Kidney Care Research Articles

Restarting living donor kidney transplant during COVID-19: a single center experience

Abstract: The decision that declared COVID-19 as a pandemic in March 2020 had become a medical emergency that also effects kidney transplantation program and care. Kidney transplantation has been a definitive treatment for end-stage renal disease (ESRD) patients since it improves patient’s quality of life. However great the beneficence is, kidney transplant procedure still carries high risk of COVID-19 infection especially for recipients who are obliged to take immunosuppression agents after transplantation.
 Purpose: This study aimed to evaluate kidney transplant procedure in Dr. Sardjito General Hospital within before and during pandemic based on recipients’ and donors’ characteristics and laboratory findings such as creatinine and urine time.
 Patients and methods: This study is designed as a cross-sectional analytic research to evaluate 30 patients that underwent kidney transplant in Dr. Sardjito General Hospital within before (April 2019-2020) and during (April 2020-2021) COVID-19 era. Data analyses were carried out using SPSS version 25.0 and were served with simple charts and tables.
 Results: There is a decrement of kidney transplant procedure within before (n=16) and during (n=14) COVID-19. Age group of recipients that underwent the most of transplantation before pandemic are 20-29 years old while during pandemic are 40-49 years old. There is no significant difference in length-of-stay within before (12.0±4.17 days) and during (9.29±3.73 days) COVID-19 (p=0,077). Laboratory findings such as creatinine of pre-transplantation (9.47±4.05; 7.81±6.00) and 3 months’ post-transplantation (1,55±0,78; 1,15±0,67) also did not show significant changes (p=0,153) as well as urine time (245.60±225.55; 428.38±657.70; p=0.321).
 Conclusion: There is a decrement of kidney transplant procedure in Dr. Sardjito General Hospital within before and during COVID-19 era. There are no significant differences found within length-of-stay, creatinine pre and 3 months’ post-transplantation and urine time. On the whole, transplant outcomes have remained similar within pre and during COVID-19 era.

Policy and Kidney Community Engagement to Advance toward Greener Kidney Care.

Policy and Kidney Community Engagement to Advance toward Greener Kidney Care.

Real Ways of Working Together: co‐creating meaningful Aboriginal community consultations to advance kidney care

ObjectiveTo describe a process of meaningful Aboriginal community engagement that repositioned and valued community members’ knowledge(s) and lived experiences while strengthening relationships, research processes and outcomes. BackgroundAboriginal Australians have the oldest continuous culture in the world, yet due to effects of colonisation, experience some of the world's poorest health outcomes. The AKction [Aboriginal Kidney Care Together – Improving Outcomes Now] project brought together Aboriginal people with lived experience of kidney disease, clinicians and researchers to improve kidney care. MethodologyUsing Aboriginal methodologies of Ganma and Dadirri within community‐based participatory action research (cb‐PAR), a core advisory group of Aboriginal people with lived experiences of kidney disease worked closely with clinicians and researchers. ResultsThree community consultation workshops that deeply valued Aboriginal knowledge(s) were co‐created. Community members formed a reference group, established partnerships and influenced health research, policy and service provision. Non‐Indigenous researchers engaged in critical self‐reflection and levelling of Western‐Aboriginal and clinician‐consumer power imbalances. ConclusionsDeeply respectful community engagement is possible through co‐creation and cb‐PAR. It results in multiple positive impacts and beneficial relationships between community members, clinicians and academics. Implications for public healthMeaningful consultation with Aboriginal communities guides culturally safe research processes, health policy and service delivery.

Chronic Kidney Disease and Nephrology Care in People Living with HIV in Central/Eastern Europe and Neighbouring Countries-Cross-Sectional Analysis from the ECEE Network.

Chronic kidney disease (CKD) is a significant cause of morbidity and mortality among patients infected with human immunodeficiency virus (HIV). The Central and East Europe (CEE) region consists of countries with highly diversified HIV epidemics, health care systems and socioeconomic status. The aim of the present study was to describe variations in CKD burden and care between countries. The Euroguidelines in the CEE Network Group includes 19 countries and was initiated to improve the standard of care for HIV infection in the region. Information on kidney care in HIV-positive patients was collected through online surveys sent to all members of the Network Group. Almost all centres use regular screening for CKD in all HIV (+) patients. Basic diagnostic tests for kidney function are available in the majority of centres. The most commonly used method for eGFR calculation is the Cockcroft–Gault equation. Nephrology consultation is available in all centres. The median frequency of CKD was 5% and the main cause was comorbidity. Haemodialysis was the only modality of treatment for kidney failure available in all ECEE countries. Only 39% of centres declared that all treatment options are available for HIV+ patients. The most commonly indicated barrier in kidney care was patients’ noncompliance. In the CEE region, people living with HIV have full access to screening for kidney disease but there are important limitations in treatment. The choice of dialysis modality and access to kidney transplantation are limited. The main burden of kidney disease is unrelated to HIV infection. Patient care can be significantly improved by addressing noncompliance.

