Role of Age and Competing Risk of Death in the Racial Disparity of Kidney Failure Incidence after Onset of CKD

SIGNIFICANCE STATEMENT

Black adults in the United States have 2-4 times higher incidence of kidney failure than White adults. Yet, the reasons underlying this disparity remain poorly understood. Among 547,188 US veterans with new-onset CKD, according to a new race-free GFR equation, Black veterans had a 2.5-fold higher cumulative incidence of kidney failure, compared with White veterans, in any follow-up period from CKD onset. This disparity resulted from a combination of higher hazards of progression to kidney failure and lower hazards of competing-risk death in Black veterans. Both, in turn, were largely explained by the younger age at CKD onset in Black veterans, underscoring an urgent need to prevent early onset and slow progression of CKD in younger Black adults.

BACKGROUND

The Black adult population is well known to have higher incidence of kidney failure than their White counterpart in the United States, but the reasons underlying this disparity are unclear. We assessed the racial differences in kidney failure and death from onset of CKD on the basis of the race-free 2021 CKD Epidemiology Collaboration equation and examined the extent to which these differences could be explained by factors at the time of CKD onset.

METHODS

We analyzed a national cohort consisting of 547,188 US veterans (103,821 non-Hispanic Black and 443,367 non-Hispanic White), aged 18-85 years, with new-onset CKD between 2005 and 2016 who were followed through 10 years or May 2018 for incident kidney failure with replacement therapy (KFRT) and pre-KFRT death.

RESULTS

At CKD onset, Black veterans were, on average, 7.8 years younger than White veterans. In any time period from CKD onset, the cumulative incidence of KFRT was 2.5-fold higher for Black versus White veterans. Meanwhile, Black veterans had persistently >2-fold higher hazards of KFRT throughout follow-up (overall hazard ratio [95% confidence interval], 2.38 [2.31 to 2.45]) and conversely had 17%-48% decreased hazards of pre-KFRT death. These differences were reduced after accounting for the racial difference in age at CKD onset.

CONCLUSIONS

The 2.5-fold higher cumulative incidence of kidney failure in Black adults resulted from a combination of higher hazards of progression to kidney failure and lower hazards of the competing risk of death, both of which can be largely explained by the younger age at CKD onset in Black compared with White adults.

Role of Anemia in Dementia Risk Among Veterans With Incident CKD

RATIONALE & OBJECTIVE

Although some evidence exists of increased dementia risk from anemia, it is unclear whether this association persists among adults with CKD. Anemia may be a key marker for dementia among adults with CKD, so we evaluated whether anemia is associated with an increased risk of dementia among adults with CKD.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

The study included 620,095 veterans aged≥45 years with incident stage 3 CKD (estimated glomerular filtration rate [eGFR]<60mL/min/1.73m2) between January 2005 and December 2016 in the US Veterans Health Administration system and followed through December 31, 2018, for incident dementia, kidney failure, or death.

EXPOSURE

Anemia was assessed based on the average of hemoglobin levels (g/L) during the 2 years before the date of incident CKD and categorized as normal, mild, or moderate/severe anemia (≥12.0, 11.0-11.9,<11.0g/dL, respectively, for women, and≥13.0, 11.0-12.9,<11.0g/dL for men).

OUTCOME

Dementia and the composite outcome of kidney failure or death.

ANALYTICAL APPROACH

Adjusted cause-specific hazard ratios were estimated for each outcome.

RESULTS

At the time of incident CKD, the mean age of the participants was 72 years, 97% were male, and their mean eGFR was 51mL/min per 1.73m2. Over a median 4.1 years of follow-up, 92,306 veterans (15%) developed dementia before kidney failure or death. Compared with the veterans with CKD without anemia, the multivariable-adjusted models showed a 16% (95% CI, 14%-17%) significantly higher risk of dementia for those with mild anemia and a 27% (95% CI, 23%-31%) higher risk with moderate/severe anemia. Combined risk of kidney failure or death was higher at 39% (95% CI, 37%-40%) and 115% (95% CI, 112%-119%) for mild and moderate/severe anemia, respectively, compared with no anemia.

LIMITATIONS

Residual confounding from the observational study design. Findings may not be generalizable to the broader US population.

CONCLUSIONS

Anemia was significantly associated with an increased risk of dementia among veterans with incident CKD, underscoring the role of anemia as a predictor of dementia risk.

PLAIN-LANGUAGE SUMMARY

Adults with chronic kidney disease (CKD) often have anemia. Prior studies among adults in the general population suggest anemia is a risk factor for dementia, though it is unclear whether this association persists among adults with CKD. In this large study of veterans in the United States, we studied the association between anemia and the risk of 2 important outcomes in this population: (1) dementia and (2) kidney failure or death. We found that anemia was associated with a greater risk of dementia as well as risk of kidney failure or death. The study findings therefore emphasize the role of anemia as a key predictor of dementia risk among adults with CKD.

Flattening the Playing Field for Treatment of Diabetic Kidney Disease

Diabetic kidney disease (DKD) remains a major health care issue and is beset with significant racial and ethnic disparities in regard to its incidence, progression, and complication rate. An individual's health is influenced strongly by an array of societal-level factors commonly called the social determinants of health. Among these, DKD is influenced highly by structured resources and opportunities, as well as an individual's socioeconomic status, health insurance status, access to care, education, health literacy, nutrition, green space exposure, level of trust in the medical community, and more. Health equity is considered a state in which everyone has a fair and just opportunity to attain his or her highest level of health. Conversely, health inequities are a consequence of a structured discriminatory system of inequitable allocation of social determinants of health. When this discriminatory system is race-based it is referred to as structural racism, which eventually leads to racial and ethnic health disparities. The further downstream sequela of structural racism, consciously or unconsciously, impacts health systems, providers, and patients, and can lead to disparities in DKD development, progression, and complications. In this article, we explore potential interventions at the societal, health system, and provider levels that can help flatten the playing field and reduce racial and ethnic disparities in DKD.

