General Nephrologists Research Articles

Management of immunosuppressive therapy after functional renal graft failure: results of a practice survey of French-speaking nephrologists

The management of patients with kidney transplant failure (KTF) remains a complex process involving multiple stakeholders. A working group of the Transplantation Commission of the French-speaking Society of Nephrology, Dialysis and Transplantation (SFNDT) conducted a survey on the management of immunosuppressants (IS) after KTF among nephrologists at transplant centres and general nephrologists in France, Switzerland and Belgium between March and June 2023. We analysed 232 replies from 58 nephrologists at transplant centres and 174 general nephrologists, aged 43.6 (+10.6) years. In the first three months following KTF, nephrologists reported discontinuing antimetabolite, calcineurin inhibitor (CNI) and corticosteroid treatment in 83%, 39.9% and 25.8% of cases respectively. Conversely, some nephrologists reported that they were continuing to use CNI (14%) and corticosteroids (19.1%) on a long-term basis. The patient’s comorbidities associated with the discontinuation of IS treatment are cancer and opportunistic infections as KT’s complications and presence of diabetes mellitus at KTF, whereas humoral rejection encourages the IS to be maintained. Transplantectomy is proposed by nephrologists most often for graft intolerance syndrome (86.5%), more rarely to discontinue IS (17.6%) or in the absence of plans of new transplantation (9.3%). In multivariate analyses, the presence of a protocol in the centre facilitated the management of IS by the general nephrologists. The management of IS after AFG by French-speaking nephrologists is heterogeneous. Specific prospective studies are needed to establish new best practice recommendations, based on more robust evidence, which could encourage better adherence by nephrologists.

The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants.

The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.

Kidney Transplant Practice in Pandemic Times: Lessons Learned for the Future.

Kidney Transplant Practice in Pandemic Times: Lessons Learned for the Future.

Understanding Donor-derived Cell-free DNA in Kidney Transplantation: An Overview and Case-based Guide for Clinicians.

Kidney transplant recipients undergo lifelong monitoring of allograft function and evaluation for transplant complications. The current monitoring paradigm utilizes blood, urine, and tissue markers that are insensitive, nonspecific, or invasive to obtain. As a result, problems are detected late, after significant damage has accrued, and often beyond the time at which complete resolution is possible. Indeed, most kidney transplants eventually fail, usually because of chronic rejection and other undetected injury. There is a clear need for a transplant-specific biomarker that enables a proactive approach to monitoring via early detection of reversible pathology. A biomarker that supports timely and personalized treatment would assist in achieving the ultimate goal of improving allograft survival and limiting therapeutic toxicity to the recipient. Donor-derived cell-free DNA (ddcfDNA) has been proposed as one such transplant biomarker. Although the test is presently utilized most in the United States, it is conceivable that its use will become more widespread. This review covers aspects of ddcfDNA that support informed use of the test by general nephrologists, including the basic biology of ddcfDNA, methodological nuances of testing, and general recommendations for use in the kidney transplant population. Clinical contexts are used to illustrate evidence-supported interpretation of ddcfDNA results and subsequent management. Finally, knowledge gaps and areas for further study are discussed.

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access.

This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials. Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation. The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development. For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%. The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance. Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use. While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Survey of Salary and Job Satisfaction of Transplant Nephrologists in the United States.

There are no standardized benchmarks to measure productivity and compensation of transplant nephrologists in the United States, and consequently, criteria set for general nephrologists are often used. A web-based survey was sent to 809 nephrologists who were members of the American Society of Transplantation to gather data on measures of productivity, compensation, and job satisfaction. Factors associated with higher total compensation and job satisfaction were examined. Of 365 respondents, 260 were actively practicing in the United States and provided data on compensation. Clinical productivity was assessed variably, and although 194 (76%) had their work relative value units (wRVUs) reported to them, only 107 (44%) had an established RVU target; 234 (90%) had fixed base compensation, and 172 (66%) received a bonus on the basis of clinical workload (68%), academic productivity (31%), service (32%), and/or teaching responsibility (31%). Only 127 respondents (49%) filled out time studies, and 92 (35%) received some compensation for nonbillable transplant activity. Mean total compensation (base salary and bonus) was $274,460±$91,509. The unadjusted mean total compensation was higher with older age and was higher for men; Hispanic and White respondents; adult care transplant nephrologists; residents of the western United States; US medical school graduates; nonuniversity hospital employees; and those with an administrative title, higher academic rank, and a higher number of years in practice. Two hundred and nine respondents (80%) thought their compensation was unfair, and 180 (70%) lacked a clear understanding of how they were compensated. One hundred forty-five respondents (55%) reported being satisfied or highly satisfied with their job. Job satisfaction was greater among those with higher amounts of compensation and US medical school graduates. We report significant heterogeneity in the assessment of productivity and compensation for transplant nephrologists and the association of compensation with job satisfaction.

