American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community.

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

Caring for patients with kidney disease: shifting the paradigm from evidence-based medicine to patient-centered care.

The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting real-world treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patient-centered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives.

Vax the Max, a Gamification Intervention for COVID-19 Vaccination Task Engagement in the Inpatient Setting.

The development of vaccines for SARS-CoV-2 has offered game-changing protection from severe disease and death from COVID-19. Despite efforts to vaccinate individuals in the ambulatory setting, a sizable minority of the US population remains unvaccinated for COVID-19. For unvaccinated patients, hospitalization for non-COVID-19 illness offers another opportunity for vaccination. In the summer of 2021, the authors noted that COVID-19 vaccination rate for medicine inpatients at their hospital had fallen to 5.3 vaccine doses administered per 4-week block. In response, they created Vax the Max, a gamification program of COVID-19 vaccination tasks where internal medicine resident teams were awarded points for completing these tasks. Residents were anonymously surveyed after participation. The hospital demonstrated higher rates of administering the initial COVID-19 vaccine dose and completing the vaccine series in the inpatient setting per 4-week plan-do-study-act cycle after implementation of Vax the Max (5.3 versus 8.8 doses per plan-do-study-act cycle). Among residents, 76.8% reported that Vax the Max spurred their COVID-19 task engagement, and 66% reported that a similar gamification model could be utilized for a different clinical task in the future. An increase was observed in the COVID-19 vaccination rate for medicine inpatients after launching the Vax the Max competition. This occurred in the setting of resident turnover every 4 weeks, which normally makes practice sustainment more challenging. Despite this, a high degree of engagement was produced by itinerant residents. There is potential to explore similar gamification approaches involving resident physicians in areas of quality improvement and patient safety.

Trajectories of kidney function decline in the 2 years before initiation of long-term dialysis.

BACKGROUND: Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003. PREDICTOR: Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis. OUTCOMES & MEASUREMENTS: Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation. RESULTS: We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR < 30 mL/min/1.73 m2 (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m2 per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m2 (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m2 per year), 9.5% had accelerated loss of eGFR from levels > 60 mL/min/1.73 m2 (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m2 per year), and 3.1% experienced catastrophic loss of eGFR from levels > 60 mL/min/1.73 m2 within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation. CONCLUSIONS: There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.

Racial composition of residential areas associates with access to pre-ESRD nephrology care.

Referral to a nephrologist before initiation of chronic dialysis occurs less frequently for blacks than whites, but the reasons for this disparity are incompletely understood. Here, we examined the contribution of racial composition by zip code on access and quality of nephrology care before initiation of renal replacement therapy (RRT). We retrospectively studied a cohort study of 92,000 white and black adults who initiated RRT in the United States between June 1, 2005, and October 5, 2006. The percentage of patients without pre-ESRD nephrology care ranged from 30% among those who lived in zip codes with <5% black residents to 41% among those who lived in areas with >50% black residents. In adjusted analyses, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased. Among patients who received nephrology care, the quality of care (timing of care and proportion of patients who received a pre-emptive renal transplant, who initiated therapy with peritoneal dialysis, or who had a permanent hemodialysis access) did not differ by the racial composition of their residential area. In conclusion, racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received.

Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults.

CONTEXT: An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis. OBJECTIVES: To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care. DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational study using a national ESRD registry to identify a cohort of 41,420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare. MAIN OUTCOME MEASURES: Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices. RESULTS: Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged > or = 80 years and women aged > or = 85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21,190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses. CONCLUSION: There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.

Characteristics of uninsured Americans with chronic kidney disease.

BACKGROUND: In the United States, public health insurance is available for nearly all persons with end-stage renal disease (ESRD). Little is known about the extent of health insurance coverage for persons with non-dialysis dependent chronic kidney disease (CKD). OBJECTIVE: To describe patterns of health insurance coverage for adults with non-dialysis dependent CKD and to examine risk factors for progression of CKD to ESRD and management of hypertension among those lacking insurance. DESIGN AND PARTICIPANTS: Cross-sectional analysis of data from a nationally representative sample of 16,148 US adults aged 20 years or older who participated in the National Health and Nutrition Examination Survey 1999-2006. MEASUREMENTS: National prevalence estimates of health insurance coverage, ESRD risk factors, and treatment of hypertension. MAIN RESULTS: An estimated 10.0% (95% CI, 8.3%-12.0%) of US adults with non-dialysis dependent CKD were uninsured, 60.9% (95% CI, 58.2%-63.7%) had private insurance and 28.7% (95% CI, 26.4%-31.1%) had public insurance alone. Uninsured persons with non-dialysis dependent CKD were more likely to be under the age of 50 (62.8% vs. 23.0%, P < 0.001) and nonwhite (58.7%, vs. 21.8%, P < 0.001) compared with their insured counterparts. Approximately two-thirds of uninsured adults with non-dialysis dependent CKD had at least one modifiable risk factor for CKD progression, including 57% with hypertension, 40% who were obese, 22% with diabetes, and 13% with overt albuminuria. In adjusted analyses, uninsured persons with non-dialysis dependent CKD were less likely to be treated for their hypertension (OR, 0.59; 95% CI, 0.40-0.85) and less likely to be receiving recommended therapy with angiotensin inhibitors (OR, 0.45; 95% CI, 0.26-0.77) compared with those with insurance coverage. CONCLUSIONS: Uninsured persons with non-dialysis dependent CKD are at higher risk for progression to ESRD than their insured counterparts but are less likely to receive recommended interventions to slow disease progression. Lack of public health insurance for patients with non-dialysis dependent CKD may result in missed opportunities to slow disease progression and thereby reduce the public burden of ESRD.