Aboriginal patients driving kidney and healthcare improvements: recommendations from South Australian community consultations

ObjectiveTo describe the experiences, perceptions and suggested improvements in healthcare identified by Aboriginal patients, families and community members living with kidney disease in South Australia. MethodsCommunity consultations were held in an urban, rural and remote location in 2019 by the Aboriginal Kidney Care Together – Improving Outcomes Now (AKction) project and Kidney Health Australia. Consultations were co‐designed with community members, using participatory action research, Yarning, Dadirri and Ganma Indigenous Methodologies. Key themes were synthesised, verified by community members and shared through formal and community reports and media. ResultsAboriginal participants identified the importance of: family and community and maintaining their wellbeing, strength and resilience; the need for prevention and early detection that is localised, engages whole families and prevents diagnosis shock; better access to quality care that ensures Aboriginal people can make informed choices and decisions about their options for dialysis and transplantation, and; more Aboriginal health professionals and peer navigators, and increased responsiveness and provision of cultural safety care by all kidney health professionals. ConclusionAboriginal community members have strong and clear recommendations for improving the quality and responsiveness of health care generally, and kidney care specifically. Implications for public healthAboriginal people with lived experience of chronic conditions wish to significantly inform the way care is organised and delivered.

Acknowledging Socioecological Systems to Address the Systemic Racial Disparities in Children with Kidney Disease.

The inescapable reality is the American health care system is rooted in a US society steeped in systemic racism. In recent years, there has been an increased acknowledgment of how systemic racism in health care has affected kidney disease and kidney care for our patients.[1][1][⇓][2]–[3][3] Many

Dialysis Decision Making, Dialysis Experiences, and Illness Perceptions: A Qualitative Study of Pakistani Patients Receiving Maintenance Hemodialysis

The incidence and prevalence of patients with kidney failure requiring dialysis are increasing in Pakistan. However, in-depth perspectives on kidney care from Pakistani people requiring maintenance dialysis are lacking. Qualitative interview study. Between September 2020 and January 2021, we interviewed 20 adults receiving maintenance hemodialysis in 2 outpatient dialysis units in Pakistan. We asked open-ended questions to explore their experiences with various aspects of kidney care. We recorded, transcribed, and then, using a phenomenological approach, thematically analyzed interviews. We observed the following 6 main themes: (1) Patients perceived various supernatural phenomena as causes of their illness and chose traditional medicine for chronic kidney disease (CKD) treatment. (2) Patients expressed dissatisfaction with their physicians' communication. They felt poorly informed and resented their decision to initiate dialysis. (3) Family members tried to dissuade patients away from dialysis but also provided support once dialysis was initiated. (4) Patients and families found it challenging to afford dialysis and transplantation and also to arrange for transportation. (5) Women found it challenging to fulfill their obligations as wives and mothers while receiving maintenance dialysis. (6) Patients seemed reluctant to discuss end-of-life care. We collected data from only 2 hospitals in neighboring cities. Additionally, patients on peritoneal dialysis were not included. Our findings shed light on patients' perspectives on kidney care in Pakistan and call for financially feasible solutions to raise kidney disease awareness and improve patients' experiences with dialysis. Physician training in communication and shared dialysis decision making along with the development of culturally adapted decision aids are needed to improve CKD knowledge and shared decision making. Although financial challenges preclude many from receiving long-term dialysis, cost-effective strategies to improve the availability of other options (eg, supportive kidney care, peritoneal dialysis, and transplantation) are still warranted.

Development and validation of algorithms to identify patients with chronic kidney disease and related chronic diseases across the Northern Territory, Australia

