is important to understand dialysis and transplant center providers’ existing practices and identified barriers to increasing the number of dialysis patients who are evaluated for and get wait-listed for a transplant.Study DesignCross-sectional survey of dialysis unit and transplant center staff in End Stage Renal Disease Network 6 (Georgia, North Carolina, South Carolina).Setting & ParticipantsNinety-one transplant staff from all 9 transplant centers in the region and 421 dialysis staff from 421 facilities responded to the survey.PredictorsN/AOutcomeProvider perceptions of barriers faced by patients in the kidney transplant evaluation process and suggestions for improving care.Analytical ApproachMixed methods. Descriptive analyses of responses to multiple-choice questions and qualitative analysis of open-ended survey responses.ResultsThe top 5 barriers to kidney transplantation as reported by transplant staff were transportation (63.7%), low health literacy (50.5%), lack of understanding about the transplant process (37.4%), distance to transplant center (29.7%), and low socioeconomic status (28.6%). When asked how dialysis units can help patients complete the evaluation process, the most common responses from transplant center staff were educating patients about transplant (54%), helping patients through steps in the process (35%), and better communication with transplant centers (15%). When dialysis unit staff were asked what could be done to help the facility improve its transplant wait-list rate, the most common responses were educational materials for patients and staff (55%), better communication with transplant centers (12%), and transportation and financial assistance (9%).LimitationsSurvey responses are from 1 end stage renal disease network.ConclusionsDialysis units, transplant centers, and ESRD networks can work together to help patients address key barriers to transplantation to improve the country’s transplantation rate.

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Utilization of CMS pre-ESRD Kidney Disease Education services and its associations with the home dialysis therapies.

Kidney Disease Education (KDE) has been shown to improve informed dialysis selection and home dialysis use, two long-held but underachieved goals of US nephrology community. In 2010, the Center for Medicare and Medicaid Services launched a policy of KDE reimbursements for all Medicare beneficiaries with advanced chronic kidney disease. However, the incorporation of KDE service in real-world practice and its association with the home dialysis utilization has not been examined. Using the 2016 US Renal Data System linked to end-stage renal disease (ESRD) and pre-ESRD Medicare claim data, we identified all adult incident ESRD patients with active Medicare benefits at their first-ever dialysis during the study period (1 January 2010 to 31 December 2014). From these, we identified those who had at least one KDE service code before their dialysis initiation (KDE cohort) and compared them to a parsimoniously matched non-KDE control cohort in 1:4 proportions for age, gender, ESRD network, and the year of dialysis initiation. The primary outcome was home dialysis use at dialysis initiation, and secondary outcomes were home dialysis use at day 90 and anytime through the course of ESRD. Of the 369,968 qualifying incident ESRD Medicare beneficiaries with their first-ever dialysis during the study period, 3469 (0.9%) received KDE services before dialysis initiation. African American race, Hispanic ethnicity, and the presence of congestive heart failure and hypoalbuminemia were associated with significantly lower odds of receiving KDE services. Multivariate analyses showed that KDE recipients had twice the odds of initiating dialysis with home modalities (15.0% vs. 6.9%; adjusted odds ratio (aOR):95% confidence interval (CI) 2.0:1.7-2.4) and had significantly higher odds using home dialysis throughout the course of ESRD (home dialysis use at day 90 (17.6% vs. 9.9%, aOR:CI 1.7:1.4-1.9) and cumulatively (24.7% vs. 15.1%, aOR:CI 1.7:1.5-1.9)). Utilization of pre-ESRD KDE services is associated with significantly greater home dialysis utilization in the incident ESRD Medicare beneficiaries. The very low rates of utilization of these services suggest the need for focused systemic evaluations to identify and address the barriers and facilitators of this important patient-centered endeavor.

Clinical Social Work End-Of-Life Survey: Constructive Work with Patients and Family Members on Advance Directives and Medical Orders for Life-Sustaining Treatment

This article identifies how clinical social workers in medical-surgical, mental health, and nephrology settings at Walter Reed National Military Medical Center (WRNMMC) and the End-Stage Renal Disease (ESRD) Network 5 Mid-Atlantic Renal Coalition assist nephrologists and other physicians in overcoming barriers to end-of-life (EOL) care planning, particularly in patients with end-stage renal disease (ESRD) or acute kidney injury (AKI). To assess differences in practice patterns, an anonymous survey was administered to determine whether social workers were comfortable having EOL care discussions with their patients, and to also assess if these social workers were able to assist the physicians with EOL care planning. Findings showed that social workers identified multiple barriers to discussing EOL care planning. Participants also identified the most important conversations to have when discussing EOL care planning with their patients.

