US Nephrology Research Articles

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.

Perceptions of Home Dialysis Training and Experience Among US Nephrology Fellows

Prior research suggests a lack of confidence among graduating US nephrology trainees in implementing both peritoneal dialysis (PD) and home hemodialysis (HHD). Gaps in fellowship training may represent an obstacle to achieving the Advancing American Kidney Health Initiative's goal of increasing the use of home dialysis. We sought to identify the strengths of and limitations in home dialysis training. A cross-sectional study surveying nephrology trainees regarding their confidence with home dialysis management and perceptions of home dialysis educational resources provided by their training program. A paper survey was distributed to 110 nephrology trainees with at least 1 year of nephrology fellowship training who attended any 1 of 3 home dialysis conferences. Data were summarized as percentages. χ2, Fisher exact, and Kruskal-Wallis rank sum tests were used for statistical analysis. Self-perception of readiness to manage PD and HHD patients. 76 of 110 (66%) attendees completed the survey. Most respondents were moderately confident regarding principles of PD. However, only 3% had initiated patients on "urgent-start PD" and 11% observed a PD catheter insertion. The level of confidence for HHD was low. Most trainees attended a home dialysis continuity clinic with mentorship from faculty. A small number of participants and the inability to verify respondent-provided data for the number of PD and HHD patients seen and clinics attended. Potential lack of generalizability owing to inclusion of only trainees who attended a home dialysis conference. Nephrology trainees perceive low and moderate levels of preparedness for managing HHD and PD, respectively. Educational innovation and optimization of resources at both the institutional and national levels may improve confidence and promote public policy goals regarding home dialysis therapies.

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.

Moral Distress among US Nephrology Fellows: Report of a Nationwide Survey (GP786)

Moral Distress among US Nephrology Fellows: Report of a Nationwide Survey (GP786)

Burnout and Emotional Well-Being among Nephrology Fellows: A National Online Survey.

Physician burnout and emotional distress are associated with work dissatisfaction and provision of suboptimal patient care. Little is known about burnout among nephrology fellows. Validated items on burnout, depressive symptoms, and well being were included in the American Society of Nephrology annual survey emailed to US nephrology fellows in May to June 2018. Burnout was defined as an affirmative response to two single-item questions of experiencing emotional exhaustion or depersonalization. Responses from 347 of 808 eligible first- and second-year adult nephrology fellows were examined (response rate=42.9%). Most fellows were aged 30-34 years (56.8%), male (62.0%), married or partnered (72.6%), international medical graduates (62.5%), and pursuing a clinical nephrology fellowship (87.0%). Emotional exhaustion and depersonalization were reported by 28.0% and 14.4% of the fellows, respectively, with an overall burnout prevalence of 30.0%. Most fellows indicated having strong program leadership (75.2%), positive work-life balance (69.2%), presence of social support (89.3%), and career satisfaction (73.2%); 44.7% reported a disruptive work environment and 35.4% reported depressive symptoms. Multivariable logistic regression revealed a statistically significant association between female gender (odds ratio [OR], 1.90; 95% confidence interval [95% CI], 1.09 to 3.32), poor work-life balance (OR, 3.97; 95% CI, 2.22 to 7.07), or a disruptive work environment (OR, 2.63; 95% CI, 1.48 to 4.66) and burnout. About one third of US nephrology fellows surveyed reported experiencing burnout and depressive symptoms. Further exploration of burnout-especially that reported by female physicians, as well as burnout associated with poor work-life balance or a disruptive work environment-is warranted to develop targeted efforts that may enhance the educational experience and emotional well being of nephrology fellows.

Treatment duration and response of advanced renal cell carcinoma (aRCC) patients (pts) who have completed first-line (1L) treatment (tx): Results from a cross-sectional real-world study.