Point-of-Care Ultrasound Use in Nephrology: A Survey of Nephrology Program Directors, Fellows, and Fellowship Graduates

Rationale & Objective

Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use.

Study Design

Anonymous, online survey.

Setting & Participants

All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program.

Analytical Approach

Descriptive.

Results

46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation.

Limitations

Loss of respondents as program directors and fellows progressed through the survey.

Conclusions

Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

108 TEIRIPE SA BHAILE TEAM (TSAB): AN EARLY SUPPORTED DISCHARGE SERVICE FOR HIP FRACTURES FROM AN ACUTE HOSPITAL

Background

Due to increasing bed strain in hospitals, Early Supported Discharge (ESD) programmes have helped to reduce length of stay for hip fracture patients. Teiripe sa Bhaile Team (TsaB) provides a multi-disciplinary, patient centred approach to care for patients over 60 with hip fractures, in their own home.

Methods

Patient demographics and data has been collected on all TsaB patients to date with consent from the patients. We measured length of intervention with TsaB, patient directed SMART (Specific, measurable, achievable, relevant, time bound) goals, Functional Independence Measure (FIM) sores. We recorded the number of visits required, medical complications and number of readmissions post discharge from our service.

Results

Since formation in 2018 until April 2022, 33 patients have been treated by TsaB. The average age is 78 years old. The average length of stay prior to discharge was 17 days, compared to 54 days for inpatient hip fracture rehabilitation. Patients received an average of 11 MDT visits during the 6 weeks of rehabilitation. The average improvement in FIM score was 42. All set SMART goals, and only 5 (17%) patients did not achieve these goals.

Only 5 (17%) patients were readmitted within 6 months. No patients required initiation of a home care package for discharge, or after our interventions. No patients developed pressure ulcers while on our service, or other medical complications.

Conclusion

Through TsaB, we are able to offer a rehabilitation service to patients based around their own needs in the home. Patients were able to set and achieve their own SMART goals. Patients were moderately frail on admission to our service, but after intervention were able to improve their FIM scores, marking reduced frailty after intervention. We had low readmission rates, and no patients required a change in home care package.

318 CARER STRESS REVIEW IN COMPLEX CASES REQUIRING INTERVENTION BY A COMMUNITY-BASED OLDER PERSONS TEAM

Background

Complex cases of older adults suffering from multimorbidity are continuing to increase in number. The integrated care team, overseen by a consultant geriatrician, aims to facilitate the management of stable complex cases in the community. Patient care is largely affected by their support system at home; therefore, it is of great importance to ensure that the patient’s primary carer is receiving the support they require to facilitate the older patients’ management in the community. Our aim is to assess carer stress levels before and after Multi-Disciplinary Team (MDT) integrated care intervention.

Methods

Study Population were carers of patients identified as complex cases by the integrated care team. Caregiver stress index was administered during the initial assessment and on the closing of active cases. The maximum score on this index is 13 with high stress classified as &gt;7. Scores were added to a spreadsheet. This spreadsheet was reviewed, and relevant data was collated. One year assessed March 2021- March 2022.

Results

Carer stress information was collected on 62 of 112 identified complex cases (55%). Of these 55 of 96 individual patients were represented (57%). Average age 82 years old. 65% female and 35%, male. Range of carer stress scores observed 0- to 12. Of the 62 cases, 85% (53 cases) had a reduction in carer stress post-intervention(p&lt;0.01). Of these 65% had a reduction below 7 (p&lt;0.01). Mean score improvement 7. No carer stress indices disimproved post-treatment.

Conclusion

Multidisciplinary, patient-centred community care has a clear positive impact on the patient carer. Improvements in carer stress scores could be further evaluated as to the benefits of specific interventions in time. In future, a more large-scale collection and interpretation of data would need to occur for a more conclusive positive impact of the community based integrated care team to be confirmed.

314 COMMUNITY-BASED INTEGRATED CARE TEAMS EFFECTIVENESS IN PREVENTING CRISIS EMERGENCY DEPARTMENT ATTENDANCES

Background

Community based integrated care Multi-Disciplinary Teams (MDT) are a mainstay for future management of older adults. They have evolved to meet the needs of many different sub-types of clinical cases in the community. Complex Cases, are patients over 65 who reside within the catchment area, suffer from at least 2 frailty traits, and would be at increased risk of crisis emergency department (ED) attendance. Can the crisis ED attendances be prevented by integrated care team intervention?

Methods

The study population comprised adults identified as complex cases as per integrated care team standard operating procedure. Collated data was reviewed, and electronic medical records assessed as to whether any complex cases had been admitted within 30 days, 60 days, and 1 year of community team review. The study time frame was March 2021- to March 2022. As many patients have more than one unique identifying number, all patients were double-checked with an assessment based on their name and date of birth.

Results

112 complex cases were identified within one year, and 96 individual patients were represented. Average age 83 years old. 65% female and 35% male. 11% were admitted to hospital within 30 days, a further 6% were admitted within 60 days and by one year 30% of reviewed complex cases had been admitted to hospital.

Conclusion

In one year 70% of complex cases have been successfully maintained in the community. This has been achieved based on a multidisciplinary-based, patient-centred care approach. Given that 53% of hospital inpatient bed days are occupied by those over 65. This review concurs with previous research suggesting that an increase in community based integrated care teams is justified and should the aim for a fully staffed team per 150,000 patients over 65 come to fruition more than two-thirds of even the most complicated geriatric cases could be managed in the community.

Age-Related Association between Multimorbidity and Mortality in US Veterans with Incident Chronic Kidney Disease

INTRODUCTION

Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD.

METHODS

The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence.

RESULTS

At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61-2.37] in ages 18-44 years and HR 1.66 [1.63-1.70] in ages 45-64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68-1.74] in ages 65-84 years and HR 1.69 [1.65-1.73] in ages 85-100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18-44 years and >2-fold higher among veterans aged 85-100 years.