BackgroundElectronic health records can be used for population-wide identification and monitoring of disease. The Territory Kidney Care project developed algorithms to identify individuals with chronic kidney disease (CKD) and several commonly comorbid chronic diseases. This study aims to describe the development and validation of our algorithms for CKD, diabetes, hypertension, and cardiovascular disease. A secondary aim of the study was to describe data completeness of the Territory Kidney Care database.MethodsThe Territory Kidney Care database consolidates electronic health records from multiple health services including public hospitals (n = 6) and primary care health services (> 60) across the Northern Territory, Australia. Using the database (n = 48,569) we selected a stratified random sample of patients (n = 288), which included individuals with mild to end-stage CKD. Diagnostic accuracy of the algorithms was tested against blinded manual chart reviews. Data completeness of the database was also described.ResultsFor CKD defined as CKD stage 1 or higher (eGFR of any level with albuminuria or persistent eGFR < 60 ml/min/1.732, including renal replacement therapy) overall algorithm sensitivity was 93% (95%CI 89 to 96%) and specificity was 73% (95%CI 64 to 82%). For CKD defined as CKD stage 3a or higher (eGFR < 60 ml/min/1.732) algorithm sensitivity and specificity were 93% and 97% respectively. Among the CKD 1 to 5 staging algorithms, the CKD stage 5 algorithm was most accurate with > 99% sensitivity and specificity. For related comorbidities – algorithm sensitivity and specificity results were 75% and 97% for diabetes; 85% and 88% for hypertension; and 79% and 96% for cardiovascular disease.ConclusionsWe developed and validated algorithms to identify CKD and related chronic diseases within electronic health records. Validation results showed that CKD algorithms have a high degree of diagnostic accuracy compared to traditional administrative codes. Our highly accurate algorithms present new opportunities in early kidney disease detection, monitoring, and epidemiological research.

Novel strategies in nephrology: what to expect from the future?

Chronic kidney disease (CKD) will become the fifth global case of death by 2040. Its largest impact is on premature mortality but the number of persons with kidney failure requiring renal replacement therapy (RRT) is also increasing dramatically. Current RRT is suboptimal due to the shortage of kidney donors and dismal outcomes associated with both hemodialysis and peritoneal dialysis. Kidney care needs a revolution. In this review, we provide an update on emerging knowledge and technologies that will allow an earlier diagnosis of CKD, addressing the current so-called blind spot (e.g. imaging and biomarkers), and improve renal replacement therapies (wearable artificial kidneys, xenotransplantation, stem cell-derived therapies, bioengineered and bio-artificial kidneys).

Marfan Syndrome and Autosomal Dominant Polycystic Kidney Disease: A Case of Rare Co-occurrence or Coincidence?

Background: Marfan syndrome (MFS) and autosomal dominant kidney disease (ADPKD) are two separate genetic disorders. The author describes the case of a young male with ADPKD who incidentally had Marfan-like features. A literature review was carried out to see if these two disorders could be linked. Case presentation: A young male presented for incidentally found renal cysts. Kidney function was well preserved, but the patient had positive family history of ADPKD. During routine follow-up, a history of aortic valve disease was mentioned. This, along with the patient’s tall, lean stature and long extremities raised the concern for MFS. A detailed physical examination and workup by other specialists confirmed a clinical diagnosis of MFS. They had no known family history of MFS. The patient has been followed at Associates in Kidney Care, Des Moines, Iowa, USA, for the past 2 years. Discussion: There are several reports of overlap of ADPKD and connective tissue disorders with an overlap of vascular disorders. ADPKD and MFS are caused by totally different mutations. However, the literature review showed that vascular abnormalities and connective tissue diseases may be more common with ADPKD. Studies have shown that there could be a common signalling pathway for connective tissue disorders when both genes are affected simultaneously. Further research is needed to identify these pathways. More frequent screening of vascular abnormalities might be warranted in those with both phenotypes.

Rates of Medicare Enrollment Among Dialysis Patients After Implementation of Medicare Payment Reform and the Affordable Care Act Marketplace

Medicare finances health care for most US patients with end-stage kidney disease (ESKD), regardless of age. The 2011 Medicare prospective payment system (PPS) for dialysis reduced reimbursement for hemodialysis, and the 2014 Patient Protection and Affordable Care Act (ACA) Marketplace increased patient access to new private insurance options, potentially influencing organizations that provide health care, such as hospitals, nursing homes, and dialysis facilities, to adjust their payer mix away from Medicare sources. To describe Medicare enrollment trends among patients with incident ESKD in 2006 to 2016. This retrospective cohort study involved US patients aged 18 to 64 years who were not enrolled in Medicare at dialysis initiation in 2006 to 2016, with 1-year follow-up through 2017. Data analysis was conducted April 2021 to June 2022. The exposure of interest was a 3-category indicator of time, whether patients initiated dialysis before policies were enacted (2006-2010), in the first years of the Medicare ESKD PPS (2011-2013), or during the Medicare ESKD PPS and implementation of the ACA Marketplace (2014-2016). Patient-level Medicare enrollment through the first year of dialysis. Logistic regression and Cox models were used to examine associations of time, patient characteristics, and Medicare enrollment, adjusting for patient demographic, clinical, and market-level characteristics. Of 335 157 patients aged 18 to 64 years with ESKD not actively enrolled in Medicare when they initiated dialysis in 2006 to 2016, the mean (SD) age was 49.9 (10.8) years, 198 164 (59.1%) were men, 188 290 (56.2%) were White, and 313 622 (93.6%) received in-center hemodialysis. New Medicare enrollment was higher in 2006 to 2010 (110 582 patients [73.1%]) than after the Medicare ESKD PPS and ACA Marketplace in 2014 to 2016 (55 382 patients [58.5%]). In adjusted analyses, declining Medicare enrollment was associated with implementation of 2011 Medicare ESKD PPS and 2014 ACA policies and was disproportionately lower among younger, racially minoritized, and ethnically Hispanic patients. There was declining Medicare enrollment among new dialysis patients associated with the 2011 Medicare ESKD PPS and 2014 ACA Marketplace that raise concerns about benefits and harms to patients and payers and continued disparities in kidney care. As the dialysis payer mix moves toward higher proportions of patients not covered by Medicare, it will be important to understand the implications for health care system and patient outcomes.

