NKF Spring Clinical Meeting 2013 Interviews: National Kidney Foundation

NKF Clinical Meeting 2013
HEMODIALYSIS.COM
Exclusive interviews
Editor: Marie Benz, MD
Updated 4/15/2013
For Informational Purposes Only: Not
intended as Specific Medical Advice
1

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4/5/13 2

Cinacalcet –Troponins: Is There An Undiscovered Link??
Hemodialysis.com Interview with Samra Abouchacra
Senior consultant nephrologist and Chairman Nephrology Department
Tawam Hospital United Arab Emirates
• Hemodialysis.com: What are the main
findings of the study?
• Answer: A possible link between Cinacalcet-
induced reductions in PTH & troponin levels in
hemodialysis patients.
• Hemodialysis.com: Were any of the findings
unexpected?
• Answer: Not completely given the role of
inflammation in both.
4/5/13
For Informational Purposes Only:
Not intended as Specific Medical Advice
3

Cinacalcet –Troponins: Is There An Undiscovered Link??
Hemodialysis.com Interview with Samra Abouchacra
Senior consultant nephrologist and Chairman Nephrology Department
Tawam Hospital United Arab Emirates
(cont)
• Hemodialysis.com: What should clinicians and patients take away from
this study?
• Answer: Treatment of SHPT in dialysis patients may have an impact on
cardiac markers suggesting an association between hyperparathyroid
dysfunction and ischemic heart disease; a relation which needs further
study including the effects of confounding variables.
• Hemodialysis.com: What recommendations do you have for future
research as a result of your study?
• Answer: PTH-dependent and independent effects may be at play in the
increased cardiovascular risk in dialysis patients. This needs to be explored
in addition to role of inflammation and the correlation with clinical
outcomes.
• Citation:
• Cinacalcet –Troponins: Is There An Undiscovered Link??
• Presented at Spring NKF 2013 Meeting.
4/5/13
4

THE “PHOSPHORUS OLYMPICS”: A Self-Management Approach for Enhancing Phosphorus Education
in a Multi-Site Dialysis Program
Hemodialysis.com Authors’ Interview:
Rachel Linzon, Josie Caruso-Ditta, Marla McKerracher,
York Region Chronic Kidney Disease Program – Mackenzie Health, Richmond Hill, Ontario, Canada.
• Objective:
• The “Phosphorus Olympics” initiative was created to test whether a self-
management approach to phosphorus education would improve patients’
decisions impacting dietary phosphorus intake, phosphate-binders usage
and serum phosphorus levels.
• Hemodialysis.com: What are the main findings of the study?
• The “Phosphorous Olympics” was a continuous quality improvement (CQI)
initiative which used a fun innovative approach to learning about dietary
phosphorus and binder usage. The goal was to empower 229 (50%)
dialysis patients recruited to improve their ability to self-manage dietary
phosphorus intake and phosphate-binder usage. Participants’ serum
phosphorus levels subsequently improved by 3.6%.
• Statistically significant improvements were observed in patients’ decisions
impacting: the use of the phosphorus education handout, reading food
labels for hidden phosphate additives, consuming baked goods containing
baking powder, taking phosphate-binders with snacks and feeling in
control of dietary phosphorus intake and phosphate –binder usage.
4/5/13
5

THE “PHOSPHORUS OLYMPICS”: A Self-Management Approach for Enhancing Phosphorus Education
in a Multi-Site Dialysis Program
Hemodialysis.com Authors’ Interview:
Rachel Linzon, Josie Caruso-Ditta, Marla McKerracher,
York Region Chronic Kidney Disease Program – Mackenzie Health, Richmond Hill, Ontario, Canada.
(cont)
• Hemodialysis.com: Were any of the findings unexpected?
• Response: There were no unexpected findings.
• Patients enjoyed the self-management approach to phosphate education and
requested more similar initiatives in the future.
• Hemodialysis.com: What should clinicians and patients take away from this
study?
• Response: Think creatively for patient education! Incorporating fun and innovative
self-management approaches to phosphorus education, empowers and
encourages independence in patients requiring renal replacement therapy.
• Hemodialysis.com: What recommendations do you have for future research as a
result of your study?
• Response: Continue to develop creative education tools and initiatives which
encourage self-management specifically addressing phosphate additives.
• Citation:
• National Kidney Foundation Spring 2013 Meeting Poster Presentation
4/5/13
6