CONCLUSION

The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

Prevalence and Characteristics of CKD in the US Military Health System: A Retrospective Cohort Study

Rationale & Objective

The US Military Health System (MHS) is a global health care network with a diverse population that is more representative of the US population than other study cohorts and with fewer disparities in health care access. We aimed to examine the prevalence of chronic kidney disease (CKD) in the MHS and within demographic subpopulations.

Study Design

Multiple cross-sectional analyses of demographic and claims-based data extracted from the MHS Data Repository, 1 for each fiscal year from 2006-2015.

Setting & Population

Multicenter health care network including active-duty military, retirees, and dependents. The average yearly sample size was 3,285,348 individuals.

Exposures

Age, sex, race, active-duty status, and active-duty rank (a surrogate for socioeconomic status).

Outcome

CKD, defined as the presence of matching International Classification of Diseases, Ninth Revision, codes on either 1 or more inpatient or 2 or more outpatient encounters.

Analytical Approach

t test for continuous variables and χ² test for categorical variables; multivariable logistic regression for odds ratios.

Results

For 2015, the mean (standard deviation) age was 38 (16). Crude CKD prevalence was 2.9%. Age-adjusted prevalence was 4.9% overall—1.9% active-duty and 5.4% non–active-duty individuals. ORs for CKD were calculated with multiple imputations to account for missing data on race. After adjustment, the ORs for CKD (all P < 0.001) were 1.63 (95% CI, 1.62-1.64) for an age greater than 40 years, 1.16 (95% CI, 1.15-1.17) for Black race, 1.15 (95% CI, 1.14-1.16) for senior enlisted rank, 0.94 (95% CI, 0.93-0.95) for women, and 0.50 (95% CI, 0.49-0.51) for active-duty status.

Limitations

Retrospective study based on International Classification of Diseases, Ninth Revision, coding.

Conclusions

Within the MHS, older age, Black race, and senior enlisted rank were associated with a higher risk of CKD, whereas female sex and active-duty status were associated with a lower risk.

118 EVALUATION OF PATIENTS ADMITTED UNDER GERIATRICS FROM SEPTEMBER TO NOVEMBER 2020: GUIDE TO ESTABLISHING A HOSPITAL AT HOME SERVICE

Background

Studies have shown that home hospital care is as effective as hospital management and improve patient satisfaction. Up to date guidelines recommends that patients who do not require care uniquely proved in hospitals should be treated at home when possible. We aim to assess the need for a new Hospital At Home (HAH) with Comprehensive Geriatric Assessment (CGA) pathway under Integrated Care Programme for Older People (ICPOP).

Methods

We conducted a retrospective medical chart review of all patients admitted under Geriatrics from September 2020 to November 2020. Demographic data and admission notes were used to assess the patient’s eligibility. Information on dementia and delirium, length of stay, discharge destination, readmission rates, number of previous admissions, length of time at home prior to readmission, use of multidisciplinary team members during admission was also collected.

Results

Over the 3 months 358 patients were admitted and 36 patients met the inclusion criteria. The average age is 84.9 years, 33% were males. 10 patients had a diagnosis of Mild Cognitive Impairment and 5 with Dementia. No patients were delirious on admission, but 7 developed delirium as an inpatient. The average length of stay was 14.8 days, with a total of 534 bed days. Discharge destination was home for 91.7%, 1 patient passed away and 2 were discharged to Long Term Care. 22 patients were readmitted. The average time to readmission was 55 days, with a median of 35 days.

Conclusion

Given the aging population, and continued bed shortage in acute hospitals, the development of a HAH service will aim to alleviate some of this pressure. We aim to provide a holistic service to our patients, focused on medical care, but also improved quality of life, reduction in delirium, continued home living and reduced carer stress.

Physical and mental health of older people while cocooning during the COVID-19 pandemic

BACKGROUND

Cocooning or shielding, i.e. staying at home and reducing face-to-face interaction with other people, was an important part of the response to the COVID-19 pandemic for older people. However, concerns exist regarding the long-term adverse effects cocooning may have on their physical and mental health.

AIM

To examine health trajectories and healthcare utilization while cocooning in a cohort of community-dwelling people aged ≥70 years.

DESIGN

Survey of 150 patients (55% female, mean age 80 years and mean Clinical Frailty Scale Score 4.8) attending ambulatory medical services in a large urban university hospital.

METHODS

The survey covered four broad themes: access to healthcare services, mental health, physical health and attitudes to COVID-19 restrictions. Survey data were presented descriptively.

RESULTS

Almost 40% (59/150) reported that their mental health was 'worse' or 'much worse' while cocooning, while over 40% (63/150) reported a decline in their physical health. Almost 70% (104/150) reported exercising less frequently or not exercising at all. Over 57% (86/150) of participants reported loneliness with 1 in 8 (19/150) reporting that they were lonely 'very often'. Half of participants (75/150) reported a decline in their quality of life. Over 60% (91/150) agreed with government advice for those ≥70 years but over 40% (61/150) reported that they disliked the term 'cocooning'.

CONCLUSIONS

Given the likelihood of further restrictions in coming months, clear policies and advice for older people around strategies to maintain social engagement, manage loneliness and continue physical activity and access timely medical care and rehabilitation services should be a priority.

Association of Race and Risk of Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis

OBJECTIVE

Scleroderma renal crisis (SRC) is a rare and severe manifestation of systemic sclerosis (SSc). Although it is well documented that Blacks with SSc have worse morbidity and mortality than non-Blacks, racial predilection for SRC is underreported. We examine the association of race and future development of SRC in an SSc cohort.

METHODS

Using the electronic health record of the United States Military Health System, we conducted a comprehensive chart review of each patient with SSc from 2005 to 2016. The final study cohort was comprised of 31 SRC cases and 322 SSc without SRC controls. We conducted logistic regression of SRC as the outcome variable and race (Black vs. non-Black) as the primary predictor variable, adjusted for age, estimated glomerular filtration rate, hypertension and proteinuria at SSc diagnosis.

