The Large Kidney Care Organizations' Experience With the New Kidney Models.

Three years ago, the Advancing American Kidney Health executive order launched a substantial effort with the goals of delaying the progression of kidney disease while also increasing kidney transplantation and the utilization of home dialysis. Included among the initiatives created by this executive order are two new payment models under the supervision of the Centers for Medicare & Medicaid Services Innovation Center. The End Stage Renal Disease Treatment Choices model is a mandatory payment model impacting nephrologists and dialysis providers in many regions across the country. The Kidney Care Choices model offers nephrologists four voluntary options for participation in value-based care. The early experience of two large kidney care organizations highlights the improvements these payment models have demonstrated over prior kidney care payment models while also suggesting additional opportunities for improvement. These models offer nephrologists the opportunity to partner with other providers and deliver patient-centered care across the kidney care continuum. The models represent another step toward value-based care and, if successful, should yield great benefits for patients with kidney disease.

Comparative Effectiveness of mRNA-based BNT162b2 Vaccine versus Adenovirus Vector-Based Ad26.COV2.S Vaccine for the Prevention of COVID-19 among Dialysis Patients.

BACKGROUND: Studies have demonstrated that mRNA-based SARS-CoV-2 vaccines are highly effective among patients on dialysis. Because individual vaccines may be differentially available or acceptable to patients, it is important to understand comparative effectiveness relative to other vaccines, such those on the basis of adenovirus technologies. METHODS: In this retrospective study, we compared the clinical effectiveness of adenovirus vector-based Ad26.COV2.S (Janssen/Johnson & Johnson) to mRNA-based BNT162b2 (Pfizer/BioNTech) in a contemporary cohort of patients on dialysis. Patients who received a first BNT162b2 dose were matched 1:1 to Ad26.COV2.S recipients on the basis of date of first vaccine receipt, US state of residence, site of dialysis care (in-center versus home), history of COVID-19, and propensity score. The primary outcome was the comparative rate of COVID-19 diagnoses starting in the 7th week postvaccination. In a subset of consented patients who received Ad26.COV2.S, blood samples were collected ≥28 days after vaccination and anti-SARS-CoV-2 immunoglobulin G antibodies were measured. RESULTS: A total of 2572 matched pairs of patients qualified for analysis. Cumulative incidence rates of COVID-19 did not differ for BNT162b2 versus Ad26.COV2.S. No differences were observed in peri-COVID-19 hospitalizations and deaths among patients receiving BNT162b2 versus Ad26.COV2.S, who were diagnosed with COVID-19 during the at-risk period. Results were similar when excluding patients with a history of COVID-19, in subgroup analyses restricted to patients who completed the two-dose BNT162b2 regimen, and in patients receiving in-center hemodialysis. SARS-CoV-2 antibodies were detected in 59.4% of 244 patients who received Ad26.COV2.S. CONCLUSIONS: In a large real-world cohort of patients on dialysis, no difference was detected in clinical effectiveness of BNT162b2 and Ad26.COV2.S over the first 6 months postvaccination, despite an inconsistent antibody response to the latter.

Hemolysis as Cause of Hemodialysis Blood Leak Alarm: Case Study of a Patient with Freshwater Near-Drowning.

Hemolysis may be an infrequent cause of hemodialysis blood leak alarms. We report the case of an unresponsive adult male who was placed on hemodialysis with a high-flux dialyzer. Within five minutes, the blood leak alarm sounded. The care team discontinued treatment and made two additional attempts to reinitiate hemodialysis with different machines, blood tubing lots, and brands of high-flux dialyzers, but continued to receive blood leak alarms. Laboratory studies were consistent with severe hemolysis. The attending nephrologist subsequently ordered continuous veno-venous hemofiltration, which was initiated and continued into the following day without incident or alarm. The patient later expired from complications of near-drowning. In the event of significant hemolysis, continuous kidney replacement therapy or hemodialysis with a low-flux dialyzer, and a lower ultrafiltration rate may be indicated.

A Hospital-Based Program to Reduce Central Line-Associated Bloodstream Infections among Hospitalized Patients Receiving Hemodialysis Using a Central Venous Catheter for Vascular Access.

Central venous catheter (CVC) vascular access is common among patients on hemodialysis. CVC use carries a substantial risk of central line-associated bloodstream infections (CLABSIs), costly events that place patients at a high risk of mortality. Our hospital and dialysis organization developed a cooperative strategy to reduce the rate of CLABSI among hospitalized patients on hemodialysis with a CVC. The program included the use of training and reporting tools to guide hospital staff with CLABSI prevention, as well as leadership committees to oversee the process. Fourteen CLABSIs were reported in the 17-month period prior to the implementation of the program, while no new CLABSIs occurred in the 30 months following implementation of the program. This prevention program effectively reduced the frequency of CLABSIs. Broader implementation of such programs may result in better outcomes and lower costs for hospitalized patients on hemodialysis.

Lower risk of urinary tract infection with low-dose trimethoprim/sulfamethoxazole compared to dapsone prophylaxis in older renal transplant patients on a rapid steroid-withdrawal immunosuppression regimen.

BACKGROUND: Urinary tract infections (UTI) are common in renal transplant recipients. Trimethoprim/sulfamethoxazole (TMP/SMZ) in moderate to high daily doses prevents Pneumocystis jiroveci (PCP) and reduces the risk of UTI in renal transplant patients. Low-dose TMP/SMZ also reduces the risk of PCP, although its ability to reduce the risk of UTI is uncertain. DESIGN: Retrospective review of 158 patients who received a renal transplant without corticosteroids for maintenance immunosuppression. RESULTS: Forty percent of patients initially prescribed TMP/SMZ ultimately stopped this medication early because of an adverse reaction. Urinary infection occurred in 16% without a significant difference in the risk of UTI between those treated with dapsone vs. those treated with TMP/SMZ (HR [95%CI]: 1.7 [0.75, 3.9], p = 0.2). In the subset of patients who were older than age 47 yr (mean age for this cohort, SD ± 6.2 yr), those treated with dapsone originally or who switched from TMP/SMZ to dapsone had a greater risk of UTI compared to patients who remained on TMP/SMZ (HR [95%CI]: 4.3 [1.2, 15.5], p = 0.024). CONCLUSIONS: For renal transplant recipients over the age of 47 yr, treated without long-term glucocorticoids, our retrospective data suggest that low-dose TMP/SMZ is associated with a lower risk of UTI compared to dapsone prophylaxis.