1770. Access to Kidney Transplantation in Persons Living with HIV and End-stage Renal Disease in Network 6

BackgroundAs persons living with HIV (PLWH) live longer, end-stage renal disease (ESRD) is emerging as a significant cause of morbidity and mortality. PLWH had a three-fold increased risk of ESRD, while also experiencing lower survival rates on dialysis compared with the general population. There are limited data on the incidence and prevalence of PLWH on dialysis. Our objective was to determine the incidence of PLWH on dialysis in ESRD Network 6 (GA, NC, SC) and assess their referral to kidney transplantation and waitlisting on the deceased donor waiting list.MethodsWe merged data from the Southeast Transplant Referral Dataset with the United States Renal Data System Medicare Part D Prescription Claims. PLWH were defined as having a prescription for antiretroviral medications or primary cause of ESRD being HIV-associated nephropathy. Descriptive analysis was performed using Student’s t-test for continuous variables and chi-squared test for categorical variables.ResultsThe dataset contained 24,587 patients (471 HIV positive) that initiated an ESRD service between 2012 and 2015. Incidence of PLWH on dialysis was 1.92%. Compared with HIV negative persons, PLWH were younger (median age 49 vs. 58, P < 0.001) and more often black (90% vs. 57%, P < 0.001). There were similar rates of referral among PLWH and HIV-negative persons (50% vs. 51%, P = 0.81), though PLWH were statistical significantly less likely to be waitlisted (8% vs. 15%, P < 0.001). PLWH had longer median time to be referred (240 days vs. 147 days, P < 0.001) and waitlisted compared with HIV-negative persons (611 days vs. 420 days, P = 0.04).ConclusionThis pilot study offers the first ESRD Network-level characterization of PLWH receiving an ESRD service proceeding through the steps of kidney transplantation. PLWH were less likely to traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant in PLWH. Disclosures All authors: No reported disclosures.

Nephrology Social Workers' Caseloads and Hourly Wages in 2014 and 2017: Findings from the National Kidney Foundation Council of Nephrology Social Workers Professional Practice Survey

In 2014 and 2017, the National Kidney Foundation Council of Nephrology Social Workers (NKF-CNSW) conducted online surveys of nephrology social workers employed in outpatient dialysis settings and transplant programs to assess caseload and salary trends at the state, national, and End-Stage Renal Disease Network levels. Between 2014 and 2017, the mean caseloads for outpatient dialysis social workers remained steady at 75 for those employed 20–31 hrs/wk, increased from 113.2 to 126.9 (up 12.1%) for those employed 32–40 hrs/wk, and increased from 116.1 to 129.5 (up 11.5%) for those employed 40 hrs/wk. Median caseloads showed a similar pattern between 2014 and 2017 for those employed 32–40 hrs/wk (110.0 to 120.0; up 9.1%) and for those employed 40 hrs/week (117.0 to 120.0; up 2.6%). Increases in mean hourly wage between 2014 and 2017 were also reported across all three employment status groups: $29.45 to $31.31 per hour (up 6.3%) for those working 20–31 hrs/wk, $28.23 to $30.62 per hour (up 8.5%) for those working 32–40 hrs/wk, and $28.21 to $30.48 per hour (up 8.0%) for dialysis social workers employed 40 hrs/wk.&#x0D; Annual pre-transplant evaluations of potential donors increased between 2014 and 2017 for transplant social workers who were employed full time (32–40 hrs/wk) and those who worked 40 hrs/wk. Specifically, the mean number of potential donor evaluations increased from 22.1 to 33.8 (up 52.9%) for those employed 32–40 hrs/wk and 23.0 to 33.8 (up 46.9%) for those employed 40 hrs/wk. Pre-transplant evaluations of potential recipients decreased for those employed full-time (283.7 to 219.2, down 22.7%) and for those employed 40 hrs/wk (315.6 to 219.2, down 30.5%). Mean hourly wage data showed an increase for transplant social workers employed full time ($30.74 to $31.50, up 2.5%) and for those employed 40 hrs/wk ($28.74 to $31.03, up 7.9%). In general, increases in social work caseloads and increases in hourly wages were found on a national level; however, variability in mean caseloads and mean hourly wages across ESRD Networks and states persists.