RESULTS

Out of 353 patients, 294 had identifiable race (79 Black, 215 non-Black). Thirteen out of 79 Blacks (16.5%) vs. 16/215 (7.4%) non-Blacks developed SRC (p=0.02). On adjusted analysis, Blacks had a significantly higher risk of developing SRC than non-Blacks (odds ratio 6.4, 95% CI 1.3-31.2, p=0.02). Anti-Ro antibody was present in a higher proportion of Black SRC patients vs. Blacks without SRC [45% vs. 14%, p=0.01]. Conversely, older age, thrombocytopenia, and anti-RNA polymerase III antibody at SSc diagnosis were significantly associated with future SRC in the non-Black cohort.

CONCLUSION

Black race was independently associated with a higher risk of future SRC. Further studies are needed to elucidate the mechanisms that underlie this important association. This article is protected by copyright. All rights reserved.

Clinical and Military Outcomes of Kidney Diseases Diagnosed in Active Duty Service Members

INTRODUCTION

Renal biopsy is a valuable tool for determining diagnosis, management, and prognosis of intrinsic kidney diseases. Indications for biopsy depend on the clinical presentation. Within the military, renal biopsies also enable medical review boards to make military service fitness assessments after diagnosis of a kidney disease. There are no recent studies evaluating kidney disease diagnoses and clinical outcomes after renal biopsy at military treatment facilities. Additionally, no studies have examined overall healthcare and military career outcomes following renal biopsy.

MATERIALS AND METHODS

We retrospectively reviewed all native renal biopsies performed on active duty beneficiaries at the Walter Reed National Military Medical Center from 2005 to 2020. We determined the prevalence of those who progressed to end-stage kidney disease (ESKD), kidney transplantation, doubling of serum creatinine, nephrotic-range proteinuria (NRP; proteinuria >3.5 g/day), medical evaluation board (MEB) outcomes, and death. The Armed Forces Health Longitudinal Technology Application and the Joint Legacy Viewer electronic medical record systems were used to access clinical and laboratory data at the time of biopsy and subsequent outcomes. Death data were collected using the Defense Suicide Prevention Office database.

RESULTS

There were 169 patients in the cohort, with a mean follow-up of 7.3 years. Mean age was 32 years; 79% male; 48% white; and 37% black. Sixty-seven percentage of them were junior or senior enlisted. The most common indication for renal biopsy was concomitant hematuria and proteinuria (31%). The most common histologic diagnoses were immunoglobulin A (IgA) nephropathy (23%), followed by focal segmental glomerulosclerosis (FSGS; 17%) and lupus nephritis (12%). Eleven percentage of them progressed to ESKD, of whom 87% received a kidney transplant (10% overall). Thirty percentage of the patients progressed to NRP and 5% died. Forty-seven percentage of our patients underwent MEB after diagnosis, and of these, 84% were not retained for further military service. Although IgA nephropathy was the most commonly diagnosed condition, FSGS and lupus nephritis diagnoses were significantly more likely to result in MEB.

CONCLUSIONS AND IMPLICATIONS

Immunoglobulin A nephropathy was the most frequent histologic diagnosis in active duty service members undergoing renal biopsy between 2005 and 2020. Despite being largely young and previously healthy, 11% progressed to ESKD and 5% died. A confirmed histologic diagnosis was associated with separation from the service and the end of military careers for 84% of the patients in the cohort who underwent MEB.

Prophylactic or Early Use of Eculizumab and Graft Survival in Kidney Transplant Recipients With Atypical Hemolytic Uremic Syndrome in the United States: Research Letter

Introduction:

Among kidney transplant recipients (KTRs) with end-stage kidney disease (ESKD) due to atypical hemolytic uremic syndrome (aHUS), recurrence is associated with poor allograft outcomes. We compared graft and patient survival of aHUS KTRs with and without prophylactic/early use of eculizumab, a monoclonal antibody that binds complement protein C5, at the time of transplantation.

Methods:

We conducted a retrospective cohort study using the United States Renal Data System. Out of 123 624 ESKD patients transplanted between January 1, 2008, and June 1, 2016, we identified 348 (0.28%) patients who had “hemolytic uremic syndrome” as the primary cause of ESKD. We then linked these patients to datasets containing the Healthcare Common Procedure Coding System (HCPCS) code for eculizumab infusion. Patients who received eculizumab prior to or within 30 days of transplant represented the exposure group. We calculated crude incidence rates and conducted exact logistic regression, adjusted for recipient age and sex, for the study outcomes of graft loss, death-censored graft loss, and mortality. We also estimated the average treatment effect (ATE) by propensity-score matching, to reduce the bias in the estimated treatment effect on graft loss.

Results:

Our final study cohort included 335 aHUS KTRs (23 received eculizumab, 312 did not), with a mean duration of follow-up of 5.8 ± 2.7 years. There were no significant differences in baseline demographic and clinical characteristics between the eculizumab versus non-eculizumab group. Patients who received prophylactic/early eculizumab were less likely to experience graft loss compared with those who did not receive eculizumab (0% vs 20%, P = .02), with an adjusted odds ratio of 0.13 (P = .02). In the propensity-score-matched sample, the ATE (eculizumab vs non-eculizumab) was −0.20 (95% confidence interval [CI] = −0.25 to −0.15, P < .001); thus, treatment was associated with an average of 20% reduction in graft loss. There was no significant difference in the risk of death between the 2 groups.

Conclusions:

Although there was no significant difference in the risk of death, prophylactic/early use of eculizumab was significantly associated with improved graft survival among aHUS KTRs. Given the high cost of eculizumab, randomized controlled trials are much needed to guide prophylactic strategies to prevent graft loss.

The peritoneal dialysis orders objective structured clinical examination (OSCE): A formative assessment for nephrology fellows

Background:

Peritoneal dialysis (PD) management is a fundamental nephrology skill, especially with the recent emphasis on home dialysis. We report a prospective multicentre cohort study of a formative objective structured clinical examination (OSCE) assessing competence in managing PD-associated bacterial peritonitis, using the unified model of construct validity.

