New research was virtually presented at NKF 2020, the Spring Clinical Meetings of the National Kidney Foundation, from March 26-29. The features below highlight some of the studies that emerged from the virtual conference.
Effects of Multidisciplinary Anemia Management in PD
Evidence suggests that traditional anemia management has limited success in peritoneal dialysis (PD) patients—when compared with hemodialysis patients—due to physicians’ limited time and interaction with these patients. For a study, researchers transferred anemia management in PD to a multidisciplinary team led by a trained PD nurse and analyzed the impact of this new model in achieving anemia targets. Data analyses were conducted on adult patients on chronic PD for more than 1 month. At 1 year after implementing the multidisciplinary team model, patients with monthly office visits and measured hemoglobin (Hg) improved from 73% to 83%; patients requiring monthly Hg recheck decreased from 30% to 17%; patients in the target Hg ranged (10-12g/dL) improved from 52% to 68%; extreme Hg (<9 or >13g/dL) rates improved from 13% to 8%, rates of noncompliance with monthly visits and erythropoietin stimulating agents reduced from 20% to 10%; and erythropoietin stimulating agent doses were reduced an average 6%, with an estimated annual cost savings of $30,000.
Post-Hemodialysis BP & Mortality Risk
With a lack of robust guidelines addressing patients on dialysis, blood pressure (BP) targets I this patient population tend to be derived from the non-hemodialysis population, data indicate. To determine if achieving a normal post-dialysis BP is associated with better survival than not achieving this target, study investigators analyzed demographic data, comorbidities, and dialysis dates from the records of 855 incident hemodialysis patients. After adjusting for age, weight, diabetes, hemodialysis treatment adequacy, and ultrafiltration rate (UFR), the team found that a post-dialysis mean arterial pressure (MAP) of 107 mm Hg or less was associated with a significant increase in mortality risk (hazard ratio, 1.53) and a greater rate of severe hypotension risk (5.4% vs 1.5%) when compared with a higher MAP. Patients in this category were older (60 vs 57 years) but had similar UF, UFR, diabetes prevalence, and congestive heart failure rates when compared with those with higher post-dialysis MAP.
Structured Transition Management & Outcomes in Patients Initiating Dialysis
Research suggests that timely receipt of transplant and modality education, as well as referral for arteriovenous fistula creation, may result in improved outcomes following dialysis initiation among patients with chronic kidney disease who are approaching the transition to dialysis. For a study, researchers assessed the impact on patient outcomes during the first year on dialysis of a transition management process that provides practice management services to physicians and includes a structured process for managing the transition to dialysis. When compared with patients not treated by physicians enrolled in the process (controls), those who initiated dialysis having received pre-dialysis care from a physician enrolled in the process (intervention group) had higher rates of peritoneal dialysis at the time of dialysis initiation (15.6% vs 8.4%) and through day 90 (18.9% vs 11.9%). Among hemodialysis patients, 90-day permanent vascular access use rates were higher among the intervention group (54.8% vs 42.5%). Mortality risk was also lower for the intervention group than for controls (hazard ratio, 0.35).
Delaying CKD Progression
Previous studies indicate that albuminuria/proteinuria measurements appear to be suboptimal among patients with CKD risk factors. Other research suggests that angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) use in CKD stage 1-4 also appears to be suboptimal. In an effort to prevent of delay end stage renal disease (ESRD), researchers developed a methodology for screening patients for proteinuria and accurately staging their CKD. The percentage of CKD 1-4 patients screened for albuminuria or proteinuria increased from 67.6% prior to implementing the methodology to 71.7% nearly 2 years after. The percentage of CKD 1-4 patients with hypertension and albuminuria/proteinuria on ACE-I or ARB has remained at 87% for the 2 years since implementation, a rate more than double that reported for the United States.
Reducing CVC Use
Despite evidence suggesting it to be the least preferred dialysis access type, due to increased infection rates, hospitalizations, and mortality rates, data indicate that central venous catheters (CVCs) are started in 80% of new dialysis patients. To help reduce CVC use, a regional independent provider of out-patient hemodialysis services established a multidisciplinary team approach to assist with creation/placement of dialysis vascular accesses and the reduction in the prevalence and length of time CVCs are in place; developed an evidence-based monitoring & surveillance algorithm for early detection of vascular access pending failure or lack of maturation; and developed a patient-centered & patient outcomes driven care process to provide the most appropriate vascular access for patients. The combination of interventions helped reduce CVC prevalence rates from 30%-40% to 16%; surgery to access maturation from 128 to 91 days (below the national average of 111 days); primary and secondary arteriovenous fistula fail rates from 12% to 0%; consult to surgery from 60 days to 34 days; and referral to consult from 28 days to 13 days.