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study

Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. Nonconcurrent observational cohort study. Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. Demographics, geographic location, dialysis vintage, comorbid conditions. Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of2014. In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. This study relies on administrative data, with monthly recording of access use. We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.

Process evaluation of the RaDIANT community study: a dialysis facility-level intervention to increase referral for kidney transplantation

BackgroundThe Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT) was an End-Stage Renal Disease (ESRD) Network 6-developed, dialysis facility-level randomized trial testing the effectiveness of a 1-year multicomponent education and quality improvement intervention in increasing referral for kidney transplant evaluation among selected Georgia dialysis facilities.MethodsTo assess implementation of the RaDIANT intervention, we conducted a process evaluation at the conclusion of the intervention period (January–December 2014). We administered a 20-item survey to the staff involved with transplant education in 67 dialysis facilities randomized to participate in intervention activities. Survey items assessed facility participation in the intervention (fidelity and reach), helpfulness and willingness to continue intervention activities (sustainability), suggestions for improving intervention components (sustainability), and factors that may have influenced participation and study outcomes (context). We defined high fidelity to the intervention as completing 11 or more activities, and high participation in an activity as having at least 75% participation across intervention facilities.ResultsStaff from 65 of the 67 dialysis facilities completed the questionnaire, and more than half (50.8%) reported high adherence (fidelity) to RaDIANT intervention requirements. Nearly two-thirds (63.1%) of facilities reported that RaDIANT intervention activities were helpful or very helpful, with 90.8% of facilities willing to continue at least one intervention component beyond the study period. Intervention components with high participation emphasized staff and patient-level education, including in-service staff orientations, patient and family education programs, and patient educational materials. Suggested improvements for intervention activities emphasized addressing financial barriers to transplantation, with financial education materials perceived as most helpful among RaDIANT educational materials. Variation in facility-level fidelity of the RADIANT intervention did not significantly influence the mean difference in proportion of patients referred pre- (2013) and post-intervention (2014).ConclusionsWe found high fidelity to the RaDIANT multicomponent intervention at the majority of intervention facilities, with sustainability of select intervention components at intervention facilities and feasibility for dissemination across ESRD Networks. Future modification of the intervention should emphasize financial education regarding kidney transplantation and amend intervention components that facilities perceive as time-intensive or non-sustainable.Trial registrationClinicaltrials.gov number NCT02092727. Registered 13 Mar 2014 (retrospectively registered).

The effect of 6% hydroxyethyl starch (130/0.4) on acute kidney injury in paediatric cardiac surgery: a prospective, randomised trial.

We have evaluated the effect of a colloid solution on acute kidney injury in paediatric cardiac surgery. A total of 195 patients were ramdomly divided into an hydroxyethyl starch group and a control group. In the starch group, 6% hydroxyethyl starch 130/0.4 (Volulyte® ) was used as the primary fluid for volume resuscitation but was limited to 30 ml.kg-1 . In the control group, only crystalloid fluid was used during the peri-operative period. The incidence of acute kidney injury, peri-operative transfusion, clinical outcomes and laboratory data were compared. The incidence of acute kidney injury determined by Paediatric Risk, Injury, Failure, Loss, End-stage renal disease (pRIFLE) and Acute Kidney Injury Network (AKIN) criteria were no different between the two groups (starch group 40.8% vs. control group 30.0%; p = 0.150 using pRIFLE; 19.6% vs. 21.1% respectively, p = 0.602 using AKIN). There were no differences in clinical outcomes such as mortality, major adverse events, intensive care unit stay or duration of mechanical ventilation. Clotting time as measured using rotational thromboelastometry (ROTEM) was prolonged, and clot firmness after 10 min and maximal clot firmness were shorter in the starch group compared with the control group after sternal closure. There was no difference in transfusion between the two groups. Patients with acute kidney injury had worse clinical courses than those without acute kidney injury. We conclude that intra-operative use of 6% hydroxyethyl starch 130/0.4 up to 30 ml.kg-1 was not associated with postoperative acute kidney injury in paediatric cardiac patients.