Methods:

The OSCE was developed by the principal investigators and reviewed by two subject matter experts. The test committee (eight nephrologists and one PD nurse) assessed test item difficulty/relevance and determined passing score. There were 22 test items (7 evidence-based/standard-of-care questions). Passing score was 16/22 (73%). No item had median relevance less than ‘important’, and all were easy to medium difficulty. Content validity index was 0.91. Preliminary validation (16 board-certified volunteers): mean score was 19 ± 2, with 94% (15/16) passing. Kappa = 0.85 [95% confidence interval (CI) 0.77–0.94]. Cronbach’s α = 0.70.

Results:

Eighty-seven fellows (16 programmes) were tested; 67% passed. Fellows scored significantly less than validators: 17 ± 3 versus 19 ± 2, p < 0.001 [95% CI 1.2–3.6]. Eighty-six per cent of evidence-based/standard-of-care questions were answered correctly by validators versus 54% by fellows; p < 0.001. Ninety-three per cent of fellows recognized that sufficient criteria were present to diagnose peritonitis, but only 17% correctly indicated all three. Seventy-seven per cent recognized peritonitis-associated ultrafiltration failure, but only 17% prescribed 21 days of antibiotic treatment for gram-negative peritonitis. Eighty-five per cent of fellows surveyed agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Second-year in-training examination and OSCE scores were positively correlated (Pearson’s r = 0.57, p < 0.00).

Conclusions:

The OSCE may be used to formatively assess fellow proficiency in managing PD-associated peritonitis.

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

BACKGROUND

The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs).

SUMMARY

From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News

RATIONALE & OBJECTIVE

Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy.

STUDY DESIGN

Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy.

SETTING & PARTICIPANTS

58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018.

PREDICTORS

Fellowship training year and clinical scenario.

OUTCOME

Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed).

ANALYTICAL APPROACH

Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario.

RESULTS

Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions.

LIMITATIONS

Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS.

CONCLUSIONS

The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Focal Segmental Glomerulosclerosis, Risk Factors for End Stage Kidney Disease, and Response to Immunosuppression

Background

FSGS is a heterogeneic glomerular disease. Risk factors for kidney disease ESKD and the effect of immunosuppression treatment (IST) has varied in previously published cohorts. These cohorts were limited by relatively small case numbers, short follow-up, lack of racial/ethnic diversity, a mix of adult and pediatric patients, lack of renin-angiotensin-aldosterone system (RAAS) inhibition, or lack of subgroup analysis of IST.

Methods

We compared demographics, clinical characteristics, histopathology, and IST to long-term renal survival in a large, ethnically diverse, adult cohort of 338 patients with biopsy-proven FSGS with long-term follow-up in the era of RAAS inhibition using data from the US Department of Defense health care network.

Results

Multivariate analysis showed that nephrotic-range proteinuria (NRP), eGFR <60 ml/min per 1.73 m², hypoalbuminemia, interstitial fibrosis and tubular atrophy, and interstitial inflammation at diagnosis and the absence of remission were all associated with worse long-term renal survival. IgM, C3, and a combination of IgM/C3 immunofluorescence staining were not associated with reduced renal survival. IST was not associated with improved renal survival in the whole cohort, or in a subgroup with NRP. However, IST was associated with better renal survival in a subgroup of patients with FSGS with both NRP and hypoalbuminemia and hypoalbuminemia alone.

Conclusions

Our study suggests that IST should be reserved for patients with FSGS and nephrotic syndrome. It also introduces interstitial inflammation as a potential risk factor for ESKD and does not support the proposed pathogenicity of IgM and complement activation.

Liver Function Enzymes are Potential Predictive Markers for Kidney Allograft Dysfunction

Introduction

Biopsy of the allograft is the gold standard for assessing kidney allograft dysfunction. The aim of our pilot study was to identify serum biomarkers that could obviate the need for biopsy.

Materials and Methods

We conducted a study to identify the biomarkers in the serum from different groups of chronic kidney disease (CKD) patients and kidney transplanted patients vs. healthy individuals. The four groups (n=25 in each group) were as follows: 1) Patients with unstable kidney allograft transplants requiring biopsy for cause, 2) Patients with stable kidney allograft transplants, 3) Patients with CKD not on immunosuppressive therapy and, 4) healthy subjects. We measured the activity and level of serum alkaline phosphatase (ALP) and other liver enzymes (alanine transaminase (ALT) and aspartate transaminase (AST)) as potential serum biomarkers in acute allograft dysfunction.

Results

We found that ALP correlated with allograft biopsy findings, liver function, and clinical outcomes and possibly graft survival. Additionally, AST and ALT were higher in patients with graft rejection compared to non-rejected and stable kidney transplants. Moreover, the low Pearson correlations (r- values) between ALP level with age (r=0.179), gender, body mass index (r=0.236), creatinine (r=0.044) or estimated glomerular filtration rate (r=0.048) suggest that ALP may be an independent biomarker which is relatively unaffected by other individual-level variables.

Conclusion

ALP may be a putative biomarker to predict kidney allograft function and rejection. Data also indicated that liver function plays an important role for the overall success of kidney transplantation.

The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey

BACKGROUND AND OBJECTIVES

An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons.

RESULTS

Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias.

CONCLUSIONS

Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial

Objectives

To test (i) if greater foot pronation (measured as midfoot width mobility) is associated with better outcomes with foot orthoses treatment, compared with hip exercises and (ii) if hip exercises are superior to foot orthoses, irrespective of midfoot width mobility.

Methods

A two-arm parallel, randomised superiority clinical trial was conducted in Australia and Denmark. Participants (18–40 years) were included who reported an insidious onset of knee pain (≥6 weeks duration); ≥3/10 numerical pain rating, that was aggravated by activities (eg, stairs, squatting, running). Participants were stratified by midfoot width mobility (high ≥11 mm change in midfoot width) and site, randomised to foot orthoses or hip exercises and blinded to objectives and stratification. Success was defined a priori as much better or better on a patient-perceived 7-point scale at 12 weeks.