643 Background: In 2019, there was an estimated 73,820 new cases of kidney cancers in the US. The tx landscape for aRCC is changing rapidly. Recently approved txs for 1L aRCC include new targeted agents and immuno-oncology (IO) therapies. We examine outcomes for pts who completed 1L tx. Methods: Real-world data were drawn from the RCC Disease Specific Programme; a cross-sectional survey administered to US oncologists, nephrologists and urologists. Physicians completed pt record forms (PRFs) for up to the next 8 consulting aRCC pts receiving drug tx, from February - September 2019, plus additional optional PRFs for pts receiving/who had received either 1L tx of nivolumab/ipilimumab combination or cabozantinib, where these pts were available. Results: Physicians (n=82) provided data on 687 pts; 230 had progressed from 1L tx and were on 2L tx at time of data collection. Of those receiving 2L tx, 61% male; mean age was 66.4 years (SD=11.0); 43% stage IV at diagnosis. At 1L, 72% (n=165) had received tyrosine kinase inhibitor (TKI) monotherapy; 16% (n=37) IO+IO, 3% (n=7) TKI+IO and 9% (n=20) other regimens. Mean 1L duration was 10.3 months (SD=9.4) and mean time to 2L initiation was 13.7 months (SD=21.1). 1L treatment responses were: 6% complete response, 21% partial response, 16% stable disease, and the remainder relapsed/progressed (44%) or unknown response (13%). Most common 2L regimens were TKI (37%) or IO (34%) monotherapy. 47% of 1L TKI monotherapy pts received 2L IO monotherapy. 86% of 1L IO+IO pts received 2L TKI monotherapy. Conclusions: Some pts with aRCC progress to 2L; many experience poor clinical outcomes with 1L txs, highlighting high unmet need in 1L for more efficacious txs. Optimal tx strategy (and sequencing) continues to evolve. Approval of IO+TKI therapies, approved during the fieldwork period, has broadened the therapeutic landscape for 1L aRCC. Whilst the proportion of 1L pts receiving IO+TKI therapies is still low, the adoption of these in 1L is likely to transform the management of aRCC. Further research is needed to determine the optimum tx sequence in these pts with high unmet need.

Experiences of US Nephrologists in the Delivery of Conservative Care to Patients With Advanced Kidney Disease: A National Qualitative Study

It is relatively unusual for US patients with advanced chronic kidney disease (CKD) to forgo initiation of maintenance dialysis. Our objective was to describe practice approaches of US nephrologists who have provided conservative care for members of this population. Qualitative study using semi-structured interviews. A national sample of 21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis. Grounded theory methods to identify dominant themes reflecting nephrologists' experiences with and approaches to conservative care for patients with advanced CKD. Nephrologists who participated in this study were primarily from academic practices (n=14) and urban areas (n=15). Two prominent themes emerged from qualitative analysis reflecting nephrologists' experiences with and approaches to conservative care: (1) person-centered practices, which described a holistic approach to care that included basing treatment decisions on what mattered most to individual patients, framing dialysis as an explicit choice, being mindful of sources of bias in medical decision making, and being flexible to the changing needs, values, and preferences of patients; and (2) improvising a care infrastructure, which described the challenges of managing patients conservatively within health systems that are not optimally configured to support their needs. Participating nephrologists described cobbling together resources, assuming a range of different health care roles, preparing patients to navigate health systems in which initiation of dialysis served as a powerful default, and championing the principles of conservative care among their colleagues. The themes identified likely are not generalizable to most US nephrologists. Insights from a select group of US nephrologists who are early adopters of conservative care signal the need for a stronger cultural and health system commitment to building care models capable of supporting patients who choose to forgo dialysis.

