Current Trends and Challenges in Nephrology Fellowship Training: Expansion of Education in Home Dialysis, Palliative Care, and Point-of-Care Ultrasound.

Nephrology education has changed significantly since the first nephrology fellowship programs were established in the United States in the 1950s and 1960s. The past several years have seen increased opportunities for subspecialization in areas such as interventional nephrology, onconephrology, and glomerular disease. Notable trends in fellowship curricula include the expansion of education in home dialysis and palliative care, driven by policy changes and focus on patient-centered care. In addition, point-of-care ultrasound has garnered significant interest due to its potential to provide diagnostic information that improves patient care. An important area that remains largely unaddressed appears to be education about the business and administrative aspects of nephrology. Meanwhile, the importance of training in hemodialysis catheter placement and kidney biopsy has come into question due to the small proportion of nephrologists performing these procedures today. Nephrology fellowship programs should strive to tailor their curriculum to meet the interests and needs of individual fellows.

The expanding role of primary care providers in care of individuals with kidney disease.

An estimated 37 million Americans have chronic kidney disease (CKD). Primary care providers (PCPs) have long played a critical role in detecting CKD and preventing disease progression, particularly in the early stages of the disease. With recent studies demonstrating substantial improvements in kidney outcomes with use of sodium glucose cotransporter 2 (SGLT2) inhibitors, PCPs have an even greater opportunity to improve care of individuals with CKD. Health disparities in nephrology have recently come to the forefront - again, PCPs will play a key role in efforts to reduce such disparities and ensure all patients receive high quality care. This review summarizes the latest guidelines for treatment of CKD and its complications, explores health disparities affecting patients with CKD, and highlights the role of the PCP in caring for this population.

Kidney Disease Symptoms before and after Kidney Transplantation.

BACKGROUND AND OBJECTIVES: Patients with kidney failure report a high symptom burden, which likely increases while on dialysis due to physical and mental stressors and decreases after kidney transplantation due to restoration of kidney function. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We leveraged a two-center prospective study of 1298 kidney transplant candidates and 521 recipients (May 2014 to March 2020). Symptom scores (0-100) at evaluation and admission for transplantation were calculated using the Kidney Disease Quality of Life Short-Form Survey, where lower scores represent greater burden, and burden was categorized as very high: 0.0-71.0; high: 71.1-81.0; medium: 81.1-91.0; and low: 91.1-100.0. We estimated adjusted waitlist mortality risk (competing risks regression), change in symptoms between evaluation and transplantation (n=190), and post-transplantation symptom score trajectories (mixed effects models). RESULTS: At evaluation, candidates reported being moderately to extremely bothered by fatigue (32%), xeroderma (27%), muscle soreness (26%), and pruritus (25%); 16% reported high and 21% reported very high symptom burden. Candidates with very high symptom burden were at greater waitlist mortality risk (adjusted subdistribution hazard ratio, 1.67; 95% confidence interval, 1.06 to 2.62). By transplantation, 34% experienced an increased symptom burden, whereas 42% remained unchanged. The estimated overall symptom score was 82.3 points at transplantation and 90.6 points at 3 months (10% improvement); the score increased 2.75 points per month (95% confidence interval, 2.38 to 3.13) from 0 to 3 months, and plateaued (-0.06 points per month; 95% confidence interval, -0.30 to 0.18) from 3 to 12 months post-transplantation. There were early (first 3 months) improvements in nine of 11 symptoms; pruritus (23% improvement) and fatigue (21% improvement) had the greatest improvements. CONCLUSIONS: Among candidates, very high symptom burden was associated with waitlist mortality, but for those surviving and undergoing kidney transplantation, symptoms improved.

Hemodialysis Emergencies: Core Curriculum 2021.