Association Between Lack of Health Insurance and Risk of Death and ESRD: Results from the Kidney Early Evaluation Program (KEEP)
Hemodialysis.com Author Interview:
Claudine Jurkovitz, MD, MPH
Christiana Care Center for Outcomes Research (CCOR)
Christiana Care Health System
John H. Ammon Education Center, 2nd Floor Newark, DE
(cont)
• Hemodialysis.com: What should clinicians and patients take away from this study?
• Dr. Jurkovitz:
• • Anybody should have easy access to care but more so patients at high risk for kidney disease
such as patients with diabetes, hypertension, cardiovascular disease or a family history of kidney
disease. These patients should be screened for kidney disease and their risk factors treated
appropriately.
• Hemodialysis.com: What recommendations do you have for future research as a result of your
study?
• Dr. Jurkovitz:
• • Will the frequency of screening for kidney disease increase as the Affordable Care Act is
implemented? Among patients at high risk for kidney disease, what is the current resource
utilization (Physician visits, Emergency Department visits or hospitalizations) according to insurance
status? Will resource utilization change with the implementation of the Affordable Care Act in this
population of patients?
• Citation:
• Association Between Lack of Health Insurance and Risk of Death and ESRD: Results from the Kidney
Early Evaluation Program (KEEP)
National Kidney Foundation Spring 2013 Meeting
Poster Number: 135
Suying Li Keith Norris Georges Saab MD
Andrew Bomback Adam Whaley-Connell Peter McCullough
4/5/13
7

Association Between Lack of Health Insurance and Risk of Death and ESRD: Results from the Kidney Early Evaluation Program (KEEP)
Claudine Jurkovitz, MD, MPH
Christiana Care Center for Outcomes Research (CCOR)
Christiana Care Health System
John H. Ammon Education Center, 2nd Floor Newark, DE
• Dr. Jurkovitz:
• • KEEP participants without insurance are at higher risk of death
and end-stage renal disease (ESRD) than participants with private
insurance
• Compared with those with insurance, KEEP participants without
insurance were less likely to have seen a physician in the past year.
• Of participants with hypertension, those without insurance
were the least likely to achieve target levels of blood pressure
• Dr. Jurkovitz:
• • We did not expect that lack of insurance would not only be a
risk factor for death but also for ESRD in this population at high risk
for kidney disease.
4/5/13
8

Impact of In-Home Education Programs on the Graduation Rate of Young Adults with Kidney Disease
Hemodialysis.com Author Interview: Lori L. Sanderson, PhD, LCSW
Lee Anne Gridley, Teacher
Peter Yorgin, Nephrologist
• Hemodialysis.com: What are the main findings of the
study?
• Dr. Sanderson: In this study population, pediatric
dialysis and transplant patients who did not attend
home school were more likely to graduate from high
school (OR: 3.778). Subjects who received home school
were more likely to come from families of parents who
did not attend college, completed high school, worked
outside of the home, and spoke English as a second
language. This study population was also more likely to
be of Hispanic origin. They were also more likely to
have received a kidney transplant rather than be
receiving dialysis treatments.
4/5/13
9

(cont)
• Dr. Sanderson: It was suspected that many of the participants in the study
population would be of Hispanic origin since this is the primary
demographic of the area. Language spoken in the home, a parent’s
education level, and whether or not parents worked outside of the home
was suspected to influence the participant’s ability to graduate on time
when enrolled in home school.
• Hemodialysis.com: What should clinicians and patients take away from
this study?
• Dr. Sanderson: Prior to this study, our nephrologists and team did not
place a high priority on reassessing the patient’s need for continued home
school. Nephrologist granted home school to patients with some of the
most limited resources. Now, it has become a standard practice to make
every effort to keep dialysis and post-kidney transplant patients in regular
school. We now use home school as a short term option only.
4/5/13
10

(cont)
• Dr. Sanderson: When assessing the patient’s ability to graduate
with their peers from high school, further research should consider
evaluating the duration of time in home education programs, the
overall health of the patient, the life expectations of the parents
regarding their children, and the children’s expectations of
themselves. Future research could also evaluate the rationale for
placing patients in home school since this might also influence a
child’s ability to succeed academically.
• Citation:
• National Kidney Foundation Spring 2013
Impact of In-Home Education Programs on the Graduation Rate of
Young Adults with Kidney Disease
Poster Number: 162
4/5/13
11

