Highlights from the July 2018 Issue

Editor’s Note: We asked authors of Original Investigations to provide short nontechnical summaries that would briefly summarize what inspired their study, the basic approach taken, what was learned, and why it matters. We hope our readers will find this valuable in helping them keep up with the latest research in the field of nephrology. From the July 2018 issue:

Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients by Mae Thamer et al [OPEN ACCESS]

From the authors: Previous studies have not examined the resources required to create and maintain a hemodialysis arteriovenous fistula (AVF) or how those resources vary with different AVF outcomes. We found that nearly half of all AVFs were not used for dialysis and the majority required additional procedures in the first year to keep them functioning. Compared to AVFs that did not require an intervention in the first year, vascular access costs per patient per year during the 2.5 years after AVF surgical creation were twice as high when an AVF required an intervention in the first year and four times as high when an AVF was never used. There is a need to improve AVF outcomes and reduce costs after AVF creation.

Editorial The Cost of Putting Fistula First by Jonathan H. Segal and Richard A. Hirth [FREE]

Residential Area Life Expectancy: Association With Outcomes and Processes of Care for Patients With ESRD in the United States by Jesse D. Schold et al

From the authors: There is wide variation in life expectancy in the United States based on residential location, thought to be a proxy for often unmeasured socioeconomic, environmental, genetic, and behavioral factors. The aim of this study was to evaluate the association of residential life expectancy with processes of care and health outcomes for patients with end-stage kidney disease (ESKD). The results indicate that patients with ESKD residing in communities with lower life expectancy have a reduced likelihood of important processes of care and decreased survival, independent of demographic characteristics and comorbid conditions. These findings illustrate that community-level measures of health are strongly and independently associated with patient outcomes.

Editorial Are County Codes More Indicative of Kidney Health Than Genetic Codes? by John W. Stanifer and Yoshio N. Hall [FREE]

A Randomized Trial of a Multicomponent Intervention to Promote Medication Adherence: The Teen Adherence in Kidney Transplant Effectiveness of Intervention Trial (TAKE-IT) by Bethany J. Foster et al [FREE]

From the authors: Poor adherence to immunosuppressive medications is a major cause of premature graft failure. Adolescents and young adults are at particularly high risk for poor adherence. We conducted a multicenter randomized clinical trial, in adolescent and young adult kidney transplant recipients, of an adherence-promoting intervention which included education, electronic adherence monitoring with feedback, text message dose reminders, identification of adherence barriers, problem-solving, and tailored action planning to address personal barriers. All participants met with a study coach every 3 months for 15 months; those assigned to intervention received all the above components while controls used the electronic monitor but received only general social support. Adherence was significantly better among patients who received the intervention than among controls. Better adherence is likely to lead to better graft survival.

Blog Post Promoting Medication Adherence Among Teen Kidney Transplant Recipients An audio interview with one of the authors, V.R. Dharnidharka [FREE]

Omega-3 Polyunsaturated Fatty Acid Supplementation to Prevent Arteriovenous Fistula and Graft Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials by Andrea K. Viecelli et al

From the authors: People who need hemodialysis for kidney failure require a surgically-created connection between their artery and vein (arteriovenous access) for a durable connection to the dialysis machine. This is challenging because newly-formed arteriovenous accesses often clot or fail to develop into a usable structure for dialysis. Patients require admissions to hospital, procedures, and central venous catheters while waiting for their access to become functional. Fish oil (omega-3 polyunsaturated fatty acids) supplements reduce clotting and assist with remodeling of blood vessels, but may cause bleeding. In this meta-analysis, fish oil probably protects dialysis patients from experiencing loss of blood flow through their access, but it remains uncertain whether fish oil improves dialysis access usability, reduces the need for additional procedures or hospital admissions, or is safe. Given that patients, caregivers, and health professionals consider vascular access to be critically important, additional trials to find healthcare interventions that improve access outcomes are needed.

Scope and Consistency of Outcomes Reported in Randomized Trials Conducted in Adults Receiving Hemodialysis: A Systematic Review by Bénédicte Sautenet et al

From the authors: What are the scope, quality, and consistency of outcomes domains and measures in hemodialysis trials? Across 362 randomized controlled trials in adults on chronic hemodialysis, 81 different outcomes domains and 10,713 outcomes measures were reported. The outcomes were predominantly focused on surrogate endpoints rather than on patient-centered outcomes, limiting the ability of trials to inform shared decision making. This study provides an empiric evidence of the extreme multiplicity and heterogeneity of the outcomes used in hemodialysis trials at every level – domain, measurement, threshold and time point, which highlights an urgent need to standardize outcome reporting in trials.