Since maintenance hemodialysis (HD) first became available in the United States in 1962, there has been tremendous growth in the population of patients with kidney failure. HD has become a routine treatment carried out in outpatient clinics, hospitals, nursing facilities, and in patients' homes. Although it is a complex procedure, HD is quite safe. Serious complications are uncommon due to the use of modern HD machines and water treatment systems as well as the development of strict protocols to monitor various aspects of the HD treatment. The practicing nephrologist must be knowledgeable about life-threatening complications that can occur during HD and be able to recognize, manage, and prevent them. This installment in the AJKD Core Curriculum in Nephrology reviews the pathogenesis, management, and prevention of 9 HD emergencies. The HD emergencies covered include dialyzer reactions, dialysis disequilibrium syndrome, uremic/dialysis-associated pericarditis, air embolism, venous needle dislodgement, vascular access hemorrhage, hemolysis, dialysis water contamination, and arrhythmia episodes.

Urgent start peritoneal dialysis: are we there yet?

The use of peritoneal dialysis (PD) has increased substantially in the United States (US) in the past decade. This was likely spurred in large part by the implementation of the expanded prospective payment system for the Medicare End Stage Renal Disease (ESRD) program in 2011. Over the same period, there has also been growing interest in urgent start PD, which is commonly defined as initiation of PD within 14 days of catheter insertion. Ye and colleagues recently reported their experience with urgent start PD in 2059 Chinese ESRD patients over a 9-year period. Rates of complications, including peri-catheter leaks and peritonitis, were very low despite initiation of PD immediately after open catheter placement via open laparotomy in nearly all patients. Long term technique survival was good, with only 75 patients developing catheter failure. This study provides further evidence to suggest that urgent start PD is feasible and effective, although the generalizability of these results to Western populations is unclear. Recent proposed changes to the payment models in the Medicare ESRD program, designed to incentivize use of kidney transplantation and home dialysis, are likely to further propel growth of PD and urgent start PD in the US. Further studies are needed to optimize use of urgent PD and patient outcomes.

HIV and HCV Medications in End-Stage Renal Disease.

Human immunodeficiency virus (HIV) infection and hepatitis C virus (HCV) infection affect populations worldwide. With the availability of over 35 Food and Drug Administration approved medications for treatment of HIV, the morbidity and mortality associated with HIV has greatly improved. On the other hand, treatment options for HCV have been limited until very recently. While the use of protease inhibitors (such as boceprevir and telaprevir) has become standard of care for treatment of hepatitis C in the general population, data for individuals with impaired kidney function, particularly those on dialysis, are extremely limited. Use of medications in dialysis patients can be challenging given the dose adjustments that must be made for renally cleared molecules, and potentially increased impact of adverse effects such as anemia. Recommendations for dosing of marketed therapies for HIV and HCV are reviewed.

Plasma Urate and Risk of a Hospital Stay with AKI: The Atherosclerosis Risk in Communities Study.

BACKGROUND AND OBJECTIVES: Higher urate levels are associated with higher risk of CKD, but the association between urate and AKI is less established. This study evaluated the risk of hospitalized AKI associated with urate concentrations in a large population-based cohort. To explore whether urate itself causes kidney injury, the study also evaluated the relationship between a genetic urate score and AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A total of 11,011 participants from the Atherosclerosis Risk in Communities study were followed from 1996-1998 (baseline) to 2010. The association between baseline plasma urate and risk of hospitalized AKI, adjusted for known AKI risk factors, was determined using Cox regression. Interactions of urate with gout and CKD were tested. Mendelian randomization was performed using a published genetic urate score among the participants with genetic data (n=7553). RESULTS: During 12 years of follow-up, 823 participants were hospitalized with AKI. Overall, mean participant age was 63.3 years, mean eGFR was 86.3 ml/min per 1.73 m(2), and mean plasma urate was 5.6 mg/dl. In patients with plasma urate >5.0 mg/dl, there was a 16% higher risk of hospitalized AKI for each 1-mg/dl higher urate (adjusted hazard ratio, 1.16; 95% confidence interval, 1.10 to 1.23; P<0.001). When stratified by history of gout, the association between higher urate and AKI was significant only in participants without a history of gout (P for interaction=0.02). There was no interaction of CKD and urate with AKI, nor was there an association between genetic urate score and AKI. CONCLUSIONS: Plasma urate >5.0 mg/dl was independently associated with risk of hospitalized AKI; however, Mendelian randomization did not provide evidence for a causal role of urate in AKI. Further research is needed to determine whether lowering plasma urate might reduce AKI risk.