Health disparities in chronic kidney disease: are we making any progress?

Health disparities in CKD remain widespread and deserve continued efforts towards elimination. Future research and policy goals should be targeted towards an understanding of the contribution of health care system practices, poor health literacy, lack of access to health care, urban segregation, and on rural isolation on the perpetuation of CKD health disparities. Eliminating these disparities will require understanding the contribution of health care system practices, geography, health care policy, biology, and genetics, which can lead to the development of novel interventions, innovative health care strategies, and ground-breaking policy interventions targeted at decreasing CKD associated health disparities.

Association of hepatitis C seropositivity with increased risk for developing end-stage renal disease.

BACKGROUND: Infection with chronic hepatitis C virus (HCV) has been linked to glomerulonephritis. We undertook this study to determine whether having a positive HCV test result was associated with an increased risk for developing treated end-stage renal disease (ESRD). METHODS: Using data from Medicare, the Department of Veterans Affairs, and the United States Renal Data System, we performed a retrospective cohort study of 474,369 adult veterans who had serum creatinine levels measured between October 1, 2000, and September 30, 2001, and HCV antibody testing within 1 year of creatinine testing. Patients were followed up until October 1, 2004, for the outcome of treated ESRD, defined as the onset of chronic dialysis or renal transplantation. Cox proportional hazards models were used to determine the relative hazard for ESRD associated with HCV, adjusted for other covariates (age, sex, race/ethnicity, and comorbidities). RESULTS: Of 474,369 patients in the cohort, 52,874 (11.1%) had a positive HCV antibody test result. Patients with HCV were more likely to develop ESRD: the rate per 1000 person-years was 4.26 (95% confidence interval, 3.97-4.57) for HCV-seropositive patients vs 3.05 (95% confidence interval, 2.96-3.14) for HCV-seronegative patients. For patients aged 18 to 70 years with an estimated glomerular filtration rate of at least 30 mL/min per 1.73 m2, HCV seropositivity was associated with a greater than 2-fold risk for developing ESRD (adjusted hazard rate, 2.80; 95% confidence interval, 2.43-3.23). CONCLUSION: In this large national cohort of adult veterans, patients younger than 70 years with HCV seropositivity were at increased risk for developing ESRD treated with dialysis or transplantation.

Geography matters: relationships among urban residential segregation, dialysis facilities, and patient outcomes.

BACKGROUND: End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated. OBJECTIVE: To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities. DESIGN: Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities. SETTING: U.S. metropolitan ZIP codes with differing percentages of black residents. PATIENTS: Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244). MEASUREMENTS: Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates). RESULTS: Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets. LIMITATIONS: Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code. CONCLUSIONS: The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.

Racial differences in end-stage renal disease rates in HIV infection versus diabetes.

Few studies have compared the incidence of end-stage renal disease (ESRD) among individuals with the human immunodeficiency virus (HIV) and diabetes. We followed a national sample of 2,015,891 US veterans over a median peroid of 3.7 years for progression to ESRD. The age- and sex-adjusted incidence of ESRD (per 1000 person-years) among HIV-infected black patients was nearly an order of magnitude higher than among HIV-positive white patients, almost twice that of diabetic whites, and similar to that among diabetic blacks. In multivariate Cox proportional hazards analysis, diabetes was associated with an increased risk of ESRD among white patients, but HIV was not. Among black individuals, however, both HIV and diabetes conferred a similar increase in the risk of ESRD (4- to 5-fold increase compared to white individuals without HIV or diabetes). HIV and diabetes carry a similar risk of ESRD among black patients, highlighting the importance of developing strategies to prevent and treat renal disease among HIV-infected black individuals.

Low rates of antiretroviral therapy among HIV-infected patients with chronic kidney disease.

