Considerations for a Primary Care Physician Assistant in Treating Kidney Transplant Recipients.

The escalating amount of kidney transplant recipients (KTRs) represents a significant dilemma for primary care providers. As the number of physician assistants (PAs) has been steadily increasing in primary care in the United States, the utilization of these healthcare professionals presents a solution for the care of post-kidney transplant recipients. A physician assistant (PA) is a state licensed healthcare professional who practices medicine under physician supervision and can alleviate some of the increasing demands for primary patient care. Here we provide an outline of the crucial components and considerations for PAs caring for kidney transplant recipients. These include renal function and routine screenings, drug monitoring (both immunosuppressive and therapeutic), pre-existing and co-existing conditions, immunizations, nutrition, physical activity, infection, cancer, and the patient's emotional well-being. PAs should routinely monitor renal function and blood chemistry of KTRs. Drug monitoring of KTRs is a crucial responsibility of the PA because of the possible side-effects and potential drug-drug interactions. Therefore, PAs should obtain a careful and detailed patient history from KTRs. PAs should be aware of pre- and co-existing conditions of KTRs as this impacts treatment decisions. Regarding immunization, PAs should avoid administering vaccines containing live or attenuated viruses to KTRs. Because obesity following kidney transplantation is associated with decreased allograft survival, PAs should encourage KTRs to maintain a balanced diet with limited sugar. In addition, KTRs should be urged to gradually increase their levels of physical activity over subsequent years following surgery. PAs should be aware that immunosuppressive medications diminish immune defenses and make KTRs more susceptible to bacterial, viral, and fungal infections. Moreover, KTRs should be screened routinely for cancer due to the higher risk of development from immunosuppressive therapy. PAs must remain cognizant of the emotional well-being of the KTR, as many transplant patients struggle with fear, frustration, and acceptance.

Geriatric nephrology: a paradigm shift in the approach to renal replacement therapy.

The population of elderly individuals diagnosed with CKD continues to grow. Many have multiple comorbid conditions that will impact life expectancy as well as decisions about whether to pursue renal replacement therapy. Nephrologists are uniquely positioned to assist their patients and caregivers in this regard and spend considerable time counseling them about the benefits and risks associated with dialysis therapy. This article presents an overview of many of the issues facing nephrologists, and provides tools to assist busy clinicians in helping their elderly patients in deciding whether to consider dialysis or intensive, nondialysis care.

Medicare reimbursement policies and hemodialysis vascular access outcomes: a need for change.

In March 2010, the Center for Medicare and Medicaid Services (CMS) convened several clinical technical expert panels (C-TEP) to provide recommendations for improving various aspects of hemodialysis management. One of the C-TEPs was tasked with recommending measures to decrease vascular access-related infections. The members of this C-TEP, who are the authors of this manuscript, concluded unanimously that the single most important measure would be to remove financial and regulatory barriers to timely placement and revision of hemodialysis fistulas and the concurrent avoidance of catheter use. The following position paper outlines the financial barriers to improved vascular access outcomes and our proposals for a future CMS demonstration project.

Chronic kidney disease: the new epidemic and its impact on West Virginia.

The prevalence and incidence of chronic kidney disease (CKD) is growing at an alarming rate. Estimates suggest that CKD affects an estimated 13 percent of Americans, and West Virginia leads the way, with the highest per capita rate in the country of patients with kidney failure starting dialysis. There is a great lack of awareness about the risks of CKD among the general population, many of whom are unaware of their risk status or even the presence of CKD. The increasingly older, diabetic and obese populations likely account for the high prevalence of advanced CKD in West Virginia, as well as the fact that a large percentage of the state's population lives 2-3 hours' distance from specialized care. Additionally, there are relatively few physicians in West Virginia specifically trained to treat the growing numbers of patients with kidney disease, which is usually silent until well past the time when medical intervention can be successful in reversing or slowing the rate of progression to kidney failure. Worse, even in its early stages, kidney disease poses significant cardiovascular risk; indeed, individuals with advanced CKD are more likely to die of cardiovascular disease than live long enough to need kidney replacement therapy.

Practice recommendations for the use of L-carnitine in dialysis-related carnitine disorder. National Kidney Foundation Carnitine Consensus Conference.

References are not cited within this report. However, they are included in the supplement to this issue of the American Journal of Kidney Diseases, which contains reports regarding each topic that was considered by the panel. These recommendations are not intended to be guidelines or standards of care. Instead, they have been developed to provide the best available information and expert opinion in decision-making for the clinician. The recommendations should not be considered as prescribing an exclusive course of management.

Hemodialysis in the elderly: vascular access and initiation of renal replacement therapy.

Elderly persons with kidney failure are faced with many important considerations. Factors contributing to the choice of vascular access are often related to issues that also affect the timing of initiation of dialysis. This article provides guidance in determining when elderly patients are likely to develop an increased risk for complications of chronic kidney failure and comorbid conditions, and should therefore assist clinicians in selecting optimal vascular access and in deciding when to advise patients to begin dialysis.