Gout Severity in Recipients of Kidney Transplant

PurposeThis retrospective analysis of medical chart data was performed to compare severity and treatment of gout in patients with or without a history of kidney transplantation (KT). MethodsVia an online survey, a panel of board-certified US nephrologists (N = 104) provided the following deidentified chart data for their 3 most recent patients with gout: age, sex, serum uric acid, numbers of swollen or tender joints, visible tophi, gout flare events (prior 12 months), gout drug treatment history, and KT history. The presence of “severe, uncontrolled gout” was defined as: serum uric acid ≥ 7.0 mg/dL, ≥1 tophi and ≥2 flares in the last 12 months, and history of xanthine oxidase inhibitor treatment. ResultsTwenty-five out of 312 (8.0%) gout patients had a history of KT. Univariate analysis found that patients with gout and history of kidney transplants had: greater prevalence of severe uncontrolled gout (27% vs 8%, P = .007) and tophi (36% vs 17%, P = .030), and higher rates of failure or physician perceived contraindication to allopurinol (44% vs 23%, P = .028). ConclusionThis study provides preliminary evidence that gout in patients with history of KT is more severe and poses greater challenges to pharmacologic management. Although gout has been linked to worse outcomes among kidney recipients in the literature, there are presently no publications on gout severity among patients with KT in comparison to other patients with gout. Further investigation of disease severity and appropriate, effective treatment options in recipients of kidney transplant with a diagnosis of gout, especially prior to the transplant, is warranted.

66 Caring for the Patients with Advanced CKD Who Forego Maintenance Dialysis: A Qualitative Study of US Nephrologists

66 Caring for the Patients with Advanced CKD Who Forego Maintenance Dialysis: A Qualitative Study of US Nephrologists

Family Involvement in Decisions to Forego or Withdraw Dialysis: A Qualitative Study of Nephrologists in the United States and England

BackgroundShared decision making may be particularly complex for the older patient with end-stage renal disease (ESRD), in part because of family involvement. Nephrologists’ perspectives on the family’s role in ESRD decision making have not been explored.Study DesignSemi-structured, individual, qualitative interviews.Setting & ParticipantsPracticing US and English adult nephrologists.MethodologyParticipants were purposively sampled based on age, race, sex, geographic location, and practice type. Each was asked about his or her perspectives and experiences related to foregoing and withdrawing dialysis therapy.Analytical ApproachInterviews were audiotaped, transcribed, and analyzed using narrative and thematic analysis.ResultsWe conducted 59 semi-structured interviews with nephrologists from the United States (n = 41) and England (n = 18). Most participants were 45 years or younger, men, and white. Average number of years since completing nephrology training was 14.2 (SD, 11.6). Nephrologists in both countries identified how patients’ families may act to facilitate or impede decisions to forego and withdraw dialysis therapy, which fell within the following subthemes: (1) emotional response to decision making, (2) involvement in patient health care/awareness of illness, (3) trust in physician, and (4) acceptance of patient wishes. Only US nephrologists raised families’ financial dependence on patients as an impediment to foregoing or withdrawing dialysis therapy.LimitationsParticipants’ views may not fully capture those of all US or English nephrologists.ConclusionsNephrologists in the United States and England identified several ways that patients’ families help and hinder ESRD decision making in keeping with patient prognosis and preferences. Nephrologists should hone their communication skills to better navigate these interactions.

Imaging of Kidney Cysts and Cystic Kidney Diseases in Children: An International Working Group Consensus Statement.

Kidney cysts can manifest as focal disease (simple and complex kidney cysts), affect a whole kidney (eg, multicystic dysplastic kidney or cystic dysplasia), or manifest as bilateral cystic disease (eg, autosomal recessive polycystic kidney disease [ARPKD] or autosomal dominant polycystic kidney disease [ADPKD]). In children, as opposed to adults, a larger proportion of kidney cysts are due to genetic diseases (eg, HNF1B nephropathy, various ciliopathies, and tuberous sclerosis complex), and fewer patients have simple cysts or acquired cystic kidney disease. The purpose of this consensus statement is to provide clinical guidance on standardization of imaging tests to evaluate kidney cysts in children. A committee of international experts in pediatric nephrology, pediatric radiology, pediatric US, and adult nephrology prepared systematic literature reviews and formulated recommendations at a consensus meeting. The final statement was endorsed by the European Society of Pediatric Radiology, the European Federation of Societies for Ultrasound in Medicine and Biology, the European Society of Pediatric Nephrology, and reviewed by the European Reference Network for Rare Kidney Diseases. Main recommendations are as follows: US is the method of choice when assessing pediatric kidney cysts, with selected indications for MRI and contrast-enhanced US. CT should be avoided whenever possible because of ionizing radiation. Renal US yields essential diagnostic information in many cases. In patients with ARPKD or other ciliopathies, abdominal US is needed for diagnosis and screening of portal hypertension. US is usually sufficient for follow-up kidney imaging, but MRI can be valuable for clinical trials in patients with ADPKD or in older children with tuberous sclerosis complex to evaluate both kidney cysts and angiomyolipomas.

