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.

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.

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.

Sharing innovations to enhance renal fellow education in dialysis.

Dialysis care is an integral part of the practice of nephrology. Despite this, education of fellows in providing dialysis often remains rudimentary, relying on a combination of didactics and learning through experience. This runs the risk of training nephrologists who can provide dialysis care without truly being experts on the subject. In this article, a collection of novel or innovative teaching methods is presented that are meant to provide training programs with additional tools with which to improve the training of their fellows in dialysis.

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.

Implementation of nephrology subspecialty curricular milestones.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows' progress toward 23 subcompetency "context nonspecific" internal medicine subspecialty milestones. Fellows' advancement toward the "ready for unsupervised practice" target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific "curricular milestones," mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Survival Disparity of African American Versus Non-African American Patients With ESRD Due to SLE.

BACKGROUND: A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non-African American patients with LN-caused ESRD, compared with other causes. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using the US Renal Data System database, we identified 12,352 patients with LN-caused ESRD among 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31, 2010. PREDICTORS: Baseline demographics and comorbid conditions, Hispanic ethnicity, socioeconomic factors (employment status, Medicare/Medicaid insurance, and area-level median household income based on zip code as obtained from the 2000 US census), and kidney transplantation as a time-dependent variable. OUTCOME: All-cause mortality. MEASUREMENTS: Multivariable Cox and competing-risk regressions. RESULTS: Mean duration of follow-up in the LN-caused ESRD and other-cause ESRD cohorts were 6.24±4.20 (SD) and 4.06±3.61 years, respectively. 6,106 patients with LN-caused ESRD (49.43%) and 853,762 patients with other-cause ESRD (76.24%) died during the study period (P<0.001). Patients with LN-caused ESRD were significantly younger (mean age, 39.92 years) and more likely women (81.65%) and African American (48.13%) than those with other-cause ESRD. In the fully adjusted multivariable Cox regression model, African American (vs non-African American) patients with LN-caused ESRD had significantly increased risk of death at age 18 to 30 years (adjusted HR, 1.43; 95% CI, 1.24-1.65) and at age 31 to 40 years (adjusted HR, 1.17; 95% CI, 1.02-1.34). Among patients with other-cause ESRD, African Americans were at significantly increased risk at age 18 to 30 years (adjusted HR, 1.17; 95% CI, 1.11-1.22). LIMITATIONS: We used zip code-based median household income as a surrogate for patient income. Residual socioeconomic confounders may exist. CONCLUSIONS: African Americans are at significantly increased risk of death compared with non-African Americans with LN-caused ESRD at age 18 to 40 years, a racial disparity risk that is 10 years longer than that in the general ESRD population. Accounting for area-level median household income and transplantation significantly attenuated the disparity in mortality of African American versus non-African American patients with LN-caused ESRD.

Effects of Traumatic Amputation on ß-Trace Protein and ß2-Microglobulin Concentrations in Male Soldiers.

BACKGROUND: Serum creatinine (SCr) levels are decreased following traumatic amputation, leading to the overestimation of glomerular filtration rate (GFR). ß-Trace protein (BTP) and ß2-microglobulin (B2M) strongly correlate with measured GFR and have not been studied following amputation. We hypothesized that BTP and B2M would be unaffected by traumatic amputation. METHODS: We used the Department of Defense Serum Repository to compare pre- and post-traumatic amputation serum BTP and B2M levels in 33 male soldiers, via the N Latex BTP and B2M nephelometric assays (Siemens Diagnostics, Tarrytown, N.Y., USA). Osterkamp estimation using DEXA scan measurements was used to establish percent estimated body weight loss (%EBWL). Results were analyzed for small (3-5.9% EBWL), medium (6-13.5%), and large (>13.5%) amputation subgroups; and for a control group matched 1:1 to the 12 large amputation subjects. Paired Student's t test was used for comparisons. RESULTS: Mean serum BTP levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. BTP appeared to decrease following large %EBWL amputation (p = 0.05). Mean serum B2M levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. B2M appeared to increase following large %EBWL amputation (p = 0.05). CONCLUSIONS: BTP and B2M levels are less affected than SCr by amputation, and should be considered for future study of GFR estimation. BTP and B2M changes following large %EBWL amputation require validation and may offer insight into non-GFR BTP and B2M determinants as well as increased cardiovascular disease and mortality following amputation.

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients.

BACKGROUND: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. METHODS: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 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 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. RESULTS: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p<0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. CONCLUSIONS: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

Assessing achievement in nephrology training: using clinic chart audits to quantitatively screen competency.

BACKGROUND: Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training. STUDY DESIGN: Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool. SETTING & PARTICIPANTS: Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years. PREDICTORS: Proportion of chart audit and quality indicator deficiencies. OUTCOMES: Longitudinal deficiency and ITE performance. MEASUREMENTS & RESULTS: Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P<0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P<0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P<0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue. LIMITATIONS: Retrospective design and small trainee numbers. CONCLUSIONS: Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

Expanding the role of objectively structured clinical examinations in nephrology training.

Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that contains both examination and training features and focuses on management and clinical knowledge of rare hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in managing the event. The OSCE tested and trained fellows in the recognition and management of rare hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty training; however, collaboration between training programs would be necessary to validate such exercises.

Cost-utility analysis of sodium polystyrene sulfonate vs. potential alternatives for chronic hyperkalemia.

PURPOSE: Hyperkalemia during renin-angiotensin-aldosterone system inhibition (RAAS-I) may prevent optimum dosing. Treatment options include sodium polystyrene sulfonate potassium binding resins, but safety and efficacy concerns exist, including associated colonic necrosis (CN). Alternative agents have been studied, but cost-utility has not been estimated. METHODS: We performed a cost-utility analysis of outpatients ≥ 18 years of age receiving chronic RAAS-I, with a history of hyperkalemia or chronic kidney disease, prescribed either sodium polystyrene sulfonate or a theoretical "drug X" binding resin for chronic hyperkalemia. Data were obtained from existing literature. We used a decision analytic model with Monte Carlo probabilistic sensitivity analyses, from a health care payer perspective and a 12-month time horizon. Costs were measured in US dollars. Effectiveness was measured in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS: Drug X could cost no more than $ 10.77 per daily dose to be cost-effective, at a willingness-to- pay (WTP) threshold of $ 50,000/QALY. At $ 40.00 per daily dose, drug X achieved an incremental cost effectiveness ratio of $26,088,369.00 per QALY gained. One-way sensitivity analysis showed sodium polystyrene sulfonate to be the cost-effective option for CN incidences ≤ 19.9%. Limitations include incomplete information on outpatient outcomes and lack of data directly comparing sodium polystyrene sulfonate to potential alternatives. CONCLUSIONS: Alternatives may not be cost-effective unless priced similarly to sodium polystyrene sulfonate. This analysis may guide decisions regarding adoption of alternative agents for chronic hyperkalemia control, and suggests that sodium polystyrene sulfonate be employed as an active control in clinical trials of these agents.

Cost-effectiveness of antiplatelet therapy to prolong primary patency of hemodialysis graft.

INTRODUCTION: The Dialysis Access Consortium (DAC) study group previously reported that treatment with extended-release dipyridamole plus aspirin (DASA) resulted in a significant but clinically modest improvement in primary unassisted arteriovenous graft (AVG) patency. Utilizing DAC published data, the objective of this study is to evaluate the cost effectiveness of antiplatelet interventions aimed at preventing loss of primary AVG patency in hemodialysis (HD) patients. METHODS: We performed a cost-utility analysis, using a decision analysis tree model with a 12-month time horizon and a third party payer perspective. Interventions included DASA with and without concurrent aspirin, aspirin alone, and no prophylaxis. The modeled population was defined as adult (≥ 18 years of age) end-stage renal disease (ESRD) patients who had undergone placement of a new AVG in the United States. The outcomes were costs, quality-adjusted life-years (QALY), incremental cost-effectiveness ratios, and net monetary benefit. Probabilities were based upon published studies performed by the DAC Study Group while costs of medications and procedures were drawn from public sources. Utilities of health states were derived from published reports and the Short Form 6D (SF-6D) instrument. RESULTS: Aspirin alone is the most cost effective strategy for AVG pharmacologic prophylaxis, as compared to no prophylaxis or DASA with or without concurrent aspirin. The results are robust on multiple scenario analyses using both deterministic and Monte Carlo probabilistic sensitivity analyses. Accounting for both costs and QALY, using aspirin alone to prevent AVG thrombosis can potentially reduce healthcare costs by $24,679,412 per year compared to no aspirin use, at a willingness-to-pay of $50,000/ QALY. CONCLUSIONS: Aspirin monotherapy compared favorably to other strategies based on cost per QALY. Our findings support the use of aspirin prophylaxis in HD patients with a new AVG who do not have a contraindication to aspirin.

Risk of intracranial hemorrhage associated with autosomal dominant polycystic kidney disease in patients with end stage renal disease.

BACKGROUND: An analysis of intracranial hemorrhage (ICH) in a national sample of autosomal dominant polycystic kidney disease (ADPKD) patients receiving long-term dialysis has not been reported. It is often assumed that patients with ADPKD are not at increased risk of ICH after starting dialysis. We hypothesized that patients with ADPKD would have a higher subsequent risk of ICH even after the start of chronic dialysis. METHODS: Retrospective cohort study of Medicare primary patients with and without ADPKD in the United States Renal Data System (USRDS), initiated on chronic dialysis or transplanted between 1 January 1999 and 3 July 2009, and followed until 31 December 2009. Covariates included age, gender, race, prior stroke, diabetes mellitus, dialysis modality, body mass index, serum albumin and other co-morbid conditions from the Medical Evidence Form. Primary outcome was ICH, based on inpatient and outpatient Medicare claims, and all-cause mortality. Kaplan-Meier analysis was used for unadjusted assessment of time to events. Cox regression was used for assessment of factors associated with ICH and mortality. We performed competing risk regression using kidney transplant and death as competing risks. Kidney transplant was also modeled as a time-dependent covariate in Cox regression. RESULTS: Competing risk regression demonstrated that ADPKD had a subhazard ratio 2.97 for ICH (95% CI 2.27-3.89). Adjusted Cox analysis showed that ADPKD patients had an AHR for death of 0.59 vs. non-ADPKD patients (95% CI 0.57-0.61). CONCLUSIONS: ADPKD is a significant risk factor for ICH among patients on maintenance dialysis. Our Medicare primary cohort was older than in previous studies of intracranial aneurysm rupture among ADPKD patients. There are also limitations inherent to using the USRDS database.

