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.

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

Rationale & Objective: Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use. Study Design: Anonymous, online survey. Setting & Participants: All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program. Analytical Approach: Descriptive. Results: 46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation. Limitations: Loss of respondents as program directors and fellows progressed through the survey. Conclusions: Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.

Adapting an Objective Structured Clinical Examination (OSCE) on Conducting Difficult Conversations Between Nephrology Fellows and Patients to a Virtual Platform: A Research Letter.

Background: We previously described a nephrology-specific "Breaking Bad News" Objective Structured Clinical Examination (OSCE) assessing nephrology fellow communication and counseling skills in 3 scenarios: kidney replacement therapy (KRT) in kidney failure, urgent KRT in acute kidney injury (AKI), and kidney biopsy (KBx). Objective: The main objectives of this study is to adapt the OSCE to a virtual platform, simulating nephrology patient telemedicine encounters involving difficult conversations, and to assess fellow and faculty satisfaction with the virtual format. Design: Description of a formative telemedicine simulation for nephrology fellows. Setting: Fully virtual simulation conducted by 2 academic medical simulation centers. Participants: Nephrology faculty and fellows at 3 urban/suburban training programs in the eastern United States. Measurements: Description of the virtual OSCE process. Fellow and faculty satisfaction overall and for each scenario. Faculty and fellow estimates of frequency of virtual patient encounters in the past year. Methods: The OSCE consisted of 3 scenarios: KRT in kidney failure, urgent KRT in AKI, and KBx. Objective Structured Clinical Examinations were administered in May 2021. Each scenario lasted 20 minutes. The AKI scenario was audio only. Fellows telephoned a simulated patient surrogate for urgent KRT consent. Kidney failure and KBx scenarios were video encounters. Faculty observed while muted/video off. Immediately after the OSCE, fellows and faculty were anonymously surveyed regarding their satisfaction with each scenario, the OSCE overall, and their estimate of outpatient encounters and inpatient KRT counseling done virtually in the preceding year. Results: Seventeen fellows completed the OSCE at 2 centers (3 programs). Sixteen (94%) completed the survey. Almost 94% rated the OSCE as a good/very good approximation of telemedicine encounters. Those satisfied/very satisfied with each scenario are as follow: 100% for AKI, 75% for kidney failure, and 75% for KBx. Two commented that they often did urgent KRT counseling by telephone. Fellows estimated a median 20% (interquartile range: 175, 50%) of counseling for acute inpatient KRT and a median 50% (IQR: 33.75, 70%) of outpatient encounters were virtual in the prior year. Two (regarding the kidney failure and KBx scenarios) indicated they would not have counseled similar outpatients virtually. Limitations: The 15-minute interactions may be too short to allow the encounter to be completed comfortably. A small number of programs and fellows participated, and programs were located in urban/suburban areas on the east coast of the United States. Conclusions: Overall, fellows felt that the OSCE was a good approximation of virtual encounters. The OSCE is an opportunity for fellows to practice telemedicine communication skills.