Survey of non-tunneled temporary hemodialysis catheter clinical practice and training.

Nephrologists are placing fewer non-tunneled temporary hemodialysis catheters. Requiring competence for nephrology fellow graduation is controversial. Anonymous, online survey of all graduates from a single, military nephrology training program (n = 81; 1985-2017) and all US Nephrology program directors (n = 150). Graduate response and completion rates were 59% and 100%, respectively; 93% agreed they had been adequately trained; 58% (26/45) place non-tunneled temporary hemodialysis catheters, independent of academic practice or time in practice, but 12/26 did ⩽5/year and 23/26 referred some or all. The most common reason for continuing non-tunneled temporary hemodialysis catheter placement was that it is an essential emergency procedure (92%). The single most significant barrier was time to do the procedure (49%). Program director response and completion rates were 50% and 79%, respectively. The single most important barrier to fellow competence was busyness of the service (36%), followed by disinterest (21%); 55% believed that non-tunneled temporary hemodialysis catheter insertion competence should be required, with 81% indicating it was an essential emergency procedure. The majority of graduates and program directors agreed that simulation training was valuable; 76% of programs employ simulation. Graduates who had simulation training and program directors with ⩽20 years of practice were significantly more likely to agree that simulation training was necessary. Of the graduate respondents from a single training program, 58% continue to place non-tunneled temporary hemodialysis catheters; 55% of program directors believe non-tunneled temporary hemodialysis catheter procedural competence should be required. Graduates who had non-tunneled temporary hemodialysis catheter simulation training and younger program directors consider simulation training necessary. These findings should be considered in the discussion of non-tunneled temporary hemodialysis catheter curriculum requirements.

PUK26 - IMPACT OF EMERGING HIF-PH INHIBITORS ON RENAL ANEMIA TREATMENT

Renal anemia (RA) is currently managed using iron supplements and erythropoiesis-stimulating agents (ESAs). ESAs are extremely efficacious, but concerns remain around their association with serious adverse cardiovascular events, including stroke. In addition to these safety concerns, nephrologists frequently lament the need for more convenient and cost-effective therapies. This research explores how the emergence of novel oral hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHi) will change the RA treatment paradigm and how reimbursement decisions will impact the prescribing and uptake of HIF-PHi in both chronic kidney disease-nondialysis (CKD-ND) and dialysis patients. Interviews with 20 thought-leading nephrologists in seven major pharmaceutical markets. 100 US nephrologists were also surveyed regarding their current and expected prescribing of iron supplements and ESAs, and future prescribing of HIF-PHi for treating RA. Interviewed nephrologists anticipate that HIF-PHi will be used in a variety of ways to treat RA in CKD-ND and dialysis patients, such as a direct alternative to ESAs in patients unable to tolerate ESAs or for whom ESAs are contraindicated. The majority of surveyed nephrologists indicate that oral administration of HIF-PHi will provide the greatest benefit to CKD-ND patients. Therefore, we expect HIF-PHi will garner significantly more patient share in CKD-ND than in dialysis populations. The gain in share for HIF-PHi will come primarily at the expense of ESAs in both the CKD-ND and dialysis markets. Assuming availability, nephrologists expect HIF-PHi to be prescribed in over a third of their RA patients. However, the anticipated high price of HIF-PHi will likely drive payers to adopt prior authorization requirements leading to use in later lines of therapy. Overall, nephrologists view HIF-PHi with excitement but express concerns regarding pricing, and access. Securing favorable reimbursement is critical for uptake of HIF-PHi, given the long-standing history of ESAs and availability of biosimilar ESAs.

Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists

BackgroundThere are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis. We conducted this study to determine if there are uniform patterns in how nephrologists transition patients to dialysis.MethodsWe designed an electronic survey with 39 questions and sent it to a database of practicing nephrologists at the National Kidney Foundation. Factors that were important for transitioning a patient to hemodialysis were evaluated, including medication changes on dialysis initiation, dry weight and dialysis prescription.Results160 US Nephrologists replied to the survey; 18% (29/160) of the responses were completed via social media sites. Prior to dialysis, 74% (118/160), prescribed furosemide and 67% (107/160) used furosemide with metolazone. Once dialysis started, only 46% (74/160) of the responders continued patients on diuretics daily. Hypertension medications prescribed in dialysis were calcium channel blockers 69% (112/160), beta blockers 36% (58/160), angiotensin converting enzyme inhibitor 32% (53/160), angiotensin receptor blocker 29% (46/160) and diuretics 25% (42/160). Once dialysis started, 68% (109/160) routinely changed medications. Most, 67% (107/160) ordered patients to avoid anti-hypertensive medications on dialysis days to allow for ultrafiltration. Dry weight was determined in the first week by 29% (46/160) and in the first month by 53% (85/160). Most, 59% (94/160) felt that multiple causes lead to hypertension. Most nephrologists would prescribe small dialyzers and a shorter period of time for the first dialysis session.ConclusionThe transition period to chronic hemodialysis has variations in practice patterns and may benefit from further studies to optimize clinical practice.

Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists

Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. Interview study of nephrologists. National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. Qualitative semistructured interviews continued until thematic saturation. Thematic and narrative analysis of recorded and transcribed interviews. Among 35 semistructured interviews withnephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management andtheir approaches to these discussions: struggling todefine nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, andtailoring information), confronting institutional barriers (timeconstraints, care coordination, incentives fordialysis, and discomfort with variedconservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view ofconservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management asa way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. Participants' views are likely mosttransferable to large academic medical centers, due to oversampling of academic clinicians. Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD)

Chronic kidney disease-mineral and bone disorder (CKD-MBD) encompasses laboratory and bone abnormalities and vascular calcification and has deleterious effects on clinical outcomes. KDOQI (Kidney Disease Outcomes Quality Initiative), an initiative of the National Kidney Foundation, addressed this issue with the publication of a clinical practice guideline for bone metabolism and disease in CKD in 2003, and 2 years later, a new definition and classification scheme for CKD-MBD was developed following a KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference. The initial KDIGO guideline on CKD-MBD was then published in 2009. New evidence was subsequently reviewed at the 2013 KDIGO Controversies Conference, andin 2017, KDIGO issued a clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of CKD-MBD. This commentary presents the views of the KDOQI CKD-MBD work group convened bythe National Kidney Foundation. The KDOQI work group agrees with most of the KDIGO guideline update recommendations, particularly the suggestions regarding bone mineral density testing, joint assessments of longitudinal trends in mineral metabolism markers, and dietary phosphate counseling focused on phosphate additives. However, the KDOQI work group has some concerns about the suggestions related to hypocalcemia and hypercalcemia, phosphate-binder choice, and treatment of abnormal parathyroid hormone concentrations. The overall goal of this commentary is to provide a broad discussion for the US nephrology community regarding CKD-MBD and its diagnosis, prevention, and treatment.

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.

Definition, Management, and Outcomes of Acute Kidney Injury: An International Survey of Nephrologists