Results

Of 218 stratified and randomised participants, 192 completed 12-week follow-up. This study found no difference in success rates between foot orthoses versus hip exercises in those with high (6/21 vs 9/20; 29% vs 45%, respectively) or low (42/79 vs 37/72; 53% vs 51%) midfoot width mobility. There was no association between midfoot width mobility and treatment outcome (Interaction effect p=0.19). This study found no difference in success rate between foot orthoses versus hip exercises (48/100 vs 46/92; 48% vs 50%).

Conclusion

Midfoot width mobility should not be used to help clinicians decide which patient with patellofemoral pain might benefit most from foot orthoses. Clinicians and patients may consider either foot orthoses or hip exercises in managing patellofemoral pain.

Trial registration number

ACTRN12614000260628.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States

BACKGROUND AND OBJECTIVES

In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others.

RESULTS

Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states.

CONCLUSIONS

Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Biotin supplement interference with immunoassays for parathyroid hormone and 25-hydroxyvitamin D in a patient with metabolic bone disease on maintenance hemodialysis

Biotin (vitamin B7) is a dietary supplement that can lead to falsely abnormal endocrine function tests. The impact of biotin on both 25-hydroxyvitamin D [25(OH)D] and intact parathyroid hormone (iPTH) have not been previously described in end-stage renal disease (ESRD). A woman with ESRD on hemodialysis taking biotin 10 mg daily had a 25(OH)D spike from 25 to >100 ng/mL and an iPTH decrease from 966 to 63 pg/mL. After discontinuation of biotin, her 25(OH)D and iPTH returned to baseline. Biotin can cause erroneous 25(OH)D and iPTH results in ESRD that could adversely affect patient care.

Aliskiren as an adjunct therapy for atypical hemolytic uremic syndrome

Direct renin inhibitors (DRIs) block the activation of the alternative complement pathway in vitro and could be a treatment option for refractory hypertension in atypical hemolytic uremic syndrome (aHUS). A 20-year-old male presented with primary aHUS complicated by end-stage renal disease and refractory malignant hypertension despite being on five antihypertensive medications at maximum dose. Only a partial response was achieved with aliskiren and eculizumab, but after increasing aliskiren to a supratherapeutic dose, antihypertensive medication was reduced, platelets increased, C3 increased and epoetin alfa requirement decreased. DRI may be an adjunct treatment for malignant hypertension associated with aHUS.

The Acute Dialysis Orders Objective Structured Clinical Examination (OSCE): Fellow Performance on a Formative Assessment of Acute Kidney Replacement Therapy Competence

BACKGROUND AND OBJECTIVES

Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey.

RESULTS

A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3-4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing "proficiency in ordering" acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format.

CONCLUSIONS

The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_08_CJASNPodcast_19_09_.mp3.

Systemic sclerosis medications and risk of scleroderma renal crisis

Background

Scleroderma Renal Crisis (SRC) is associated with significant morbidity and mortality. While prednisone is strongly associated with SRC, there are no previous large cohort studies that have evaluated ace inhibitor (ACEi) calcium channel blocker (CCB), angiotensin receptor blocker (ARB), endothelin receptor blocker (ERB), non-steroidal anti-inflammatory drug (NSAID), fluticasone, or mycophenolate mofetil (MMF) use in systemic sclerosis (SSc) and the risk of SRC.

Methods

In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the use of ACEi, ARB, CCB, NSAID, ERB, fluticasone, and MMF after SSc diagnosis for 31 cases who subsequently developed SRC to 322 SSc without SRC disease controls.

Results

ACEi was associated with an increased risk for SRC adjusted for age, race, and prednisone use [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.6–10.2, P = 0.003]. On stratified analyses, ACEi was only associated with SRC in the presence [OR 5.3, 95% CI 1.1–29.2, p = 0.03], and not the absence of proteinuria. In addition, a doubling of ACEi dose [61% vs. 12%, p < 0.001) and achieving maximum ACEi dose [45% vs. 4%, p < 0.001] after SSc diagnosis was associated with future SRC. CCB, ARB, NSAIDs, ERB, fluticasone, and MMF use were not significantly associated with SRC.

Conclusion

ACEi use at SSC diagnosis was associated with an increased risk for SRC. Results suggest that it may be a passive marker of known SRC risk factors, such as proteinuria, or evolving disease. SSC patients that require ACEi should be more closely monitored for SRC.

Use of Percutaneous Coronary Intervention Among Black and White Patients With End-Stage Renal Disease in the United States

Background Racial disparities in invasive cardiac procedures such as percutaneous coronary intervention (PCI) in the general population are well documented; however, national-level data on such disparities in the end-stage renal disease (ESRD) population are lacking. We assessed racial differences in PCI between black and white patients with ESRD on maintenance dialysis. Methods and Results Using the US Renal Data System database, we abstracted Medicare inpatient procedure claims for PCI in a cohort of 268 575 Medicare-primary patients who initiated treatment on maintenance dialysis from January 1, 2009, through June 1, 2013. We conducted Cox regression analyses with PCI being the event, adjusted for demographic characteristics, Hispanic ethnicity, cause of ESRD, comorbidities, and socioeconomic factors. We also assessed the probability of PCI, accounting for death or transplant in competing risk regression models. The crude incidence rate of PCI among white patients was 25.8 per 1000 patient-years versus 15.5 per 1000 patient-years among black patients. Cox regression analyses demonstrated that black patients were significantly less likely to undergo PCI compared with white patients (adjusted hazard ratio: 0.64; 95% CI, 0.62-0.67; P<0.001). In the competing risk models, the racial gap for PCI among black and white patients remained significant with death (subdistribution hazard ratio: 0.81; 95% CI, 0.76-0.85; P<0.001) or transplant as a competing event (subdistribution hazard ratio: 0.67; 95% CI, 0.64-0.70; P<0.001). Conclusions A racial gap exists in PCI use among dialysis patients despite having comprehensive coverage with Medicare. These findings persisted despite accounting for demographic, clinical, socioeconomic factors, and death or transplant as competing events.

Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis

OBJECTIVES

The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code-level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis.

DESIGN

Retrospective cohort study.

PARTICIPANTS/SETTING

Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014.

