In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and lar...In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures...The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures patient success further engaging more patients. The initial planning regarding the surrounding patient population, stakeholders, economics, and physical location is essential. The services offered including modality education and different kinds of HHD modalities depend on local expertise and economics. The program should fulfill conditions for coverage requirements for personnel, physical infrastructure, and quality metrics to begin operations. The patient recruitment is facilitated by a patient-centric modality education program developed by the multidisciplinary team. If the patient is interested, a training schedule should be discussed with the patient and caregiver. A system to ensure remote patient monitoring, respite care, and 24 hours on-call availability should be established. These practical considerations ensure initial success and future growth of the program.
Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on detail...Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.
The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there...The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.
The Advancing American Kidney Health Initiative places financial incentives largely aimed at nephrologists and dialysis providers, but including other health care providers, in an attempt to improve clinical outcomes and...The Advancing American Kidney Health Initiative places financial incentives largely aimed at nephrologists and dialysis providers, but including other health care providers, in an attempt to improve clinical outcomes and lower costs in the chronic kidney disease population. Both peritoneal and home hemodialysis utilization will need to be markedly increased to achieve these policy goals. This article looks at some of the concerns that may stand in the way of achieving those goals.
Acute kidney injury continues to be a highly occurring disease in the intensive care unit, specifically affecting up to a third of critically ill neonates as per various studies. Although first-line treatments of acute k...Acute kidney injury continues to be a highly occurring disease in the intensive care unit, specifically affecting up to a third of critically ill neonates as per various studies. Although first-line treatments of acute kidney injury are noninvasive, kidney replacement therapy (KRT) is indicated when conservative management modes fail. There are various modalities of KRT which can be used for neonatal populations, including peritoneal dialysis, hemodialysis, and continuous KRT. However, these KRT modalities present their own challenges in this specific patient population Thus, it is the aim of this review to introduce each of these KRT modalities in terms of their challenges, advances, and future directions, with specific emphasis on new technology including the Cardio-Renal Pediatric Emergency Dialysis Machine, Newcastle infant dialysis and ultrafiltration system, and the Aquadex system for ultrafiltration.
The use of point-of-care ultrasound (POCUS) is rapidly increasing in nephrology. It provides the opportunity to obtain complementary information that is more accurate than the classic physical examination. One can quickl...The use of point-of-care ultrasound (POCUS) is rapidly increasing in nephrology. It provides the opportunity to obtain complementary information that is more accurate than the classic physical examination. One can quickly follow the physical examination with a systematic POCUS evaluation of the kidneys, ureter bladder, inferior vena cava, heart, and lungs, which can provide diagnostic information and an accurate assessment of the patient's hemodynamics and volume status. Moreover, because it is safe and relatively easy to perform, it can be performed in a repeated manner as often as necessary so that the physician can reassess the patient's hemodynamics and volume status and adjust their therapy accordingly, permitting a more personalized approach to patient care (rather than blindly following protocols), especially to patients in acute care nephrology. Despite these advantages, nephrologists have been slow to adopt this diagnostic modality, perhaps because of lack of expertise. This review will provide an overview of the most commonly used POCUS examinations performed by nephrologists in the acute care setting. Its aim is to spark interest in in POCUS and to lay the foundation for readers to pursue more advanced training so that POCUS becomes a readily available tool in your diagnostic arsenal.
Adv Chronic Kidney Dis
· 2021 Jan · PMID 34389139
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Artificial intelligence (AI) is the development of computer systems that normally require human intelligence. In the field of acute kidney injury (AKI) AI has led to an evolution of risk prediction models. In the past, s...Artificial intelligence (AI) is the development of computer systems that normally require human intelligence. In the field of acute kidney injury (AKI) AI has led to an evolution of risk prediction models. In the past, static prediction models were developed using baseline (eg, preoperative) data to evaluate AKI risk. Newer models which incorporated baseline as well as evolving data collected during a hospital admission have shown improved predicative abilities. In this review, we will summarize the advances made in AKI risk prediction over the last several years, including a shift toward more dynamic, real-time, electronic medical record-based models. In addition, we will be discussing the role of electronic AKI alerts and decision support tools. Recent studies have demonstrated improved patient outcomes through the use of these tools which monitor for nephrotoxin medication exposures as well as provide kidney focused care bundles for patients at high risk for severe AKI. Finally, we will briefly discuss the pitfalls and implications of implementing these scores, alerts, and support tools.