BACKGROUND: It is unknown whether chronic kidney disease (CKD) influences receipt of highly active antiretroviral therapy (HAART) among patients with the human immunodeficiency virus (HIV) and whether prescription practices contribute to excess mortality. METHODS: We conducted a retrospective observational study involving HIV-infected patients with established indications for HAART and an outpatient serum creatinine level measured in the Veterans Affairs health care system. Patients were followed up for the outcomes of HAART exposure (percentage of follow-up time treated with HAART), inadequate dose adjustment of renally eliminated antiretroviral medications, and time to death. RESULTS: A total of 1041 patients (8.5%) had CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). Compared with patients with an eGFR >or=60 mL/min/1.73 m(2), HAART exposure was 14% less (95% confidence interval [CI], 2%-24% less), 24% less (95% CI, 4% more to 45% less), 64% less (95% CI, 38%-79% less), and 49% less (95% CI, 32%-61% less) in patients who had an eGFR of 30-59 mL/min/1.73 m(2), 15-29 mL/min/1.73 m(2), and <15 mL/min/1.73 m(2) (and were not receiving dialysis) and in patients receiving long-term dialysis, respectively. At study entry, 15.4% of patients with CKD received HAART unadjusted for the level of renal function. The adjusted hazard ratio for death was 1.36 (95% CI, 1.08-1.72) for patients with an eGFR of 30-59 mL/min/1.73 m(2), 2.17 (95% CI, 1.43-3.27) for patients with an eGFR of 15-29 mL/min/1.73 m(2), 5.97 (95% CI, 3.18-11.19) for patients with an eGFR <15 mL/min/1.73 m(2), and 1.92 (95% CI, 1.30-2.82) for dialysis-dependent patients. Underexposure and inadequate dose adjustment of HAART were associated with 22.5%-35.5% of the excess mortality found among patients with different levels of CKD. CONCLUSIONS: Underexposure and inadequate dose adjustment of HAART may contribute to excess mortality among HIV-infected patients with CKD.

Low ankle-brachial index associated with rise in creatinine level over time: results from the atherosclerosis risk in communities study.

BACKGROUND: A low ankle-brachial index (ABI) predicts risk of cardiovascular death, myocardial infarction, peripheral arterial disease events, and stroke. However, it is unknown whether a low ABI also predicts a decline in renal function. METHODS: We examined the association between ABI and change in serum creatinine level over time among 13 655 participants in the Atherosclerosis Risk in Communities (ARIC) study who underwent serum creatinine and ABI measurement at baseline and also underwent serum creatinine measurement 3 years later at the second study visit. The study outcome was a 50% rise in serum creatinine level from baseline to the second study visit. RESULTS: Overall, 0.48% of participants with an ABI of 1 or higher, 0.9% of participants with an ABI between 0.9 and 0.99, and 2.16% of participants with an ABI lower than 0.9 experienced a 50% or greater increase in serum creatinine level. In multivariate analysis, participants with an ABI lower than 0.9 were still more than twice as likely as those in the referent category (ABI > or = 1) to experience an increase in serum creatinine level (odds ratio 2.5; 95% confidence interval, 1.1-5.7) (P = .04), and a linear trend in the incidence of worsening renal function was noted across ABI categories (P = .02). Analyses excluding participants with renal insufficiency, diabetes, and hypertension at baseline all produced similar results. CONCLUSION: In addition to known associations of the ABI with stroke, myocardial infarction, peripheral arterial disease events, and cardiovascular death, a low ABI also predicts an increase in serum creatinine level over time.

Interpretation of serologic tests in an HIV-infected patient with kidney disease.

BACKGROUND: A 32-year-old African American man with HIV infection presented with hemoptysis, shortness of breath and renal insufficiency. Serologic testing revealed the presence of anti-glomerular basement membrane antibodies and equivocal levels of anti-myeloperoxidase antibodies. INVESTIGATIONS: Physical examination, urine and blood analysis, kidney ultrasound, chest radiograph, sputum cultures, bronchoscopy and renal biopsy. DIAGNOSIS: Reactivation of tuberculosis infection, immune complex glomerulonephritis, and 'false-positive' anti-glomerular basement membrane and anti-myeloperoxidase antibodies. MANAGEMENT: Directly observed therapy with four-drug anti-tuberculosis therapy and conservative management of chronic kidney disease.

Dialysis for undocumented immigrants in the United States.

The United States offers near-universal coverage for treatment of ESRD. Undocumented immigrants with ESRD are the only subset of patients not covered under a national strategy. There are 2 divergent dialysis treatment strategies offered to undocumented immigrants in the United States, emergent dialysis and chronic outpatient dialysis. Emergent dialysis, offering dialysis only when urgent indications exist, is the treatment strategy in certain states. Differing interpretations of Emergency Medicaid statute by the courts and state and federal government have resulted in the geographic disparity in treatment strategies for undocumented immigrants with ESRD. The Patient Protection and Affordable Care Act of 2010 ignored the health care of undocumented immigrants and will not provide relief to undocumented patients with catastrophic illness like ESRD, cancer, or traumatic brain injuries. The difficult patient and provider decisions are explored in this review. The Renal Physicians Association Position Statement on uncompensated renal-related care for noncitizens is an excellent starting point for a framework to address this ethical dilemma. The practice of "emergent dialysis" will hopefully be found unacceptable in the future because of the fact that it is not cost effective, ethical, or humane.