Inclement Weather and Risk of Missing Scheduled Hemodialysis Appointments

Background and Aim: Non-adherence to dialysis treatments results in health complications that are associated with increased morbidity and mortality in hemodialysis patients. We examined the association between different types of inclement weather conditions and missed dialysis treatments. Methods: We obtained health records on end-stage kidney disease (ESKD) patients who received hemodialysis at Fresenius Kidney Care (FKC) clinics across the Northeastern U.S. during 2001-2019. County-level daily meteorological data on rainfall, hurricane events, snowfall, snow depth, and wind speed were extracted through the National Oceanic and Atmosphere Agency (NOAA) database. A time-stratified case-crossover study design with conditional Poisson regression was employed to estimate the effect of inclement weather exposures on hemodialysis treatment adherence. We applied distributed lag non-linear model (DLNM) framework to estimate the delayed effect of inclement weather for up to one week. Results: We studied 28,620 ESKD patients from 27 northeastern counties who had any missed hemodialysis appointment. Overall, the missed appointment rate was higher for all of the inclement weather type (rainfall, hurricane, snowfall, snow depth, and wind advisory) compared to non-inclement weather days. The risk of missed appointment was highest at lag 0 for 10mm increase of rainfall (RR=1.027, 95% CI: 1.021, 1.032), snowfall (RR=1.019, 95% CI: 1.017, 1.021), and snow depth (RR=1.014, 95% CI: 1.013, 1.016). Hurricane events showed the highest RR at lag 5 (RR=1.163, 95% CI: 1.016, 1.332). Wind advisory showed sustained higher risk compared to non-exposure days through up to lag 5. Conclusions: All types of inclement weather events showed increased risk of missed hemodialysis appointments. Since inclement weather events are projected to increase due to ongoing climate change, our findings suggest the need for enhanced climate readiness by health care delivery systems that include early warning systems disaster response plans for delivering uninterrupted dialysis-related health services. Keywords: inclement weather, climate change, hemodialysis

Determining best practices to delivering comprehensive medication management in practices with patients with chronic kidney disease: A qualitative study

AbstractIntroductionNew payment models have intensified the importance of providing comprehensive medication management (CMM) to patients with chronic kidney disease. While some practices have pharmacists integrated into their kidney care teams, increasing the presence of pharmacists providing CMM will be key to practices achieving kidney‐related care outcomes and taking advantage of emergent value‐based payment models. To support future practices, the objective of this study was to understand what an ideal practice providing CMM to patients with kidney disease would look like from the perspective of those already in practice.MethodsQualitative semi‐structured interviews were carried out with 11 pharmacists practicing in diverse settings where kidney care was provided. Transcripts were coded deductively using a CMM practice management framework to determine the state of current practice, limitations, and components of an ideal practice.ResultsSome components of an ideal CMM practice that were coded include alternative methods of CMM billing and revenue capture, incorporating methods for identifying CMM patients beyond a referral‐based system, and having collaborative practice agreements in place. Barriers cited by those currently in practice include not always having support staff available for CMM, and a lack of processes in place to consistently and frequently measure CMM outcomes.ConclusionWhile this study outlined several of the components that would contribute to an ideal practice providing CMM to patients with kidney disease, it also revealed that many existing CMM practices face practice management barriers or limitations. Given the rising importance of providing CMM to patients with kidney disease, a number of implementation supports are now under development. Utilization of these supports will be key to expanding and optimizing CMM services thereby meeting the public health need of improving kidney health and reducing health care costs.