Contexte: Nous avions précédemment décrit un examen clinique objectif structuré (ECOS) de type « annonce d'une mauvaise nouvelle ¼ en néphrologie afin d'évaluer les compétences en communication et consultation des résidents en néphrologie. L'ECOS comportait trois scénarios: thérapie de remplacement rénal (TRR) pour l'insuffisance rénale, TRR urgente dans les cas d'insuffisance rénale aiguë (IRA), et biopsie du rein (BxR). Objectifs: Adapter l'ECOS à une plateforme virtuelle, simuler des rencontres de télémédecine impliquant des conversations difficiles avec des patients en néphrologie, et évaluer la satisfaction des résidents en néphrologie et du corps enseignant à l'égard du format virtuel. Conception: Description d'une simulation de télémédecine pour la formation des résidents en néphrologie. Cadre: Des simulations entièrement virtuelles réalisées dans deux centers universitaires de simulation médicale. Participants: Les professeurs et les résidents en néphrologie de trois programs de formation urbains/suburbains de l'est des États-Unis. Mesures: Description du processus de l'ECOS virtuel. Satisfaction générale des résidents en néphrologie et du corps enseignant pour chacun des scénarios. Estimation, par les professeurs et les résidents, de la fréquence des rencontres virtuelles avec des patients au cours de la dernière année. Méthodologie: L'ECOS était composé de trois scénarios: TRR en insuffisance rénale; TRR urgente en contexte d'IRA et biopsie rénale. Les ECOS ont été réalisés en mai 2021. Chaque scénario durait 20 minutes. Le scénario IRA était audio uniquement; les boursiers devaient téléphoner à un patient simulé afin d'obtenir un consentement pour une TRR urgente. Les scénarios pour l'insuffisance rénale terminale et la BxR étaient sous forme de rencontres vidéo. Les professeurs observaient les scénarios en sourdine/hors vidéo. Immédiatement après l'ECOS, les résidents en néphrologie et les professeurs ont été interrogés de façon anonyme sur leur satisfaction à l'égard de chaque scénario et de l'ECOS dans son ensemble. Ils ont également été invités à estimer le nombre de consultations externes et de conseils prodigués sur la TRR à des patients hospitalisés au cours de l'année précédente. Résultats: Dix-sept résidents en néphrologie ont complété l'ECOS dans les deux centers (trois programs) et seize (94 %) ont répondu au sondage. La très grande majorité (94 %) a évalué l'ECOS comme une bonne/très bonne simulation des rencontres de télémédecine. Le taux de personnes satisfaites/très satisfaites s'établissait à 100 % pour le scénario de l'IRA, à 75 % pour celui de l'insuffisance rénale terminale et à 75 % pour celui de la BxR. Deux personnes ont dit faire régulièrement des consultations par téléphone pour la TRR urgente. Les résidents en néphrologie ont estimé que 20 %, (proportion médiane) ÉIQ= 175; 50 %, des consultations avec des patients hospitalisés et 50 %, (proportion médiane) ÉIQ = 33,75; 70 %, des consultations externes avaient été faites virtuellement au cours de l'année précédente. Pour les scénarios d'insuffisance rénale terminale et de BxR, deux personnes ont indiqué qu'elles ne feraient pas de consultations virtuelles pour ces patients. Limites: Les interactions de 15 minutes sont probablement trop courtes pour compléter confortablement la rencontre. Un faible nombre de programs et de résidents en néphrologie ont participé. Les programs évalués se situaient en zones urbaines et suburbaines de la côte est des États-Unis. Conclusion: Dans l'ensemble, les résidents en néphrologie ont estimé que l'ECOS était une bonne représentation des rencontres virtuelles. L'ECOS est une occasion pour les résidents de mettre en pratique leurs compétences en communication dans un contexte de télémédecine.

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.

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.

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.

Nephrology Program Director Protected Time for Program Administration in the United States.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) required that program directors receive 10-20 h/wk of protected time for program administration (including didactic teaching). In July 2022, this was reduced for all internal medicine subspecialties on the basis of program size, with 8 h/wk required for programs with fewer than seven fellows, the majority of nephrology programs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We surveyed all 151 US adult nephrology program directors (ACGME Public List of Programs 2021-2022) to determine how much protected time they receive, how much they think is necessary, and the division of their professional time. The anonymous 20-question online survey was administered from March 31 to April 30, 2022. The analysis was descriptive. RESULTS: Response rate was 66% (99 of 151). Geographic distribution and approved fellow positions were similar to programs nationally; 59% had fewer than seven approved positions. Median protected time was 10 h/wk (interquartile range, 5-10), with 8 h/wk (interquartile range, 5-10) for those with fewer than seven positions. Program directors estimated needing 12 h/wk (interquartile range, 10-16) to effectively administer programs, including those with fewer than seven positions, a median 5 h/wk (interquartile range, 0-7) more than received. Of program directors reporting <10 h/wk for program administration, 62% provided >20 hours of direct patient care. Thirty-nine percent had no protected time for core faculty. Fellow recruitment (68%) was the most time-consuming task, and didactic teaching (80%) was the most professionally rewarding. CONCLUSIONS: Approximately half of the nephrology programs surveyed were not in compliance with the ACGME-stipulated 10-h/wk minimum protected time for the 2021-2022 training year. Program directors estimated a median of 12 h/wk are needed to effectively manage programs.

The Kidney Diet Challenge: An Experiential Educational Experience.