Survey of factors associated with the willingness toward living kidney donation

Living donor kidney transplantation (LDKT) is an important organ resource, especially in countries with low deceased donation rates. Strategies for expanding access to transplantation should be developed by identifying the modifiable factors. In this study, we evaluated these factors in the relatives of patients from both medical centers and dialysis clinics using questionnaires. The questionnaires were anonymous and confidential. We collected questionnaires from previous donors, relatives of patients on the waitlist in the medical center, and relatives of dialysis patients in three nephrology clinics. The study groups were divided into three categories: donor group (n=68), willing group (n=43), and non-donor group (n=65). Respondents in the clinics had lower cognition and willingness towards LDKT than those in the medical center. More knowledge of LDKT, better relationship with patients, more familial support, and female gender were positively related to donation. The non-donor group tended to want to maintain an intact body for the afterlife. There was no significant difference in age, educational degree, average monthly income, and medical compliance among the three groups. More efforts need to be made in dialysis clinics, where general nephrologists are important for the outreach of information. In addition, dealing with religious ambivalence and reestablishing cultural mindsets with health education programs are important issues in a non-Christian country.

MO878THE DYNAMICS OF THE COLLABORATION BETWEEN GENRAL PRACTITIONER AND NEPHROLOGIST DURING PRE-DIALYSIS CARE: A MIXED METHOD STUDY

Abstract Background and Aims Nephrologists and General Practitioners (GP) are critical in the care trajectory of patients with CKD through the medical work they provide: screening, referral, follow-up, slowing down CKD progression and renal replacement therapy preparation. They often intervene simultaneously in a collaborative context. Several guidelines define this medical work and collaborative care models. However, evidence suggests that the implementation of such models is limited and suboptimal. For example, 18% of patients who started dialysis in 2018 in France did not see a nephrologist before.The objectives of this study were 1) to quantitatively describe the practices of both French nephrologists and GPs through drug and biology lab test prescriptions for patients with CKD and its evolution before and after dialysis start, 2) to qualitatively describe how they see each other’s role and from this 3) identify the factors interfering with optimal care trajectory Method All incident 2015 dialysis patients from France were identified using the national REIN registry. Healthcare consumption of those patients 2 years before and 1 year after dialysis start was retrieved from the French national health insurance database (SNDS) via indirect record linkage. The items of interest were drug and lab test prescriptions as well as the prescriber medical specialty. Prescription frequencies and percentages per months and per prescriber specialty were reported. Anatomical Therapeutic Chemical (ATC) classification level 2 was used for drugs. Semi-structured interviews with general practitioners and nephrologists exploring their practices surrounding CKD care were performed in a sample from the Bretagne region. Thematic analysis was performed on the transcripts. Results A total of 2 263 935 drug prescriptions were found for 8679 patients who started dialysis in 2015 in France in the span of 2 years before and 1 year after dialysis start. The place of each professional changed through time: drug prescribed by GPs decreased from 83.6% of the total during the 2 years before dialysis start to 62.6% during the year following dialysis start. Nephrologist’s place increased from 4.9% of the total prescriptions to 21%. Although GPs and nephrologists had differences between the drugs they prescribe (nephrologists prescribed more frequently vitamins and antianemic preparations whereas GPs prescribed more frequently analgesics and drugs used in diabetes), they also had similarities (frequencies of beta blocking agents, calcium channel blockers and lipid modifying agents). Similarly, the interviews highlighted that despite the unique technical nature of a large part of nephrologists’ practice (nephropathy aetiology, dialysis and kidney transplantation, nephrotoxicity) another part was similar to GPs’, including the long-term holistic care of patients with multiple comorbidities as well as diet and lifestyle advices. This appears to blur the perimeter of the role of each professionals regarding CKD care and favours an increased presence of nephrologists, as suggested by the quantitative prescription analysis. In turn, as interviews revealed, some GPs expressed a fear of losing their patients and regretted a decreased communication from specialists. Nephrologists’ description of the role of GPs ranged from a strict addressor to nephrologists, to an intermediary support to reduce uncertainties, to a constant partner with transfer of therapeutic objectives. Conclusion Combining the crossed point of view of GPs and nephrologists and robust prescription data, this study highlights an overlap in the roles and practices and suggests a competition in the control of therapeutic strategies that might hinder an optimal care trajectory for patients. Development of integrated renal care network could address these obstacles