Gender disparity in fistula use at initiation of hemodialysis varies markedly across ESRD networks-Analysis of USRDS data.

Gender disparities had been noted in the care of women with end stage renal disease (ESRD) in the early 2000's, including less frequent initiation of hemodialysis utilizing a fistula but more recent data have not been examined and underlying factors have not been extensively studied. Data from the United States Renal Data System (USRDS) were examined, including 202,999 hemodialysis patients. Only those who had received prior nephrology care were included. Multiple logistic regression was used, adjusted for possible confounders, including age, race, cause of ESRD, BMI, height, history of alcohol or drug abuse, medical comorbidities, ability to ambulate, time of nephrology care, type of insurance, and ESRD network. The odds of arteriovenous fistula (AVF) use at initiation of hemodialysis were significantly lower in women compared to men (OR = 0.69, 95% CI 0.67-0.71, P < 0.0001). The gender gap in AVF use at initiation was highest in New York and the upper Midwest (networks 2 and12) and smallest for Southern California and the Pacific Northwest and Alaska (18 and 16). Gender disparity was more pronounced for black women, with odds ratios for AVF use at initiation of dialysis (OR = 0.66, 95% CI 0.62-0.69), P < 0.0001 as compared to non-black (OR 0.70, 95% CI 0.68-0.73), P ≤ 0.0001. Limitations include use of USRDS data. Data misclassification or errors in data reporting may exist and certain comorbid conditions may be underreported. Data regarding rate of primary fistula non-function are also not available. Adjusted odds ratio for AVF use was significantly lower in women compared to men, independent of time of nephrology care and other predictors. The gender disparity was most pronounced for black women and also varied from 20% to 46% lower odds for AVF use in women for different ESRD networks, after controlling for possible confounding variables, suggesting that practice based factors may be of importance in explaining this important finding.

The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: A Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity

IntroductionThe United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end-stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplantation.MethodsWe describe the ASCENT (Allocation System Changes for Equity in Kidney Transplantation) study, a randomized, controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis facility−specific transplantation performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States.ResultsThis study is estimated to enroll ∼600 US dialysis facilities with low waitlisting in all 18 ESRD networks. The co-primary outcomes include change in waitlisting and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplantation, and the intent of the medical director to refer patients for transplantation evaluation.DiscussionThe results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased donor kidney waitlist and to reduce racial disparities in waitlisting.

Diabetic nephropathy as the cause of end-stage kidney disease reported on the medical evidence form CMS2728 at a single center.

Background: End-stage renal disease (ESRD) incidence due to Type 2 diabetic nephropathy (DN) is 35–50%, according to the United States Renal Data System. Methods: A single-center, retrospective cohort study to determine incidence and diagnostic accuracy for Type 2 DN as the primary cause of ESRD (Code 250.40) on the Center for Medicare & Medicaid (CMS) Medical Evidence Report form (CMS2728) submitted at renal replacement therapy initiation. All patients ≥18 years of age with a CMS2728 submitted between 1 March 2006 and 31 March 2015 at a single academic military medical center (ESRD Network 5) were included. Medical records of those with a Code 250.40 diagnosis were reviewed to determine whether they met the Kidney Disease Outcomes Quality Initiative (KDOQI) 2007 criteria for DN. Results: ESRD incidence secondary to Type 2 DN was 18.7% (56/299 individual CMS2728 submissions over 9.09 years). In all, 12/56 (21.4%) did not meet KDOQI criteria for Type 2 DN. Although all had diabetes, those not meeting criteria had shorter disease duration (P = 0.007), were more likely to have active urine sediment (P = 0.006), and were less likely to have macroalbuminuria (P = 0.037) or retinopathy (P = 0.002) prior to ESRD. On exact logistic regression, retinopathy was significantly associated with KDOQI-predicted DN [odds ratio = 19.16 (confidence interval 2.76–223.7), P = 0.0009]. Conclusions: In this single-center cohort, 21.4% identified as having Type 2 DN as the primary cause of ESRD were incorrectly assigned per KDOQI 2007 clinical criteria. If replicated in larger populations, this could have substantial implications regarding the epidemiology of ESRD in the USA.

Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada.