Pregnancy outcomes in Advanced Chronic Kidney Disease
Hemodialysis.com Author Interview: Dr. Zichun Feng PGY3
Medical Resident at Baylor College of Medicine.
• Hemodialysis.com: What are the main findings
of the study?
• Dr. Feng: Severe CKD (eGFR <30ml/min) in
pregnancy is associated with increased risks of
adverse maternal and fetal outcomes. The
incidence of pre-term delivery, small for
gestational age, and decline of maternal renal
function increased with a decline in eGFR.
Women with severe CKD may experience a
reduced rate of preeclapsia / eclampsia and
preterm delivery with earlier initiation of dialysis.
4/5/13
12

(cont)
• Dr. Feng: Previous studies have shown adverse fetal outcomes such
as intrauterine growth
retardation, oligohydryamnios, polyhydramnios are also increased
in pregnancy with severe CKD.
• However, in our studies, these adverse fetal outcomes were rare
occurrences and were not significantly different from mild CKD.
• Hemodialysis.com: What should clinicians and patients take away
from this study?
• Dr. Feng: Pregnancy with severe CKD carries high risks for both
maternal and fetal adverse outcomes. Early initiation of dialysis in
this high risk group of women may reduce preterm delivery and
preeclampsia/eclampsia.
4/5/13
13

(cont)
• Hemodialysis.com: What recommendations do you have
for future research as a result of your study?
• Dr. Feng: Further studies with multicenter studies may
increase sample size and increase statistical power of study.
• In that case, prospective study of placing pregnant women
with severe CKD on dialysis and their pregnancy outcomes
may also be pursued.
• Citation:
National Kidney Foundation Spring Meeting
• Pregnancy outcomes in Advanced Chronic Kidney Disease
Poster Number: 158
Authors: Rajeev Raghavan Silvia Feng Charles Minard
4/5/13
14

Infection Rates and Associated Pathogens in Patients on Nocturnal Home Hemodialysis Over a Six Year Period
Hemodialysis.com Author Interview: Marisa Battistella, BSc Phm, Pharm D, ACPR
Pharmacy Clinician Scientist Assistant Professor
Leslie Dan Faculty of Pharmacy, University of Toronto
Clinical Pharmacist-Nephrology University Health Network
• Dr. Battistella: Our study consisted of a 6 year retrospective analysis of the
90 NHD patients.
• We evaluated the culture and sensitivity of all samples drawn in NHD
patient, prescribed antibiotics and clinical demographic data such as
age, gender, race, primary renal disease, comorbidities and duration of
dialysis.
• Out of the 90 patients we investigated, 64 of them had a culture and
sensitivity sample drawn at least once. Rates of exit site infections and
bacteremia were defined according to Health Canada and Centre of
Infectious Disease definitions. There is a low exit site infection rate-
averaging less than 5 per year and the most common organism causing
exit site infections is staph aureus. There is a much higher rate of
bacteremia infections averaging about 20 infections and the most
common organisms causing bacteremia infections are Coagulase-Negative
Staphylococci and Staphylococcus Aureus. Bacteremia infections were the
most common type of infection in home hemodialysis patients but other
infections included urine, pneumonia and fistula/graft but at a much lower
rate.
4/5/13
15

(cont)
• Dr. Battistella: There were larger number of samples drawn
but most of them were negative suggesting unnecessary
laboratory measurements.
• However, the number of samples drawn has decreased
over the number of years. The reason for this decrease may
be that patients are more familiar with the signs and
symptoms of a true infection
• Hemodialysis.com: What should clinicians and patients
take away from this study?
• Dr. Battistella: Careful monitoring of infections and
educating patients on proper techniqu
4/5/13
16

(cont)
• Hemodialysis.com: What recommendations do you
have for future research as a result of your study?
• Dr. Battistella: Our next steps are to evaluate the
infection outcomes and treatment outcomes in this
population.
• Citation:
National Kidney Foundation Spring Clinical Meeting
2013
• Infection Rates and Associated Pathogens in Patients
on Nocturnal Home Hemodialysis Over a Six Year
Period
Poster Number: 91
4/5/13
17

Dietary Sodium Intake in Hemodialysis Patients Does Not Correlate with Interdialytic Weight Gain
Hemodialysis.com Author Interview: Deepika Jain, MD
Renal fellow, The Renal Electrolyte Division
University of Pittsburgh Medical Center Pittsburgh, PA
• Dr. Jain: Our study was aimed to analyze the baseline self reported sodium
intake in maintenance hemodialysis population and see if it correlates
with interdialytic weight gain. We know that sodium intake plays an
important role in blood pressure and cardiovascular outcomes in non
dialysis patients. In dialysis population, there is some evidence that
sodium load affects volume control, but how much of it actually
associated with self reported dietary sodium intake in unknown.
• Our study showed that there was no correlation between self reported
dietary sodium intake and interdialytic weight gain. This correlation did
not change when presence or absence of urine output was accounted
for. Mean sodium intake in our cohort was 2.29 gram sodium/day and
interdialytic weight gain was 1.23 kg/day. Male gender and longer time on
dialysis subjects were more likely to have higher dietary sodium intake.
4/5/13
18