Background: Acute kidney injury (AKI) is a complex disease burdened by uncertainties of definition, management strategies, and prognosis. This study explores the relationship between demographic characteristics of nephrologists and their perceptions about the definition, management, and follow-up of AKI. Methods: We developed a Web-based survey, the International Survey on Acute Kidney Injury (ISAKI), consisting of 29 items in 4 categories: (1) demographic and practice characteristics, (2) definition of AKI, (3) management of renal replacement therapy (RRT) in AKI, and (4) sequelae of AKI. A multivariable stepwise logistic regression model was used to examine relationships between the dependent variables and the demographic characteristics of the respondents. Results: Responses from 743 nephrologists from 90 countries were analyzed. The majority (60%) of respondents reported using RIFLE and/or AKIN criteria regularly to define AKI, although US nephrologists were less likely to do so (OR: 0.58; 95% CI: 0.42-0.85). The most common initial RRT modality was intermittent hemodialysis (63.5%), followed by continuous RRT (23.8%). Faculty affiliation was associated with a higher likelihood of using a dialysis schedule of ≥4 times a week (OR: 1.75; 95% CI: 1.20-2.55). The respondents believed that a single episode of AKI increases the likelihood of development of chronic kidney disease (CKD) (55%), subsequent AKI (36%), and rapid progression of preexisting CKD (87%). US nephrologists were less likely to recommend follow-up after resolution of AKI (OR: 0.15; 95% CI: 0.07-0.33). Conclusions: Our findings highlight the need for a widely accepted consensus definition of AKI, a uniform approach to management, and improved follow-up after resolution of AKI episodes.

PUK22 - Renal Anemia Treatment in the Us- How Payer Policies and Physician Preferences Drive Prescribing and How will the Emerging Oral HIF-PH Inhibitors Influence Payers and Physicians?

Novel oral hypoxia inducible factor-prolyl hydroxylase inhibitors (HIF-PHi) offer a more convenient therapeutic option over erythropoiesis-stimulating agents (ESAs), which are administered intravenously for the treatment of renal anemia (RA). However, HIF-PHi could result in increased expenditures in an environment of tightening healthcare budgets for US insurers and dialysis centers. This research explores how payers and physicians interact and how reimbursement decisions impact the prescribing and uptake of RA therapies in chronic kidney disease-nondialysis (CKD-ND) and dialysis patients. In February 2016, 100 US nephrologists were surveyed regarding their current and expected prescribing of ESAs, IV iron and future prescribing of HIF-PHi for treating RA. 30 managed care organization pharmacy directors/medical directors were also surveyed. 59% of physicians report pressure from their dialysis units regarding RA treatment. Payers employ a wide range of measures to control access to premium-priced ESAs. 33%-48% of payers quoted prior authorization (PA) as the main control across ESAs. However, PA can be overcome as payers want to ensure that drugs are used according to the FDA label and are prescribed by specialists. 32% of nephrologists reported they would prescribe HIF-PHi over ESAs in CKD-ND due to its less invasive route of administration. Assuming availability, nephrologists expect HIF-PHi to capture approximately 38% of their RA patients. The main market access challenge HIF-PHi will face is likely an anticipated high price compared with ESAs—and thus unfavorable tiering. However, 67% of payers indicate they would place HIF-PHi on tier 1 if priced at a 20% discount to ESAs. Opportunity exists for HIF-PHi, partly due to the intravenous administration of ESAs and increased scrutiny of costs at dialysis centers. Although nephrologists expect to decrease their ESA use following the launch of HIF-PHi, these agents will need to convincingly demonstrate cost-effectiveness to secure optimum reimbursement status.

Renal Ultrasound, Dialysis Catheter Placement, and Kidney Biopsy Experience of US Nephrology Fellows.

Procedures are a key component to the practice of nephrology. The Accreditation Council for Graduate Medical Education (ACGME) requires nephrology fellows to acquire skills and demonstrate competency in the performance of several procedures during fellowship training, including temporary hemodialysis catheter placement, biopsy of native and transplanted kidneys, and various dialytic therapies. It is also required that fellows acquire competency in the interpretation of renal imaging, including renal ultrasound, during their training. To gain a more recent perspective of nephrology fellows' experiences regarding renal ultrasonography, dialysis catheter placement, and kidney biopsies, we carried out a national survey of nephrology fellows in May 2014. A majority of the programs did not offer formal clinical training in renal ultrasonography. In addition, a significant percentage of fellows in adult nephrology may not be acquiring the required procedural skills and competency during fellowship training. In this perspective, we explore some of the reasons for this occurrence and propose some measures that the nephrology training community can take to enhance procedural skills and competency of fellows.