MEASUREMENTS

We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences.

RESULTS

Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13).

CONCLUSIONS/IMPLICATIONS

Black and Hispanic NH residents on dialysis had an apparent survival advantage. This "survival paradox" occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

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

BACKGROUND

Nephrologists are placing fewer non-tunneled temporary hemodialysis catheters. Requiring competence for nephrology fellow graduation is controversial.

METHODS

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).

RESULTS

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.

CONCLUSION

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.

Risk Factors for Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis

OBJECTIVE

Systemic sclerosis (SSc) is a disease of autoimmunity, fibrosis, and vasculopathy. Scleroderma renal crisis (SRC) is one of the most severe complications. Corticosteroid exposure, presence of anti-RNA polymerase III antibodies (ARA), skin thickness, and significant tendon friction rubs are among the known risk factors at SSc diagnosis for developing future SRC. Identification of additional clinical characteristics and laboratory findings could expand and improve the risk profile for future SRC at SSc diagnosis.

METHODS

In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the demographics, clinical characteristics, and laboratory results at SSc diagnosis for 31 cases who developed SRC after SSc diagnosis to 322 SSc without SRC disease controls.

RESULTS

After adjustment for potential confounding variables, at SSc diagnosis these conditions were all associated with future SRC: proteinuria (p < 0.001; OR 183, 95% CI 19.1-1750), anemia (p = 0.001; OR 9.9, 95% CI 2.7-36.2), hypertension (p < 0.001; OR 13.1, 95% CI 4.7-36.6), chronic kidney disease (p = 0.008; OR 20.7, 95% CI 2.2-190.7), elevated erythrocyte sedimentation rate (p < 0.001; OR 14.3, 95% CI 4.8-43.0), thrombocytopenia (p = 0.03; OR 7.0, 95% CI 1.2-42.7), hypothyroidism (p = 0.01; OR 2.8, 95% CI 1.2-6.7), Anti-Ro antibody seropositivity (p = 0.003; OR 3.9, 95% CI 1.6-9.8), and ARA (p = 0.02; OR 4.1, 95% CI 1.2-13.8). Three or more of these risk factors present at SSc diagnosis was sensitive (77%) and highly specific (97%) for future SRC. No SSc without SRC disease controls had ≥ 4 risk factors.

CONCLUSION

In this SSc cohort, we present a panel of risk factors for future SRC. These patients may benefit from close observation of blood pressure, proteinuria, and estimated glomerular filtration rate, for earlier SRC identification and intervention. Future prospective therapeutic studies could focus specifically on this high-risk population.

Survey of Kidney Biopsy Clinical Practice and Training in the United States

BACKGROUND AND OBJECTIVES

Practicing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken.

RESULTS

Walter Reed graduates' response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01).

CONCLUSIONS

Almost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.

Mortality in Living Kidney Donors With ESRD: A Propensity Score Analysis Using the United States Renal Data System

Introduction

In recent years, data have emerged on the outcomes of living kidney donors who develop end-stage renal disease (ESRD). We aimed to evaluate mortality rates in kidney donors who had initiated dialysis compared with a propensity-matched cohort of dialysis patients without previous kidney donation.

Methods

We used the United States Renal Data System (USRDS) and abstracted 274 previous living kidney donors between 1995 and 2009. There were 609,398 individuals on dialysis without kidney donation. We used propensity score matching to identify 258 donors and 258 nondonors. The time-dependent Cox proportional hazards model was used to compare survival between the 2 matched cohorts.

Results

In the propensity score−matched cohort, mortality was lower in donors compared with nondonors (19% vs. 49%; P < 0.0001). The time-dependent Cox proportional hazards model demonstrated that donors had significantly lower mortality compared with nondonors 0 to 5 years since start of dialysis (hazard ratio [HR]: 0.17; 95% confidence interval [CI] 0.11−0.27; P < 0.0001) and with nondonors 5 to 10 years on dialysis (HR: 0.34; 95% CI: 0.19−0.63; P < 0.001). We were unable to estimate the difference between the 2 groups after 10 years on dialysis with any precision (HR: 0.51; 95% CI: 0.18−1.42; P = 0.20) due to the small sample size.

Conclusion

We observed a lower mortality rate in living kidney donors with ESRD compared with matched nondonors. This data should guide clinicians in the informed consent process with prospective donors.

The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows

BACKGROUND

Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis.

METHODS

The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than 'important'. The content validity index was 0.91. Ninety-five percent of positive-point items were easy-medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46-51], κ = 0.68 (95% CI 0.59-0.77), Cronbach's α = 0.84.

RESULTS

We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43-45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful.

CONCLUSIONS

The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress.

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System

BACKGROUND

Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period.

METHODS

In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables.

RESULTS

MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access.

CONCLUSIONS

MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.

The Foot Orthoses versus Hip eXercises (FOHX) trial for patellofemoral pain: a protocol for a randomized clinical trial to determine if foot mobility is associated with better outcomes from foot orthoses

BACKGROUND

Patellofemoral pain (PFP) is a prevalent, often recalcitrant and multifactorial knee pain condition. One method to optimize treatment outcome is to tailor treatments to the patient's presenting characteristics. Foot orthoses and hip exercises are two such treatments for PFP with proven efficacy yet target different ends of the lower limb with different proposed mechanisms of effect. These treatments have not been compared head-to-head, so there is a dearth of evidence for which to use clinically. Only foot orthoses have been explored for identifying patient characteristics that might predict a beneficial effect with either of these two treatments. Preliminary evidence suggests patients will do well with foot orthoses if they have a midfoot width in weight bearing that is ≥ 11 mm more than in non-weight bearing, but this has yet to be verified in a study that includes a comparator treatment and an adequate sample size. This trial will determine if: (i) hip exercises are more efficacious than foot orthoses, and (ii) greater midfoot width mobility will be associated with success with foot orthoses, when compared to hip exercises.