(cont)
• Dr. Jain: Our findings were somewhat surprising because
the sodium intake and weight gain did not correlate with
each other. The sodium intake restriction has been the
main focus of volume management and blood pressure
control in dialysis population. The sodium intake was
recorded by performing three dietary recalls on different
days to account for variations in intake during the week.
• Even if we consider the underreporting of sodium intake
with the dietary recall method, the average sodium intake
in our group was 2.29 grams/day ( according to current
guidelines recommendations are at 2-3gram sodium per
day) which means that a number of our patients were likely
compliant with sodium restriction guidelines.
4/5/13
19

(cont)
• Hemodialysis.com: What should clinicians and
patients take away from this study?
• Dr. Jain: Our results suggest that self reported sodium
intake did not associate with interdialytic weight gain.
Of course, one cannot overlook the underreporting
with dietary sodium recall method. But we feel that
there could be other sodium loading processes in our
dialysis population which could be contributing to the
interdialytic weight gain like sodium load from
dialysate, excessive ultrafiltration rates, rapid shifts
post dialysis stimulating thirst leading to increased
volume status.
4/5/13
20

(cont)
• Dr. Jain: We feel that the sodium intake restriction
guidelines in dialysis population should be studied in
detail again taking into account other sodium exposure
parameters. Ours is an observational study and hence a
possibility of potential biases always exists.
• Citation:
• Dietary Sodium Intake in Hemodialysis Patients Does
Not Correlate with Interdialytic Weight Gain
Poster Number: 133 Deepika Jain
University of Pittsburgh, Renal Fellow
4/5/13
21

Medication-Related Error in Outpatient Hemodialysis Center
Timothy Nguyen, PharmD, BCPS, CCP, FASCP
Assistant Professor of Pharmacy, Clinical Pharmacology, & Nephrology
Arnold & Marie Schwartz College of Pharmacy & Health Sciences Long Island University & Mount Sinai Kidney Center
• Hemodialysis.com: What are the main
findings of the study?
• Dr. Nguyen: The main finding of this study is
that hemodialysis patients commonly
experience medication-related problems and
drug interactions due to multiple medications
that they are taking for their kidney disease
and co-morbidities.
4/5/13
22

(cont)
• Dr. Nguyen: We know that dialysis patients have many co-
morbid disease conditions and that they need to take many
medications, but we did not expect that those medications
that were suppose to help but ended up being actually
harmful.
• Hemodialysis.com: What should clinicians and patients
take away from this study?
• Dr. Nguyen: Clinicians and patients should appreciate the
complex condition dialysis patients have, appreciate the
multiple medications they take, recognize potential for
medication-related problems and prevent further negative
consequences.
4/5/13
23

(cont)
• Dr. Nguyen: Future research should help improve dialysis patients
via understanding the complexity of the medication
regimens, recognizing for potential adverse events, increasing
surveillance and reducing the numbers of medication-related
problems.
• Citation:
• Medication-Related Error in Outpatient Hemodialysis Center
Poster Number: 154
Timothy Nguyen PharmD and Brian Radbill MD
Department of Medicine-Renal Medicine Mt. Sinai Hospital NY
National Kidney Foundation 2013 Spring Clinical Meetings
April 2 – 6, 2013 – Walt Disney World Swan and
Dolphin, Orlando, Florida
4/5/13
24

Perceptions of Facilitators and Barriers to Chronic Kidney Disease Educational Sessions
Author Interview: Della Connor, APRN
The University of Texas at Tyler
study?
• Della Connor: Trusting relationships must exist
between healthcare providers and patients to address
barriers to educational sessions.
• Providers must recommend educational sessions to
patients, telling them of the potential benefits of
attendance, concentrating on the effects of slowing the
progression of Chronic Kidney Disease (CKD)
. Accommodation issues, such as work and
transportation, must be addressed to facilitate
attendance at these sessions.
4/5/13
25