Background: Health care providers who care for patients with CKD must be able to provide effective counseling about a kidney-friendly diet. Nutrition is underemphasized in medical curricula, and the kidney diet is one of the most challenging diets. We hypothesized that participation in an experiential educational program in kidney diet would result in improved knowledge of the underlying principles behind it and provide concrete examples of how to explain this diet to patients. Methods: The first part of this study was a knowledge assessment administered to all US nephrology fellows during the 2020 National Board of Medical Examiners Nephrology In-Training Examination. We later opened the assessment to a broader, global audience via social media. Respondents included trainees, practicing nephrologists, dieticians, and other health professionals. Participants self-identified willingness to participate in the second part of the study, the Kidney Diet Challenge (KDC). The 5-day challenge included daily webinars by experts in nutrition. Daily surveys captured self-reported adherence to the diet. Social media was used to engage with participants. All participants received a follow-up knowledge assessment. Results: Among the nephrology fellows (n=317), the median pretest score was 2 out of 5 (40%) questions correct, and results did not differ by year of training (P=0.31). Of the participants (n=70) who completed the 5-day challenge and responded to the post-challenge survey, the distribution of the number of correct answers improved after the KDC (median [25th, 75th percentile]: 3 [2, 3] versus 3 [2, 4]; P<0.001). Statistics from our official hashtag for this study (#kidneydietchallenge) showed that we achieved 406,241 reaches and 1,004,799 impressions, with a total of 974 posts using this hashtag. Conclusions: The KDC is an immersive, experiential educational tool that enabled a global population to learn how to counsel their patients better about adherence to a complex kidney diet.

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

INTRODUCTION: Among kidney transplant recipients (KTRs) with end-stage kidney disease (ESKD) due to atypical hemolytic uremic syndrome (aHUS), recurrence is associated with poor allograft outcomes. We compared graft and patient survival of aHUS KTRs with and without prophylactic/early use of eculizumab, a monoclonal antibody that binds complement protein C5, at the time of transplantation. METHODS: We conducted a retrospective cohort study using the United States Renal Data System. Out of 123 624 ESKD patients transplanted between January 1, 2008, and June 1, 2016, we identified 348 (0.28%) patients who had "hemolytic uremic syndrome" as the primary cause of ESKD. We then linked these patients to datasets containing the Healthcare Common Procedure Coding System (HCPCS) code for eculizumab infusion. Patients who received eculizumab prior to or within 30 days of transplant represented the exposure group. We calculated crude incidence rates and conducted exact logistic regression, adjusted for recipient age and sex, for the study outcomes of graft loss, death-censored graft loss, and mortality. We also estimated the average treatment effect (ATE) by propensity-score matching, to reduce the bias in the estimated treatment effect on graft loss. RESULTS: Our final study cohort included 335 aHUS KTRs (23 received eculizumab, 312 did not), with a mean duration of follow-up of 5.8 ± 2.7 years. There were no significant differences in baseline demographic and clinical characteristics between the eculizumab versus non-eculizumab group. Patients who received prophylactic/early eculizumab were less likely to experience graft loss compared with those who did not receive eculizumab (0% vs 20%, P = .02), with an adjusted odds ratio of 0.13 (P = .02). In the propensity-score-matched sample, the ATE (eculizumab vs non-eculizumab) was -0.20 (95% confidence interval [CI] = -0.25 to -0.15, P < .001); thus, treatment was associated with an average of 20% reduction in graft loss. There was no significant difference in the risk of death between the 2 groups. CONCLUSIONS: Although there was no significant difference in the risk of death, prophylactic/early use of eculizumab was significantly associated with improved graft survival among aHUS KTRs. Given the high cost of eculizumab, randomized controlled trials are much needed to guide prophylactic strategies to prevent graft loss.