Usefulness to assess the disease progression and mortality risk profiles, in a population of chronic kidney disease patients followed by general practitioners and nephrologists

Usefulness to assess the disease progression and mortality risk profiles, in a population of chronic kidney disease patients followed by general practitioners and nephrologists

Perceived Clinical Utility and Barriers to Genetic Testing in the Adult CKD Population: A Survey of General Nephrologists

Perceived Clinical Utility and Barriers to Genetic Testing in the Adult CKD Population: A Survey of General Nephrologists

Securing the future of kidney transplantation by addressing the challenges of transplant nephrology.

Kidney transplant is a life-changing procedure, and transplant nephrologists, as part of a larger transplant team, play an important role in the field by managing the complex medical needs of transplant patients. The subspecialty of transplant nephrology, however, faces structural challenges related to its workforce, reporting structures, compensation, research and innovation, and health care information technology. The position of transplant nephrology at the academic and operational intersection of medicine and surgery may limit its access to critical resources, hinder academic promotion, and contribute to physician burnout. The authors provide an overview of the subspecialty transplant nephrology and propose solutions. Collaborative efforts that fortify the subspecialty of transplant nephrology will ultimately improve the lives of patients suffering from kidney disease.

Is It Time to Make Renal Transplantation Referral Mandatory?

In the last 2 decades, renal transplantation has been established as the best form of replacement therapy for most patients with end-stage kidney disease.1,2 Yet, the majority of patients who can benefit from renal transplantation are referred late or never referred to a transplant center.3 Barriers to referral have 3 different sources: the treating nephrologist, the patient, and the medical system. Often, treating physicians may have considered a transplant option but judged the patient to be too old or have many comorbidities to be eligible for renal transplantation. Sometimes, the nephrologists have to concentrate on the immediate initiation of dialysis due to the patient’s rapid deterioration of renal function. Patients have to overcome the complexity of the referral process that can be lengthy and exhausting, including medical suitability, pretransplant workup, and interest in transplantation, before they can be waitlisted. Some patients may simply give up or become too ill. Finally, there are both financial incentives and disincentives for nephrologists, dialysis centers, and eligibility for Medicare coverage for end-stage renal disease.4 It is important to point out that similarly restrictive practices to transplantation referral also exist in public healthcare systems such as in Canada and the United Kingdom.5,6 Part of the process to improve the effectiveness of the transplantation referral and waitlisting includes a comprehensive transplant education. In this issue of Transplantation, Waterman et al7 report on a survey of 1694 US dialysis centers, an extension of their prior work from 2015,8 on their educational practices and determined which are associated with increased waitlisting rates. The majority of the educators surveyed were female, Caucasian, and social workers. There were 12 transplant education practices and 8 reported barriers to providing transplant education assessed by the authors. Combined transplant education strategies such as distribution of print education and using >1 intensive education practice within dialysis centers were associated with higher waitlisting rates. This goes along with the Center for Medicare and Medicaid Services requirement for providers to inform patients of their transplant options within 45 days of initiating dialysis and a more recent Center for Medicare and Medicaid Service Technical Expert Panel requiring more specific metrics for transplant educational delivery in dialysis centers.9 The most important finding from this report is that a minority of centers used what is considered an intensive education approach which was associated with an increased odds ratio of waitlisting. The current study shows that a reduced odds ratio of using intensive education strategies is associated with centers having a greater percentage of uninsured patients, rural locations, for profit ownership, and dialysis patients >65 years old. Considering that the mortality rate of patients on dialysis at 5 years exceeds 60%,10 a timely referral and transplantation should be viewed with the same urgency perspective as for patients with other life threatening conditions. Perhaps we should review the process of mandatory information of transplant options and complement it with more intensive education practices and improved communication between dialysis and transplant centers. Perhaps the transplant community can encourage a change in the paradigm toward a form of mandatory referral of patients for a transplantation assessment. Transplant centers can help in the process of educating dialysis centers in better identifying eligibility of candidates and to rule out those with specific contraindications. Our patients certainly deserve to have every option to be able to make the best decision for their care. Increasing education of patients, patients' families, and general nephrologists about renal transplantation should harmonize practice and increase referral for renal transplantation. ACKNOWLEDGMENTs The authors wish to thank Andrea Herrera-Gayol, MD, MSc, PhD, for her critical review on the commentary.