(cont)
• Della Connor: Patients expressed that they were willing to
share their diagnosis of diabetes with others, but did
not want them to know about their kidney disease. Prior
media attention to CKD and celebrities with this disease
process are seldom viewed favorably.
• Another surprise finding was that patients identified their
nephrologist as the one person who could convince them
to attend CKD educational sessions. They picked the
nephrologist over family members, and other healthcare
providers.
4/5/13
26

(cont)
• Hemodialysis.com: What should clinicians and
patients take away from this study?
• Della Connor: Clinicians need to recommend
these classes. They need to explain the benefits
of attendance and especially point out the
evidence that the classes may slow the
progression to dialysis. Both clinicians and
patients need to engage more with mainstream
media to portray accurate representations of
persons living with CKD.
4/5/13
27

(cont)
• Della Connor: Additional research is needed in this emerging field
of attendance of CKD education sessions for patients in all stages of
the disease process.
• A cohesive CKD education program, such as Your Treatment, Your
Choice (National Kidney Foundation, 2012), needs to be compared
to other CKD educational programs, to determine the best learning
program for these patients. Specific CKD education measurement
tools must also be developed.
• Citation:
• National Kidney Foundation Spring 2013 Meeting Poster Number:
81
4/5/13
28

An Evaluation of Clinical Factors Associated with the Decision to Transfuse Chronic Dialysis Patients
Cynthia Whitman
Research Coordinator for the UCLA/VA Center for Outcomes Research and Education.
(cont)
• Cynthia Whitman: The main findings of our study include:
• Among 10 patient clinical attributes studied, hemoglobin (Hb) level was
found to be the most important for driving provider decision-making
regarding red blood cell transfusions in CKD patients, however this
attribute alone does not inform providers enough for them to base their
decisions.
• 92% of providers transfused when Hb was 7.5 g/dL.
• In multivariable regression, we found Veterans Administration providers 6
times as likely to transfuse earlier at 8.0 g/dL, than others.
• The more experienced providers had (at least 20 years) and the more
exposure they had to patients, the more selective they were about using
transfusions in CKD patients, and the more likely they were to require the
patients to exhibit more serious clinical characteristics such as iron
repletion.
4/5/13
29

Cynthia Whitman
unexpected?
• Cynthia Whitman:
• We did not expect providers with less experience
to recommend transfusions more often than
more experienced providers.This finding
highlights the greater awareness that providers
with more experience may offer regarding the
potential negative consequences of RBC
transfusions, rather than reliance on
erythropoiesis-stimulating agents (ESAs).
4/5/13
30

Cynthia Whitman
(cont)
from this study?
• Clinical vignettes presented using conjoint analysis provide an
insight into provider preferences for recommending/performing
blood transfusions.
• In the debate over best-practice management of CKD patients, we
understand that there are many patient factors that are taken
together when providers make their decisions.
• While hemoglobin level is responsible for 29% of the decision-
making process, it is by no means the stand-alone factor that is
considered; patient functional status and cardiovascular
comorbidities play a substantial role in this process as well (16%
and 12%, respectively).
4/5/13
31

Cynthia Whitman
(cont)
• Findings suggest that in order to better understand the RBC
transfusion decision-making process in CKD patients the next step
may be to conduct a case-study/ chart analysis of actual transfusion
events, taking intoconsideration provider type, region, and
experience.
• Educational interventions aimed at providers about current practice
guidelines, and the benefits and risks of ESAs and transfusions may
ensure/contribute to more informed and uniform decisions.
• Citation: National Kidney Foundation 2013: Abstract Poster
Presentation #50.
4/5/13
32

Cost implications of switching from sevelamer to lanthanum carbonate
within a bundled reimbursement scenario
Interview with Dr. Michael S Keith Shire Pharmaceuticals, Wayne, PA, USA
(cont)
study?
• Dr. Keith: The key finding from this post hoc analysis is
that phosphate control was similar regardless of the
prior sevelamer dose a patient received. Overall mean
phosphate binder doses were SH 7703 mg/day and LC
2800 mg/day. Drug cost-savings were realized when
applying clinically utilized doses of lanthanum
carbonate (LC) 3000 mg/day ($26.46/day) and
sevelamer hydrochloride (SH) from doses of 6400
mg/day ($29.68/day) and above. Cost savings were as
high as $18/day when converting patients from SH
9600 mg/day to LC 3000 mg/day.
4/5/13
33