INTRODUCTION: Chez les receveurs d'une greffe rénale (RGR) dont l'insuffisance rénale terminale (IRT) est due au syndrome hémolytique et urémique atypique (SHUa), la récidive est associée à de mauvais résultats d'allogreffe. Nous avons comparé la survie du greffon et des patients RGR-SHUa avec et sans administration prophylactique/précoce d'éculizumab, un anticorps monoclonal qui lie la protéine C5 du complément, au moment de la transplantation. MÉTHODOLOGIE: Nous avons mené une étude de cohorte rétrospective en utilisant le United States Renal Data System. Parmi les 123 624 patients atteints d'IRT transplantés entre le 1er janvier 2008 et le 1er juin 2016, nous avons répertorié 348 (0,28 %) patients présentant un « syndrome hémolytique urémique ¼ comme cause principale de l'IRT. Nous avons ensuite lié ces patients à des ensembles de données contenant le code du Healthcare Common Procedure Coding System (HCPCS) pour la perfusion d'éculizumab. Les patients ayant reçu de l'éculizumab avant l'intervention ou dans les 30 jours suivant la transplantation représentaient le groupe d'exposition. Nous avons calculé les taux bruts d'incidence et procédé à une régression logistique exacte, corrigée selon l'âge et le sexe du receveur, pour les résultats de l'étude concernant la perte du greffon, la perte du greffon censurée par le décès et la mortalité. Nous avons également estimé l'effet de traitement moyen (ETM) par appariement des scores de propension, afin de réduire le biais de l'effet estimé du traitement sur la perte du greffon. RÉSULTATS: Notre cohorte d'étude finale comprenait 335 patients RGR-SHUa (23 ayant reçu de l'éculizumab et 312 n'en ayant pas reçu) dont le suivi s'établissait à 5,8 ± 2,7 ans. Aucune différence significative n'a été observée entre les caractéristiques cliniques et démographiques initiales des deux groupes de sujets. Les patients ayant reçu de l'éculizumab prophylactique/précoce étaient moins susceptibles de subir une perte du greffon que ceux qui n'en avaient pas reçu (0 % vs 20 %; P = 0,02), avec un rapport de cotes corrigé de 0,13 (P = 0,02). Dans l'échantillon aux scores de propension appariés, l'ETM (éculizumab vs sans éculizumab) était de −0,20 (IC 95 %: −0,25 à −0,15; P < 0,001), le traitement a donc été associé à une réduction moyenne de 20 % de la perte du greffon. Aucune différence significative n'a été observée entre les deux groupes quant au risque de décès. CONCLUSION: Bien qu'aucune différence significative n'ait été observée pour le risque de mortalité, l'administration prophylactique/précoce d'éculizumab a été associée de façon significative à une amélioration de la survie du greffon chez les patients RGR-SHUa. Étant donné le coût élevé de l'éculizumab, des essais contrôlés randomisés sont nécessaires pour orienter les stratégies prophylactiques visant à prévenir la perte du greffon.

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

BACKGROUND: Peritoneal dialysis (PD) management is a fundamental nephrology skill, especially with the recent emphasis on home dialysis. We report a prospective multicentre cohort study of a formative objective structured clinical examination (OSCE) assessing competence in managing PD-associated bacterial peritonitis, using the unified model of construct validity. METHODS: The OSCE was developed by the principal investigators and reviewed by two subject matter experts. The test committee (eight nephrologists and one PD nurse) assessed test item difficulty/relevance and determined passing score. There were 22 test items (7 evidence-based/standard-of-care questions). Passing score was 16/22 (73%). No item had median relevance less than 'important', and all were easy to medium difficulty. Content validity index was 0.91. Preliminary validation (16 board-certified volunteers): mean score was 19 ± 2, with 94% (15/16) passing. Kappa = 0.85 [95% confidence interval (CI) 0.77-0.94]. Cronbach's α = 0.70. RESULTS: Eighty-seven fellows (16 programmes) were tested; 67% passed. Fellows scored significantly less than validators: 17 ± 3 versus 19 ± 2, p < 0.001 [95% CI 1.2-3.6]. Eighty-six per cent of evidence-based/standard-of-care questions were answered correctly by validators versus 54% by fellows; p < 0.001. Ninety-three per cent of fellows recognized that sufficient criteria were present to diagnose peritonitis, but only 17% correctly indicated all three. Seventy-seven per cent recognized peritonitis-associated ultrafiltration failure, but only 17% prescribed 21 days of antibiotic treatment for gram-negative peritonitis. Eighty-five per cent of fellows surveyed agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Second-year in-training examination and OSCE scores were positively correlated (Pearson's r = 0.57, p < 0.00). CONCLUSIONS: The OSCE may be used to formatively assess fellow proficiency in managing PD-associated peritonitis.

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

BACKGROUND: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). SUMMARY: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

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

RATIONALE & OBJECTIVE: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. STUDY DESIGN: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. SETTING & PARTICIPANTS: 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018. PREDICTORS: Fellowship training year and clinical scenario. OUTCOME: Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). ANALYTICAL APPROACH: Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. RESULTS: Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. LIMITATIONS: Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. CONCLUSIONS: The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

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

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

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

BACKGROUND AND OBJECTIVES: An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons. RESULTS: Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias. CONCLUSIONS: Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

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

BACKGROUND AND OBJECTIVES: Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey. RESULTS: A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3-4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing "proficiency in ordering" acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format. CONCLUSIONS: The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_08_CJASNPodcast_19_09_.mp3.

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

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