Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK).

Introduction: Multidisciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care; however, the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard. Methods: We conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 ml/min per 1.73 m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney Disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a preemptive kidney transplant. Secondary outcomes included home dialysis initiation, preemptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor, and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019. Results: Among 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 patients (62%) who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) on peritoneal dialysis, 16 (5%) on home hemodialysis, and 36 (12%) to preemptive transplant. Of the 195 patients (65%) starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% confidence interval [CI]: 1.05-1.71, P = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than the national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor. Conclusion: Patients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.

Emergency Department Utilization Among Maintenance Hemodialysis Patients: A Systematic Review.

RATIONALE & OBJECTIVE: To evaluate predictors of emergency department (ED) utilization by adult patients receiving hemodialysis (HD) and interventions to reduce ED utilization by HD patients. STUDY DESIGN: We searched Ovid MEDLINE, Ovid Embase, and the Cochrane Library for randomized controlled trials and observational studies published until April 2020. SETTING & PARTICIPANTS: We included studies that investigated predictors of ED utilization and/or interventions to reduce ED utilization in HD patients. We extracted data regarding the study design and study population and results regarding ED utilization from 38 studies using Excel software. ANALYTICAL APPROACH: We performed a narrative synthesis to group articles that investigated similar themes. RESULTS: 1,060 titles and abstracts were screened, of which 98 were selected for full-text review. In total, 38 studies met the inclusion criteria and underwent data extraction. Quality was high according to the Downs and Black tool, with 11 studies rated as good, 22 as fair, and 5 as poor. 34 studies described predictors of ED utilization, whereas 4 studies investigated interventions in which ED utilization was studied. Our narrative synthesis produced 8 concept subgroups in the core concepts of access to care, comorbid condition burden, and new health care models. Poor access to care and a high comorbid condition burden are associated with increased ED use. No ED-based interventions designed to reduce ED utilization were identified, but recent changes in health care systems, like the formation of End-Stage Renal Disease Seamless Care Organizations and greater involvement of palliative care services, are associated with improved outcomes. LIMITATIONS: Clinical heterogeneity and variability in the included studies precluded a meta-analysis. CONCLUSIONS: HD patients' high ED use is multifactorial. Further research is required to understand and predict ED utilization in this vulnerable population, which will facilitate the development of interventions to reduce avoidable ED use. PROSPERO REGISTRATION NUMBER: CRD42020196569.

Renal disease in an urban HIV population in the era prior and following the introduction of highly active antiretroviral therapy.

Renal disease related to human immunodeficiency virus (HIV) has been a past and present burden on the HIV positive community, both in the United States and worldwide. Previously, focus has been on the impact of HIV-associated nephropathy (HIVAN) on the black population. This paper presents a large renal biopsy series of 108 HIV patients from an urban setting with early renal dysfunction. The purpose of the paper is to highlight clinical characteristics and epidemiological changes in HIV-related renal disease between 2 distinct time periods: pre- and postintroduction of highly active antiretroviral therapy. Our data show a persistence of HIVAN in the black HIV US population and, in addition, an increase in other renal diseases in that population. These findings are discussed in regard to current and future HIV renal disease management.

Effect of Renal Function on Gadolinium-Related Signal Increases on Unenhanced T1-Weighted Brain Magnetic Resonance Imaging.

OBJECTIVES: The purpose of this study was to determine if renal function affects signal changes in the deep brain nuclei on unenhanced T1-weighted images after administration of linear gadolinium-based contrast agents (GBCAs). METHODS: An electronic medical records search of 2 large medical centers identified 25 patients who received linear GBCA while on hemodialysis and had unenhanced T1-weighted images of the brain before and after. The dentate-to-cerebellar peduncle (DCP) ratio, globus pallidus-to-mid thalamus (GPT) ratio, and choroid plexus-to-nearby white matter ratio were measured and compared with 25 age/sex/GBCA exposure-matched control patients with normal or near-normal renal function (estimated glomerular filtration rate >60 mL/min per 1.73 m). Two additional control groups included 13 patients on hemodialysis without GBCA exposure and 13 age/sex-matched patients with estimated glomerular filtration rate greater than 60 mL/min per 1.73 m. RESULTS: Hemodialysis patients (n = 25) with an average of 1.8 linear GBCA administrations had a 4.9% mean increase (1.00 ± 0.04 vs 1.05 ± 0.05; P < 0.001) in DCP, which was greater than the 1.6% change (0.99 ± 0.04 vs 1.00 ± 0.05; P = 0.08) observed in matched controls (P = 0.01). There was no significant signal change in the DCP ratio in the 13 hemodialysis patients (0.99 ± 0.04 vs 0.99 ± 0.04; P = 0.78) and 13 age/sex-matched patients (0.99 ± 0.02 vs 0.99 ± 0.03; P = 0.78) who did not receive GBCA. The hemodialysis patients had a baseline GPT that was higher than nondialysis patients (P < 0.001). However, the GPT change after GBCA administration was not significantly different from controls. Increased signal in the choroid plexus on unenhanced T1-weighted images after GBCA administration was noted in hemodialysis patients (0.72 ± 0.20 vs 0.86 ± 0.23; P = 0.006); however, a multivariate analysis showed this to be primarily related to hemodialysis (P = 0.003) with only a trend toward relating to GBCA exposure (P = 0.07). CONCLUSIONS: Hemodialysis patients receiving linear GBCA have greater dentate nucleus signal increases on unenhanced T1-weighted images, suggesting that renal function may affect the rate of gadolinium accumulation in the brain after linear GBCA-enhanced magnetic resonance imaging.