• Dr. Keith: We expected there would be a comparative dosing point
where LC would be more cost-effective than SH, with similar
phosphate control, but the inflexion point at which this occurred
was perhaps surprisingly low, which represented a large percentage
of patients taking SH monotherapy in the original study.
from this study?
• Dr. Keith: In this study, 65% of patients were taking SH
monotherapy doses of 6400 mg/day or more at baseline. If these
patients were switched to LC 3000 mg/day their costs and their
daily pill burden could be reduced, while maintaining similar
phosphate levels. Therefore, converting patients to LC may be a
viable and cost-efficient alternative to continuing to escalate the
dose of SH to 6400 mg/day or above.
4/5/13
34

(cont)
• Dr. Keith: This study evaluated the cost implications of treatment
switching in the USA. Additional studies would be useful to assess
whether similar conclusions can be drawn for Europe and Asia.
• Citation:
• Presented at National Kidney Foundation NKF Spring 2013 Meeting
• Cost implications of switching from sevelamer to lanthanum
carbonate within a bundled reimbursement scenario
• Michael S Keith,1 Rosamund J Wilson,2 J Brian Copley1
• 1Shire Pharmaceuticals, Wayne, PA, USA
• 2Spica Consultants, Marlborough, UK
4/5/13
35

Influence of Wasting on Hyperparathyroidism in Black Diabetic Hemodialysis Patients
Hemodialysis.com Interview with Rapeepat Lekkham, MD
Nephrology Fellow,
Albert Einstein Medical Center,
Philadelphia, PA
• Dr. Lekkham: We conducted the retrospective study on
hemodialysis patients who mainly (92.9%) were black and stratified
by the absence or presence of wasting syndrome (which defined by
serum albumin less than 3.8 g/dl, normalized protein nitrogen
appearance (nPNA) less than 0.8 g/kg/day and BMI less than 23
kg/m2) and the association with secondary hyperparathyroidism.
Compared to non-diabetic patients, our study found that diabetic
patients had a higher mean serum iPTH. Also, serum iPTH was
higher in all diabetic non-wasting subgroups patients as well. Other
related parameters including mean serum phosphate, serum
alkaline phosphatase, the requirement of cinacalcet, vitamin D
analogues and phosphate binders were comparable in both groups.
4/5/13
36

Nephrology Fellow,
Philadelphia, PA
(cont)
• Dr. Lekkham: Even though the main finding of our study showed
that the serum iPTH in diabetic patients was higher in the non-
wasting condition especially defined by BMI more than or equal to
23 kg/m2. Surprisingly, when we did subgroup analysis in diabetic
patients who had obesity (BMI more than or equal to 30
kg/m2), this association was no longer exist.
from this study?
• Dr. Lekkham: There are several factors that potentially related or
modified the severity of secondary hyperparathyroidism in
hemodialysis patients that both nephrologists and patients should
be aware of. Our study suggests that non-wasting condition but not
obesity is associated with the severity of secondary
hyperparathyroidism in black diabetic hemodialysis patients.
4/5/13
37

Nephrology Fellow,
Philadelphia, PA
(cont)
• Dr. Lekkham: There are several limitations to our study which we
would hope that future research would be able to address. The
further studies with multicenter studies may increase sample size
and statistical power of study. Also the population in our study
mainly were mainly African American descent, the result may be or
may not be able to apply to the general hemodialysis population.
Finally, to generalize and reproduce the result of further
studies, the standard definition of wasting condition is required.
Citation:
• Influence of Wasting on Hyperparathyroidism in Black Diabetic
Hemodialysis Patients
• NKF Spring Clinical Meetings April 2013
4/5/13
38

The PICC Epidemic and the Kidney Patient
Hemodialysis.com eInterview: Rita McGill MD
Allegheny General Hospital
Pittsburgh, PA USA
• The major finding of this study is that more than 20%
of hospital inpatients have PICC lines. Compared to
hospital patients in general, PICC patients are sicker
and have more chronic kidney disease. This is
particularly unfortunate, since national ASDIN
guidelines advise against PICC placement in kidney
patients. Despite this recommendation, CKD patients
actually bear a disproportionate brunt of the PICC
‘epidemic, with a PICC rate of 30%, which is higher than
other patients.
• The reasons for the enthusiastic embrace of excess
PICC lines are complicated, and often reflect
convenience more than actual health benefits
4/5/13
39

The PICC Epidemic and the Kidney Patient
Hemodialysis.com eInterview: Rita McGill MD
Allegheny General Hospital
Pittsburgh, PA USA
(cont)
• Clinicians should come away with a heightened
awareness that indiscriminate use of PICCs in CKD
patients is apt to create future problems when
patients require fistula access for dialysis. Further
study is needed to define effective strategies for
PICC avoidance and CKD patient protection, and
define the underlying factors that are promoting
an epidemic of PICC placement.
• Citation:
• Spring NKF Clinical Meeting Poster:
‘The PICC Epidemic and the Kidney Patient”
4/5/13
40