Pulmonary Hypertension, Mortality, and Cardiovascular Disease in CKD and ESRD Patients: A Systematic Review and Meta-analysis by Mengyao Tang et al

From the authors: Pulmonary hypertension (PH), abnormally high pressures in the blood vessels of the lung, is common among patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), and may be associated with worse outcomes. However, the magnitude of PH’s association with mortality is uncertain. We conducted a systematic review and meta-analysis of observational studies to summarize the impact of PH on clinical outcomes in patients with CKD and ESRD. Over 7,000 patients were included, with an overall PH prevalence of 23%. PH was associated with a substantially increased risk of death and cardiovascular illness in patients with CKD and ESRD. The risk was highest in ESRD patients on dialysis. More research is needed to determine if interventions to lower pulmonary artery pressure improve survival in these patients.

From the authors: C3 glomerulopathy is a type of kidney disease characterized by glomerular C3 deposits for which there is no well-established treatment. Small series and case reports have reported variable effects of the C5 blocker, eculizumab. We reviewed 26 cases of C3 glomerulopathy treated with eculizumab in France and Québec, Canada. The beneficial effect of eculizumab was most evident in patients with rapidly deteriorating kidney function and evidence of extensive inflammation on the kidney biopsy. The effect of eculizumab in cases without inflammation was more limited or absent.

Perspectives on Research Participation and Facilitation Among Dialysis Patients, Clinic Personnel, and Medical Providers: A Focus Group Study by Jennifer E. Flythe et al 

From the authors: Most studies involving individuals receiving maintenance dialysis have been small, and many have suffered from poor clinical translatability. Improved stakeholder engagement in research may enhance the relevance of clinical trials. Little is known about dialysis clinic stakeholder perspectives on research. We undertook this study to characterize the perspectives of dialysis clinic stakeholders (patients, clinic personnel and medical providers) on 1) research participation by patients and 2) research facilitation by clinic personnel and medical providers. We found stakeholder interest in participating in and facilitating research. However, we identified numerous individual, relationship, research operations and clinic barriers to stakeholder engagement in research including knowledge gaps, mistrust, competing personal and professional priorities, and disjoined clinical and research activities. Our findings suggest that creation of a research-ready dialysis clinic environment is feasible despite these barriers. Cultivation of a research knowledgeable atmosphere via stakeholder education and alignment of clinical and research activities may foster research-readiness.

International Medical Graduates in Nephrology: Roles, Rules, and Future Risks by Jeffrey S. Berns et al

Number of nephrology fellows who were graduates of US allopathic or osteopathic medical schools and international medical schools (US and non-US IMGs). Figure 1 from Berns et al, AJKD © National Kidney Foundation.

International medical graduates (IMGs) are physicians who, regardless of their citizenship, received their medical degrees from a medical school outside of the United States and Canada. Many come to the United States, often with postgraduate clinical training in their home country or elsewhere, for residency and fellowship training. IMGs without US citizenship (non-US IMG) have become an integral part of many residency and fellowship programs in the United States. They also contribute significantly to the US health care system as practicing physicians in virtually every state, constituting approximately a quarter of practicing physicians in the United States. As such, recent discussions of immigration restrictions and revisions to the H-1B visa program (which allows immigrants to work for a specific employer in the United States) have the potential to greatly affect graduate medical education (GME), trainees and the hospitals that train them, and patient care. Given the important role of non-US IMGs in nephrology, this Policy Forum Perspective reviews training, licensure, and visa issues relevant to these individuals and those involved in their training.

On the Cover: Teenagers on skateboards used to be an unwelcome sight in many neighborhoods, perhaps unfairly viewed as potential troublemakers and rabble-rousers. Nowadays, however, many cities have installed skateparks as part of their urban revitalization projects—skateboarding has gone from counterculture to an official Olympic sport in 2020. Skateboarders or not, teenagers often have their own unique way of processing the world around them, and physicians working with this population often seek ways to communicate with them more effectively. In this issue of AJKD, Bethany J. Foster et al report on an intervention to improve medication adherence among adolescent and young adult kidney transplant recipients, addressing a major cause of premature allograft failure, poor adherence to immunosuppressive medications.

The photograph “Skateboarder” is by Garry Knight, available under a CC BY 2.0 license.


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