Implications of the Advancing American Kidney Health Initiative for kidney transplant centers.

The announcement of the Advancing American Kidney Health (AAKH) Initiative on July 10, 2019 was met with a mix of excitement and trepidation, befitting a proposed radical reconfiguration of the delivery of kidney disease care. Aspiring to reduce the incidence of end-stage renal disease, increase the prevalence of home dialysis, and double the number of organs available for transplant, the AAKH payment models primarily focus on incenting behaviors of general nephrologists, though actualizing positive incentives will require the active cooperation of dialysis providers and transplant centers. Here, we review the AAKH initiatives' potential impact on all stakeholders and opine on financial and regulatory pressures on kidney transplant programs, outlining areas of uncertainty and concern, and suggest key points of reflection for clinical and administrative leaders of kidney transplant centers weighing participation in any of the voluntary payment models.

The global burden of immunoglobulin - A nephropathy: A message for general practitioners and nephrologists

The global burden of immunoglobulin - A nephropathy: A message for general practitioners and nephrologists

Bedside Tunneled Dialysis Catheter Removal-A Lesson Learned From Nephrology Trainees.

Semi-permanent dual-lumen tunneled (or tunneled-cuffed) hemodialysis catheters (TDC) are increasingly utilized during renal replacement therapy, while awaiting permanent access maturation or renal recovery. Although there is a wealth of literature focused on placement, infection prevention, and maintenance of catheter patency, circumstances and indications for TDC removal are less well understood. Timely removal of these catheters is an important management decision, with the length of TDC duration representing the largest cumulative risk factor for catheter-associated blood stream infections. Waiting for assistance from surgical or radiological services-which may not be available in all hospitals-may result in delays in services and potential harm to the patients. Imparting and maintaining procedural skills to remove infected TDC may be very valuable for training programs in clinical nephrology. In this article the current literature on bedside TDC removal, including potential anticipated complications during removal, are reviewed. To date, the authors have documented successful implementation of bedside TDC removal in training programs from two different settings, including both in- and outpatients and with trainee involvement. In summary, training general nephrologists for bedside TDC removal will afford immediate removal of infected hardware in ill patients and avoid potential delays in outpatient setting.

Outpatient removal of tunneled dialysis catheters by nephrology fellows in training at a Veterans Affairs Medical Center.

Removal of tunneled dialysis catheters (TDC) usually occurs in dedicated procedure suites and is performed relatively rarely at the bedside. Scarce evidence exists in the literature to assess the safety and success of this procedure when performed during supervised academic training. We conducted a retrospective chart review of all TDC removals performed on an outpatient basis by nephrology fellows under faculty supervision during a 5-year period at an academic Veterans Affairs Medical Center. Data were collected regarding patient demographics, basic laboratory studies, pertinent clinical information and procedure-related variables. We evaluated the safety, success and complication rate of this procedure. We identified 72 TDC removals that met the above criteria. Mean age was 63 ± 10 years. All patients were male and hypertensive, 68% were diabetic and 69% were African-American. Overall, 88% of procedures were performed in end-stage renal disease (ESRD) patients, while the rest had needed temporary dialysis for acute kidney injury. Notably, 49 patients (68%) were taking one or more of aspirin, clopidogrel or warfarin at the time of TDC removal. Overall complication rate was low (<2%). There was no increase in risk of bleeding, even in subjects receiving anti-platelet therapy; only one of the 49 patients (2%) had a minor bleeding complication. Outpatient TDC removal by trainees was successful and safe in the vast majority of cases (99%). We propose that TDC removal skills should be actively pursued and acquired by all nephrology fellows. This would expand the scope of practice for future general nephrologists and facilitate timely patient care.

Prediction of Arteriovenous Fistula Dysfunction: Can it be Taught?