Pilot Study of a Physician-Delivered Education Tool to Increase Patient Knowledge About CKD
Hemodialysis.com Authors’ eInterview
J.A. Wright Nunes, MD MPH University of Michigan Health System
Kerri Cavanaugh, MD MHS Vanderbilt University Medical Center
study?
• Answer: The main finding of the study was that a
simple, efficient educational worksheet designed to
facilitate patient-provider communication about kidney
disease, increased patient knowledge in fundamental areas
related to their kidney health.
• We are also encouraged by the very positive response in
patients who received the educational worksheet, as well
as the providers who delivered the tool in practice.
4/5/13
41

Kerri Cavanaugh, MD MHS Vanderbilt University Medical Center (cont)
unexpected?
• Answer: Although the educational worksheet
increased patient knowledge in many areas, patients
receiving the intervention were still less likely to
acknowledge their ‘decreased kidney function’ and
were less likely to understand that there were stages of
chronic kidney disease (CKD). We believe these issues
reflect patient difficulty understanding the meaning of
the term ‘kidney function’ and reflect debate amongst
providers about CKD staging and its definition.”
4/5/13
42

Kerri Cavanaugh, MD MHS Vanderbilt University Medical Center (cont)
• Answer: Although results of our study are
encouraging, this was a pilot design, using a historical
cohort for comparison. Randomized trials are needed
to study the impact of education interventions on
intermediate measures and long term clinical
outcomes.
• Citation:
• Pilot Study of a Physician-Delivered Education Tool to
Increase Patient Knowledge About CKD
• Spring National Kidney Foundation NKF Meetings 2103
4/5/13
43

Disease Progression and Surgical Parathyroidectomy in the EVOLVE Trial
Hemodialysis.com eInterview with:
Patrick Parfrey, MD, FRCPC, FACP on behalf of the EVOLVE investigators
University Research Professor at Memorial University St. John’s, Newfound
• Dr. Parfrey: The EVOLVE trail enrolled 3883 patients with secondary
hyperparathyroidism from 22 countries , randomly allocated them to the
calcimimetic, cinacalcet ,or placebo, and followed them for up to 64
months. Parathyroidectomy was undertaken in patients with severe
unremitting hyperparathyroidism: PTH level prior to surgery 2143 mg/dl in
the cinacalcet group and 1873 in the placebo group.
• Selection bias was observed in that surgery was undertaken in younger
patients, of longer dialysis vintage, with less co-morbidity.
• In addition the rates of parathyroidectomy differed across countries with
the lowest rate in USA.
• Surgery was undertaken significantly less frequently in the cinacalcet
treated patients compared to placebo treated patients:7% v 14%,hazard
ratio= 0.44.95% confidence intervals 0.36-0.54.
4/5/13
44

(cont)
• Dr. Parfrey: There were substantial differences in the
management of severe hyperparathyroidism across the
world, and severe unremitting hyperparathyroidism
occurred frequently despite good use of conventional
therapy to treat hyperparathyroidism, including Vitamin D
agents and phosphate binders.
• Hemodialysis.com: What should clinicians take from your
study?
• Dr. Parfrey: Cinacalcet is an effective drug to prevent
severe unremitting hyperparathyroidism in hemodialysis
patients. It’s side effects include nausea and vomiting ,and
it can induce hypocalcemia.
4/5/13
45

(cont)
• Hemodialysis.com: What recommendations do you have
for future research as a result of your study?
• Dr. Parfrey: EVOLVE was designed to test the hypothesis
that prevention of hyperparathyroidism with cinacalcet
could prevent cardiovascular events. The answer was non-
definitive, although there was suggestive evidence to
indicate a clinical effect on cardiovascular events.
• Further trials to provide a definitive answer are indicated.
• Citation:
• Disease Progression and Surgical Parathyroidectomy in the
EVOLVE Trial
• NKF National Kidney Foundation Spring Clinical Meetings
4/5/13
46