Protected Time for Program Administration among Nephrology Program Leadership in the United States.

BACKGROUND: In 2022, the Accreditation Council for Graduate Medical Education reduced minimum program director protected time for program administration from 10 to 8 h/wk, with no core faculty requirement. We surveyed program leaders regarding the effect of these changes. METHODS: This is an anonymous, online survey of all US adult nephrology program directors (March 2023), who forwarded core faculty/associate program director (APD) surveys. The questions included protected time in 2022-2023 and 2021-2022, whether it was sufficient, estimated time needed, and two validated single-item burnout measures (emotional exhaustion and depersonalization). The analysis was descriptive. RESULTS: Program directors: Their response was 62% (92/149), with geographic distribution/approved fellow positions similar to those nationally. Overall, protected time slightly increased from 2021 to 2022, largely in >6-fellow programs, but 42% (13/31) of these were still not meeting minimum requirements. Only 37% (30/81) agreed that they had sufficient protected time. Those with ≤6 fellows estimated needing 11±4 h/wk (15±4 h/wk with >6 fellows). Twenty-five percent (20/81) reported high levels of emotional exhaustion. Core faculty: 57 of 149 program directors (38%) forwarded the link to 454 faculty. Ninety-four percent of APDs (49/52) responded, reported 3±3 h/wk protected time (42% had none), and estimated needing 6±3 h/wk, regardless of program size. Sixty-seven of 402 core faculty (17%) responded, reported 2±3 h/wk (50% had none), and estimated needing 5±3 h/wk, regardless of program size. ≥85% of APDs and core faculty precepted clinical rotations, gave lectures, evaluated fellows, mentored scholarly work, and participated in recruitment. The majority assisted in fellow remediation. Thirty-four percent (15/44) of APDs and 21% (13/61) of core faculty reported high levels of emotional exhaustion. CONCLUSIONS: Program leaders estimated minimum necessary program administration times (on the basis of program size) that exceeded the Accreditation Council for Graduate Medical Education requirements. APDs/core faculty contributed substantially to nonclinical training. Thirty-four percent of APDs and 25% of program directors had a high likelihood of burnout.

Surgical intervention and long-term renal outcomes of congenital ureteropelvic junction obstruction in a young adult cohort.

PURPOSE: To evaluate the impact of surgical intervention on long-term renal outcomes for adult patients with congenital ureteropelvic junction obstruction (UPJO). METHODS: We queried service members diagnosed with UPJO from the United States Military Health System electronic health records from 2005 to 2020. We assessed demographic, laboratory, radiology, surgical intervention, and outcome data. We evaluated the impact of surgical intervention on renal function based on the estimated glomerular filtration rate (eGFR), hypertension (HTN, defined as any prescription for blood pressure [BP] medication and/or average of two BP readings ≥ 130/80 mmHg more than 2 weeks apart), and changes in renal excretory function on radionuclide scans. RESULTS: We identified 108 individuals diagnosed with congenital UPJO; mean follow-up of 7 years. Mean age at diagnosis was 25 years; 95% male; 69% White, 15% Black. At diagnosis, median BP was 130/78 mmHg and mean eGFR 93 ml/min/1.73m2. Subsequently, 85% had pyeloplasty and 23% had stent placement. There were no significant differences in mean eGFR pre- and post-intervention (94 vs. 93 ml/min/1.73m2, respectively; p = 0.15) and prevalence of defined HTN (59% vs. 61%, respectively; p = 0.20). Surgical intervention for right-sided UPJO significantly reduced the proportion of patients with delayed cortical excretion (54% pre vs. 35% post, p = 0.01) and T½ emptying time (35 min vs. 19 min, p = 0.009). Similar trends occurred with left-sided UPJO but were not significant. CONCLUSION: Surgical intervention was not associated with significant differences in the long-term outcomes of kidney function and HTN prevalence in our young adult cohort. However, renal excretory function improved on radionuclide scans.

A Healthy Active Duty Soldier with an Elevated Serum Creatinine.

Creatine products and sports supplements are widely used by active duty soldiers. These products are associated with both acute renal failure and elevated serum creatinine levels without renal injury. We present a case involving an active duty, 26-year-old Caucasian soldier who was evaluated in our clinic for elevated creatinine levels. This patient had no active medical problems and was noted on repeat labs to have significantly elevated creatinine levels. Subsequent investigations led us to conclude these values were not associated with renal injury and were due to ingested supplements.

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.