In the United States, kidney transplant rates vary significantly across end-stage renal disease (ESRD) networks. We conducted a population-based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1-, 5-, and 10-year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for "healthy" dialysis patients (aged 18-50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow-up of 11 years). Among 23 022 chronic dialysis patients, the 10-year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8-10.7%) to 31.4% (95% CI 16.5-47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2-0.5) to 1.5 (95% CI 1.4-1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.

Pregnancy outcomes in women on hemodialysis: a national survey.

Background. Pregnancy occurs among 1–7% of women on chronic dialysis. Experience regarding pregnancy and dialysis originates from anecdotal reports, case series and surveys. This survey updates the US nephrologists’ experience with pregnancy on hemodialysis (HD) over the past 5 years. We evaluated maternal and fetal outcomes, certain practice patterns such as dialysis regimens utilized and nephrologist knowledge and comfort level when caring for a pregnant patient on HD. Methods. An anonymous Internet-based 23-question survey was e-mailed to end-stage renal disease Networks of America program directors for forwarding to practicing nephrologists. Results. A total of 196 nephrologists responded to the survey, reporting >187 pregnancies. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week. Conclusion. Providing intensive HD is a common treatment approach when dialyzing pregnant women. Maternal and fetal outcomes can be improved. There is a trend toward better live birthrates with more intense HD. Whether more cumulative hours of dialysis per week increases the risk of preeclampsia needs to be further investigated.

Vascular Access Guidelines: Summary, Rationale, and Controversies

Dialysis vascular access management in the United States changed significantly after National Kidney Foundation-Kidney Disease Outcome Quality Initiative (NKF-KDOQI) clinical practice guidelines were first published in 1997. The Centers for Medicare and Medicaid Service adopted these guidelines and in collaboration with the End-Stage Renal Disease Networks established the Fistula First Breakthrough Initiative (FFBI) in 2003 to improve the rate of arteriovenous fistula use over arteriovenous graft and central venous catheter in the dialysis population. The implementation of guidelines and FFBI has led to a significant increase in the arteriovenous fistula use in the prevalent dialysis population. The guidelines are criticized for being opinion based and often impractical. Over the past 2 decades, the patient population undergoing dialysis has become older with complex comorbidities and challenges for creating an ideal vascular access. Advancing knowledge about access pathophysiology, improved treatment options, and improved process of care with team approach model point toward diminishing relevance of few of the existing guidelines. Moreover, several guidelines remain controversial and may be leading to clinical decisions that may be unfavorable to the patients. The review discusses the historical aspect of vascular access care in the United States and evolution of current practice standards and controversies surrounding few of these guidelines in the current time.

Geographic variation of parathyroidectomy in patients receiving hemodialysis: a retrospective cohort analysis.

BackgroundSecondary hyperparathyroidism (SHPT) is associated with adverse outcomes in patients receiving maintenance dialysis. Parathyroidectomy is a treatment for SHPT; whether parathyroidectomy utilization varies geographically in the US is unknown.MethodsA retrospective cohort analysis was undertaken to identify all patients aged 18 years or older who were receiving in-center hemodialysis between 2007 and 2009, were covered by Medicare Parts A and B, and had been receiving hemodialysis for at least 1 year. Parathyroidectomy was identified from inpatient claims using relevant International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Patient characteristics and End-Stage Renal Disease Network (a proxy for geography) were ascertained. Adjusted odds ratios for parathyroidectomy were estimated from a logistic model.ResultsA total of 286,569 patients satisfied inclusion criteria, of whom 4435 (1.5%) underwent PTX. After adjustment for a variety of patient characteristics, there was a 2-fold difference in adjusted odds of parathyroidectomy between the most- and least-frequently performing regions. Adjusted odds ratios were more than 20% higher than average in four networks, and more than 20% lower in four networks.ConclusionsParathyroidectomy use varies substantially by geography in the US; the factors responsible should be further investigated.

APOL1 renal-risk genotypes associate with longer hemodialysis survival in prevalent nondiabetic African American patients with end-stage renal disease

Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided bythe ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis.