Withdrawal from dialysis and palliative care
for severely ill dialysis patients in terms of patient-centered medicine
Hemodialysis.com Author Interview: M.D. Hideaki Ishikawa
Tokai Central Hospital of Japan Mutual Aid Association of Public School Teachers
• Answer: In daily works for our dialysis patients, we occasionally have
some difficulty in diagnosis of severely ill patients. Although dialysis is life-
sustaining therapy, however, it can no longer be helpful to improve their
life expectancy in that situation.
• Moreover, we feel that dialysis itself may be burdensome for these
seriously ill patients such as terminal phase of cancer, severe heart
failure, sepsis due to infectious diseases and so on.
• So, in our hospital, we sometimes recommend or propose “withdrawal
from dialysis (WD) ” for them as an optional treatment. As a result, we
believe that the patients can die with peace and dignity.
• In my opinion, current end-of-life care for dialysis patients who are
seriously ill have not be sufficient. We assessed the quality of end-of-life
care using “QODA” scale and verified that it may be acceptable and
worth considering for better clinical care to them.
4/5/13
47

(cont)
• Answer: It is related to the limitations of our study. There is no established
consensus about withdrawal from dialysis in Japan, so a number of patients could
not accept WD until their painful death.
• Hemodialysis.com: What should clinicians and patients take away from this
study?
• Answer: For clinicians, our results suggested that withdrawal from dialysis may
possibly improve our practice for end-of-life care of severely ill dialysis patients. In
addition, palliative care is also necessary to control severe intolerable symptoms
such as pain, respiratory distress, etc. after withdrawal from dialysis.
• In summary, nephrologists are required to be trained to get skills to undertake
satisfactory management of end-of-life care.
• For patients, We think every dialysis patients should consider their preference of
of end-of-life care even if they are doing well at present.
• The obvious statement about their living will may be useful for both physicians and
patients to refine a treatment of the end-of-life care.
4/5/13
48

(cont)
• Hemodialysis.com: What recommendations do you have for further research as a
result of your study?
• Answer: The term “patient-centered-medicine” has currently been focus in some
studies.
• As physicians for dialysis patients, we need to reevaluate whether our clinical
practices contribute to patients’ satisfaction even if they are in terminal stage.
• In that context, we think our concept of withdrawal from dialysis option for
severely ill dialysis patients is consistent with the concept.
• We think that it may be also worth discussing in further research whether non-
dialysis care for end-stage-renal disease patients who are severely ill is a
reasonable option for some patients.
• Citation:
• Withdrawal from dialysis and palliative care for severely ill dialysis patients in
terms of patient-centered medicine
• Hideaki Ishikawa Waichi Sato Chisato Shigematsu Saori Tsukushi Junichi
Sakamoto Shoichi Maruyama Seiichi Matsuo
• NKF 2013 Spring Clinical Meetings Abstract
4/5/13
49

Do ESRD patients really want to know prognosis
Hemodialysis.com eInterview with Krishna Manda, MD
Berkshire Medical Center in Pittsfield, Mass.
• Dr. Manda:
• • Our small study shows that dialysis patients
are at risk of “optimistic bias”.
• • Despite the extremely high mortality
associated with ESRD, most of our patients do not
believe their health will deteriorate in future and
a large number do not know the meaning of the
word, prognosis, and/or are hesitant to have
discussions on this subject with their
nephrologist.
4/5/13
50

Berkshire Medical Center in Pittsfield, Mass. (cont)
• Dr. Manda:
• • A surprising finding was that only half (54%) of the
sample expressed a desire to have a meeting with the
nephrologist to learn about their prognosis.
• • 84% of patients thought they knew what “prognosis”
meant, but only 62% of this subgroup were found during
the interview to know the correct meaning.
• • The sample was optimistic about the future, and 92%
of patients felt their health would likely remain stable or
improve over the next six months.
4/5/13
51

Berkshire Medical Center in Pittsfield, Mass. (cont)
from this study?
• Dr. Manda: End-of-life care can be improved by acquainting
patients with their prognoses and instituting ongoing conversations
about terminal care goals and preferences.
• Hemodialysis.com: What recommendations do you have for
future research as a result of your study?
• Dr. Manda: This study model should be expanded to a large group
of patients to know what ESRD patients know about their
prognosis, what their expectations/preferences are about end of
life care if that situation comes.
• Source:
• National Kidney Foundation
• Manda K, et al “Do ESRD patients really want to know prognosis?”
NKF 2013; Abstract 146
4/5/13
52

From Hemodialysis.com
• Please keep in mind that information
presented in these abstracts is usually
preliminary and will need to be confirmed by
further research and published in peer-
reviewed journals.
4/5/13
53

NKF Spring Clinical Meeting 2013 Interviews: National Kidney Foundation

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