An Endorsement of the Removal of Race From GFR Estimation Equations: A Position Statement From the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

An Endorsement of the Removal of Race From GFR Estimation Equations: A Position Statement From the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

Consent and the law

Hannah Ellis and Peter Ellis discuss consent and the law in relation to kidney care and how it is applied to clinical practice

Chronic Kidney Disease and Severe Mental Illness: Addressing Disparities in Access to Health Care and Health Outcomes.

Individuals with severe mental illness, including conditions such as schizophrenia and bipolar disorder, are at a higher risk of developing CKD. Higher incidences of CKD in this population can be partially explained by known risk factors, such as the use of lithium treatment and higher rates of cardiovascular disease. However, this does not fully explain the higher proportion of CKD in individuals with severe mental illness, and further research investigating the factors influencing disease onset and progression is needed. Similarly, although it is well documented that mental health difficulties, such as depression and anxiety, are highly prevalent among individuals with CKD, there is a lack of published data regarding the rates of severe mental illness in individuals with CKD. Furthermore, for individuals with CKD, having severe mental illness is associated with poor health outcomes, including higher mortality rates and higher rates of hospitalizations. Evidence also suggests that individuals with severe mental illness receive suboptimal kidney care, have fewer appointments with nephrologists, and are less likely to receive a kidney transplant. Limited research suggests that care might be improved through educating kidney health care staff regarding the needs of patients with severe mental illness and by facilitating closer collaboration with psychiatry. Further research investigating the rates of severe mental illness in patients with CKD, as well as the barriers and facilitators to effective care for this population, is clearly required to inform the provision of appropriate supports and to improve health outcomes for individuals with CKD and co-occurring severe mental illness.

Impact of the COVID-19 pandemic on the kidney community: lessons learned and future directions.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.

EP-345 How do we get these lines out?

Abstract Aims The aim of our study was to identify the factors influencing patient decision-making in conversion from tunnelled lines to arterio-venous fistulas/ grafts (AVF/G). Methods We consented and interviewed 40 patients who were currently dialysing through lines at a main dialysis unit in a tertiary hospital to understand factors influencing their decision. We designed and implemented a patient intervention education programme. Results Age range 24 to 86 years, (median 59), Females to Males ratio-1:1.4. Twenty-three patients (57.5%) started dialysis on a line and have remained on a line, 8 (20%) have a maturing graft and 9 (22.5%) have a fistula that is not maturing well or one that has failed. None on lines had had any previous face-to-face education regarding the benefits of fistulas over lines. After one session, 14/18 patients (78%) agreed to attend the access clinic. The remaining 5 patients did not participate in the intervention. Conclusion We were able to convert 78% of patients in just one single face-to-face education session. In the Patient Reported Experience of Kidney Care in the UK 2020 (PREM) report “Patient experience of Sharing Decisions About Your Care” received the lowest scores (5.49/7) among the 13 theme scores. Just providing a leaflet to the patient is not enough. Hence, an educational intervention like ours should be made part of the routine practice at all dialysis units. Reference The Renal Association and Kidney Care UK (2020) ‘Patient Reported Experience of Kidney Care in the UK 2020’, p. 14. Available at: https://renal.org/sites/renal.org/files/KQuIP/PREM report 2021.pdf

Predicting Kidney Care Behaviors in Patients with Type 2 Diabetes: An Application of Health Belief Model

Purpose: Kidney failure is one of the most important late complications of diabetes with more than half of people waiting for a kidney transplant are people with diabetes. The purpose of the present study was to predict kidney care behaviors in patients with type 2 diabetes based on Health Belief Model. The purpose of this study, was predict to care of kidney in type 2 diabetes patients based on Health Belief Model (HBM). Methods: In this cross-sectional analytical study, 240 patients with type 2 diabetes were selected by simple random sampling method from health centers in Arak in 2020 and information on kidney care behaviors were collected through a reliable and valid questionnaire based on the Health Belief Model and analyzed using Linear regressions. Results: The mean age of patients was 47.51±7.86 years, the mean FBS was 159.65 ± 55.01 mg / dl and the mean score of patients' performances in kidney care was 30.31± 6.42. Among the constructs of the Health Belief Model, awareness (67.6%), severity (38%), self-efficacy (31.8%) and internal cues to action (16.4%) have the highest predictive power and all of the above structures predicted 49% kidney care behavior. Conclusion: This study showed that increasing the information of patients in the field of recognizing renal complications, emphasizing the role of cues to action and finally, increasing the ability of patients to care for the kidneys and prevent kidney complications should be emphasized in educational programs for patients with diabetes.

Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care.

Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care.