METHODS

Two hundred and twenty participants, aged 18-40 years, with a clinical diagnosis of PFP will be randomly allocated with a 1:1 ratio to receive foot orthoses or progressive resisted hip exercises, and stratified into two subgroups based on their presenting midfoot width mobility (high mobility defined as ≥11 mm). The primary outcome will be a 7-point Likert scale for global rating of change. All analyses will be conducted on an intention-to-treat basis using regression models.

DISCUSSION

This trial is designed to compare the efficacy of foot orthoses versus hip exercise, as well as to determine if high midfoot width mobility is associated with better outcomes with foot orthoses when compared to hip exercises. Results of this trial will assist clinicians in optimising the management of those with PFP by testing whether a simple measure of midfoot width mobility can help to determine which patients are most likely to benefit from foot orthoses.

TRIAL REGISTRATION

This trial is registered on the Australian New Zealand Clinical Trials Register (ACTRN12614000260628).

Mortality after Renal Allograft Failure and Return to Dialysis

INTRODUCTION

The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival.

METHODS

We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome.

RESULTS

We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality.

CONCLUSIONS

Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.

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

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

Can we predict the outcome for people with patellofemoral pain? A systematic review on prognostic factors and treatment effect modifiers

BACKGROUND

Patellofemoral pain (PFP) is a multifactorial and often persistent knee condition. One strategy to enhance patient outcomes is using clinically assessable patient characteristics to predict the outcome and match a specific treatment to an individual.

AIM

A systematic review was conducted to determine which baseline patient characteristics were (1) associated with patient outcome (prognosis); or (2) modified patient outcome from a specific treatment (treatment effect modifiers).

METHODS

6 electronic databases were searched (July 2016) for studies evaluating the association between those with PFP, their characteristics and outcome. All studies were appraised using the Epidemiological Appraisal Instrument. Studies that aimed to identify treatment effect modifiers underwent a checklist for methodological quality.

RESULTS

The 24 included studies evaluated 180 participant characteristics. 12 studies investigated prognosis, and 12 studies investigated potential treatment effect modifiers. Important methodological limitations were identified. Some prognostic studies used a retrospective design. Studies aiming to identify treatment effect modifiers often analysed too many variables for the limiting sample size and typically failed to use a control or comparator treatment group. 16 factors were reported to be associated with a poor outcome, with longer duration of symptoms the most reported (>4 months). Preliminary evidence suggests increased midfoot mobility may predict those who have a successful outcome to foot orthoses.

CONCLUSIONS

Current evidence can identify those with increased risk of a poor outcome, but methodological limitations make it difficult to predict the outcome after one specific treatment compared with another. Adequately designed randomised trials are needed to identify treatment effect modifiers.

Impact of poverty and race on pre-end-stage renal disease care among dialysis patients in the United States

Background

Access to nephrology care prior to end-stage renal disease (ESRD) is significantly associated with lower rates of morbidity and mortality. We assessed the association of area-level and individual-level indicators of poverty and race/ethnicity on pre-ESRD care provided by nephrologists.

Methods

In this retrospective cohort study using the US Renal Data System database, we identified 739 537 patients initiated on maintenance dialysis from 1 January 2007 through 31 December 2012. We assessed the Medicare–Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data obtained from the 2010 US census. We conducted multivariable logistic regression of pre-ESRD nephrology care as the outcome variable.

Results

Among patients in the lowest area-level MHI quintile, 61.28% received pre-ESRD nephrology care versus 67.68% among those in higher quintiles (P < 0.001). Similarly, the proportions of dual-eligible and nondual-eligible patients who had pre-ESRD nephrology care were 61.49 and 69.84%, respectively (P < 0.001). Patients in the lowest area-level MHI quintile were associated with significantly lower likelihood of pre-ESRD nephrology care (adjusted odds ratio [aOR] 0.86 [95% confidence interval (CI) 0.85–0.87]) compared with those in higher quintiles. Both African American (AA) and Hispanic patients were significantly less likely to have received pre-ESRD nephrology care [aOR 0.85 (95% CI 0.84–0.86) and aOR 0.72 (95% CI 0.71–0.74), respectively].

Conclusions

Individual- and area-level measures of poverty, AA race and Hispanic ethnicity were independently associated with a lower likelihood of pre-ESRD nephrology care. Efforts to improve pre-ESRD nephrology care may require focusing on the poor and minority groups.

Combating Grade Inflation in Nephrology Clinical Rotation Evaluations Using Faculty Education and a 5-Point Centered Rating Scale

Background From 2010 to 2011, more than 70% of the clinical rotation competency evaluations for nephrology fellows in our program were rated "superior" using a 9-point Likert scale, suggesting some degree of "grade inflation." Objective We sought to assess the efficacy of a 5-point centered rotation evaluation in reducing grade inflation. Methods This retrospective cohort study of the impact of faculty education and a 5-point rotation evaluation on grade inflation was measured by superior item rating frequency and proportion of evaluations without superior ratings. The 5-point evaluation centered performance at the level expected for stage of training. Faculty education began in 2011-2012. The 5-point centered evaluation was introduced in 2012-2013 and used exclusively thereafter. A total of 68 evaluations, using the 9-point Likert scale, and 63 evaluations, using the 5-point centered scale, were performed after first-year fellow clinical rotations. Nine to 12 faculty members participated yearly. Results Faculty education alone was associated with fewer superior ratings from 2010-2011 to 2011-2012 (70.5% versus 48.3%, P = .001), declining further with 5-point centered scale introduction (2012-2013; 48.3% versus 35.6%; P = .012). Superior ratings declined with 5-point centered versus 9-point Likert scales (37.3% versus 59.3%, P = .001), specifically for medical knowledge, patient care, practice-based learning and improvement, and professionalism. On logistic regression, evaluations without superior scores were more likely for 5-point centered versus 9-point Likert scales (adjusted odds ratio [aOR] = 8.26; 95% CI 1.53-44.64; P = .014) and associated with faculty identifier (aOR= 1.18; 95% CI 1.03-1.35; P = .013), but not fellow identifier or training year quarter.

CONCLUSIONS

Grade inflation was reduced with faculty education and the 5-point centered evaluation scale.