Physical examination (PE) is an excellent means of predicting arteriovenous fistula (AVF) dysfunction. Although quick and inexpensive, PE is seldom used as a tool to assess stenosis by general nephrologists, dialysis nurses, and dialysis technicians. Previous studies have demonstrated that PE can be taught to interventional specialists, but the perception remains that it is too complex to be performed by other health care professionals. We hypothesized that the physical exam can be taught to a nonmedical professional, and that, with time, it would be comparable to the physical exam performed by a full-time interventional specialist. An undergraduate student and an interventional specialist (MD) examined AVF for dysfunction in a tertiary care hospital over a 6-month period. PE was performed on patients who were suspected of having dialysis access dysfunction and were referred for angiography and intervention (n=49). Physical exam findings were categorized blindly by each examiner into four categories of lesion location: inflow, outflow, both, or neither. Data were privately recorded and compared to the gold standard of angiographic results. Potential confounding variables, including age, gender, diabetic status, and location of AVF were recorded. Weighted Cohen's kappa value was used as a measurement of the level of agreement beyond chance between the diagnoses made by physical exam and angiography. The full-time interventional specialist demonstrated correct prediction of lesion location of 89.8% (kappa=0.850), while the undergraduate student had a correct prediction of 77.6% (kappa=0.625). The student's performance, however, differed significantly over time. The student correctly predicted the location of the lesion in 6 (42.9%) of the first 14 patients (kappa=0.082), compared to 32 (91.4%) of the last 35 patients (kappa=0.855). We suggest that physical exam of AVF can be taught to a nonmedical professional in a short duration of time and the predictive value of the exam can be similar to that of an interventional specialist.

L'insuffisance rénale chronique: quelle est la diète optimale?

The optimal diet for chronic kidney disease (CKD) is an issue frequently brought up by patients and/or their relatives during outpatient visits. For patients without malnutrition who are motivated and supported by an experienced multidisciplinary team, the optimal protein intake of 0,6 g/kg of ideal body weight/day is recommended to halt the progression of CKD. A calorie intake of 30 to 35 kcal/kg of ideal body weight/day is necessary to reduce the risk of malnutrition from a low protein diet and to maintain a neutral nitrogen balance. A low-salt diet, namely 5 to 6 g/d, is useful to optimize the treatment of hypertension associated with CKD and to limit fluid overload. At the advanced stage of CKD, it is also necessary to restrict the intake of phosphorus and sometimes potassium. Given the complexity of optimal renal diet, coordination between general practitioners, nephrologists and dietitians is essential to foster optimal care.

Promissory Concept of medical education

Continuing medical education (CME) is a dynamic system, where distance learning is an important component. In this article, we posit the Promissory Concept of distance learning. The central principle upon which this methodology is based is that the doctor can be located in any place where the information needed for his or her practice is easily available to the patient and where the doctor is able to monitor the development of his or her knowledge and practical skills, and is able to build his or her educational record of accomplishment. The Promissory Concept combines the availability of existing online opportunities with professional self-development which can be put to the test by an external supervisor (a professor or curator), who in turn will be able to identify existing advantages in knowledge, as well as those requiring further improvement, thus helping the learner's professional development. This approach was introduced to general practitioners and nephrologists practising in Ukraine in 2013. From 2014, the Promissory Concept has been associated with the Renal Eastern Europe Nephrology Academy's (REENA) annual CME course, which has been accredited by ERA-EDTA (European Renal Association–European Dialysis and Transplant Association) for the past 8 years. REENA is controlled by the state organisation of postgraduate education – Shupyk National Medical Academy of Postgraduate Education. The Promissory Concept is supported by printed educational material in the scientific medical Ukrainian journal Kidneys, which is registered in scientific databases (as a Google scholar, etc.). An important characteristic of the Promissory Concept is the active involvement of doctors, who give constructive feedback on the programme. This feedback contributes to the content of the CME learning activity, as well as enhancing compliance in participation. As a result, it helps create motivated adherence and improved professional development.

Childhood nephrotic syndrome in the 21st century: What's new?

Childhood nephrotic syndrome is a condition managed by general paediatricians and paediatric nephrologists. Whether treating a first presentation or a relapse, the clinician requires expertise in order to minimise the risk of serious complications and optimise long-term care. Indeed, many children suffer a difficult relapsing course in their disease, warranting consideration of second-line therapies. The last two decades have witnessed a growing knowledge of the condition and increased complexity of diagnostic and therapeutic options, which poses a challenge for the general paediatrician, given the condition's relative rarity in daily practice. This review aims to familiarise the reader with some of the most important recent developments and particularly to provide an insight into what management options are available and when it may be appropriate to seek advice from a nephrologist.