Unmet Supportive Care Needs in U.S. Dialysis Centers and Lack of Knowledge of Available Resources to Address Them

ContextBecause of high symptom burden, numerous comorbidities, and shortened life expectancy, dialysis patients are increasingly recognized as appropriate candidates for early and continuous supportive care. ObjectivesThe objectives of this study were to describe dialysis professionals' perceptions of the adequacy of supportive care in dialysis centers, barriers to providing it, suggestions for improving it, and familiarity with the existing evidence-based resources for supportive care of dialysis patients. MethodsThe Coalition for Supportive Care of Kidney Patients conducted an online survey of dialysis professionals and administrators solicited through the 18 End-Stage Renal Disease Networks and the Renal Physicians Association. ResultsOnly 4.5% of 487 respondents believed their dialysis centers were presently providing high-quality supportive care. They identified bereavement support, spiritual support, and end-of-life care discussions as the top three unmet needs. They reported that lack of a predictive algorithm for prognosis was the top barrier, and “guidelines to help with decision-making in seriously ill patients” was the top priority to improve supportive care. A majority of respondents were unaware that an evidence-based validated prognostic model and a clinical practice guideline to help with decision-making were already available. ConclusionDialysis professionals report significant unmet supportive care needs and barriers in their centers with only a small minority rating themselves as competently providing supportive care. There is an urgent need for education of dialysis professionals about available supportive care resources to provide quality supportive care to dialysis patients.

Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care

Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ² test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients receiving hemodialysis in these networks, the data on 464,547 individuals who were beginning renal replacement therapy were analyzed. Analysis was started April 1, 2013, and ended August 3, 2014. Mortality hazard variation between ESRD Network Programs in the United States and incident AVF frequency. Of the 464,547 patients beginning hemodialysis in this cohort, first hemodialysis with an AVF ranged from 11.1% to 22.2% depending on the ESRD Network in which they maintained residency (P < .001). Similarly, corrected mortality hazard varied by 28% (hazard ratios from 0.99 [95% CI, 0.96-1.03] to 1.27 [95% CI, 1.22-1.31]; P < .001). Logistic regression determined nephrology care to increase the odds of a patient beginning hemodialysis using an AVF by 11-fold (odds ratio, 11.42 [95% CI, 10.93-11.93]; P < .001); congestive heart failure was a negative correlatefold (odds ratio, 0.65 [95% CI, 0.64-0.67]; P < .001). No region achieved the 50% Fistula First Breakthrough Initiative (now known as Fistula First Catheter Last) target for incident AVF access. Marked regional variation in functional incident AVF frequency and risk-adjusted ESRD mortality exists across the United States. Differences in access to preoperative nephrology care and patient comorbidities may explain some of these variations, but an opportunity to implement best-practice guidelines exists.

Nephrology Social Workers’ Caseloads and Hourly Wages in 2010 and 2014: Findings from the National Kidney Foundation Council of Nephrology Social Work Professional Practice Survey

In 2010 and 2014, the National Kidney Foundation Council of Nephrology Social Workers (NKF-CNSW) conducted online surveys of nephrology social workers to assess caseload and salary trends at the state, national, and End-Stage Renal Disease Network level. Between 2010 and 2014, outpatient dialysis social workers experienced decreases in mean caseload size from 79 to 75 (down 5.1%) for those employed 20–31 hrs/wk, 121 to 113 (down6.6%) for those employed 32–40 hrs/wk, and 126 to 116 (down 7.9%) for those employed 40 hrs/wk. Increases in mean hourly wage between 2010 and 2014 were also reported across all three employment status groups: $28.16 to $29.45 per hour (up 4.6%) for those working 20–31 hrs/wk, $27.18 to $28.23 per hour (up 3.9%) for those working 32–40 hrs/wk, and $26.93 to $28.21 per hour (up 4.8%) for social workers employed 40 hrs/wk. Pre-transplant evaluations of potential donors decreased between 2010 and 2014 for social workers who were employed full time (32–40 hrs/wk) and those who worked 40 hrs/wk. Specifically, the mean number of potential donor evaluations declined from 40.5 to 22.1 (down 45.4%) for those employed 32–40 hrs/wk and 44.7 to 23.0 (down 48.5%) for those employed 40 hrs/wk. However, pre-transplant evaluations of potential recipients decreased for those employed full-time (522.5 to 283.7, down 45.7%) and increased for those employed 40 hrs/wk (232.6 to 315.6, up 35.7%). Mean hourly wage data showed a slight increase for transplant social workers employed full-time ($29.56 to $30.74, up 4%) and a slight decrease for those employed 40 hrs/wk ($29.79 to $28.74, down 3.5%). In general, decreases in social work caseload and increases in hourly wages were found on a national level; however, variability across states requires further attention.