Therapeutic plasma exchange (TPE) is frequently the most common Apheresis Medicine technique used for extracorporeal therapy of a wide variety of renal, neurological, hematological, and other clinical indications. Many o...Therapeutic plasma exchange (TPE) is frequently the most common Apheresis Medicine technique used for extracorporeal therapy of a wide variety of renal, neurological, hematological, and other clinical indications. Many of these clinical indications require intensive care during critical illness. Conventional TPE uses one of two main technical methods to achieve the goal of removing known disease mediators from the plasma: using centrifugal forces to separate and remove components of blood, or a membrane filtration method that separates plasma from the cellular components of blood. The following review discusses the basic principles of TPE, the technological aspects, and relevant clinical scenarios encountered in the intensive care unit, including relevant guidelines and recommendations from the American Society for Apheresis.
Severe liver failure, including acute liver failure and acute-on-chronic liver failure, is associated with high mortality, and many patients die despite aggressive medical therapy. While liver transplantation is a viable...Severe liver failure, including acute liver failure and acute-on-chronic liver failure, is associated with high mortality, and many patients die despite aggressive medical therapy. While liver transplantation is a viable treatment option for liver failure patients, a large proportion of these patients die given the shortage in the liver donation and the severity of illness, leading to death while waiting for a liver transplant. Extracorporeal liver support devices, including molecular adsorbent recirculating system (MARS), have been developed as bridge to transplantation (bridge for patients who are decompensating while waiting for liver transplantation) and bridge to recovery (for whom recovery is deemed reasonable). In addition to its uses in acute liver failure and acute-on-chronic liver failure, the MARS system has also been applied in various clinical settings, such as drug overdosing and poisoning and intractable cholestatic pruritus refractory to pharmacological treatment. This review aims to discuss the controversies, potential benefits, practicalities, and disadvantages of using MARS in clinical practice.
Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failur...Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failure. Kidney dysfunction, if present, makes candidate selection for LVADs challenging and contributes to multiple complications while the patients are on an LVAD support. Although kidney function generally improves after LVAD implantation, some patients develop acute and then chronic kidney disease sometimes requiring kidney replacement therapies (KRTs). Overall, chronic KRT in LVAD recipients is feasible and well tolerated, but routine technique of blood pressure monitoring should be adjusted to the continuous blood flow. Both hemodialysis and peritoneal dialysis can be used. Unique challenges for chronic KRT posed by the presence of LVAD are discussed in this review.
Continuous kidney replacement therapy (CKRT) has improved remarkably since its first implementation as continuous arteriovenous hemofiltration in the 1970s. However, when looking at the latest generation of CKRT machines...Continuous kidney replacement therapy (CKRT) has improved remarkably since its first implementation as continuous arteriovenous hemofiltration in the 1970s. However, when looking at the latest generation of CKRT machines, one could argue that clinical deployment of breakthrough innovations by device manufacturers has slowed in the last decade. Simultaneously, there has been a steady accumulation of clinical knowledge using CKRT as well as a multitude of therapeutic and diagnostic innovations in the dialysis and broader intensive care unit technology fields adaptable to CKRT. These include multiple different anticlotting measures; cloud-computing for optimized treatment prescribing and delivered therapy data collection and analysis; novel blood purification techniques aimed at improving the severe multiorgan dysfunction syndrome; and real-time sensing of blood and/or filter effluent composition. The authors present a view of how CKRT devices and programs could be reimagined incorporating these innovations to achieve specific measurable clinical outcomes with personalized care and improved simplicity, safety, and efficacy of CKRT therapy.
The number of patients using critical care is increasing as our populations live longer thanks to advances in medical therapies. This is reflected by an increase in both usage and number of critical care beds as compared...The number of patients using critical care is increasing as our populations live longer thanks to advances in medical therapies. This is reflected by an increase in both usage and number of critical care beds as compared with total hospital beds across the United States. As this aging population suffers more and more from multiorgan dysfunction, including but not limited to respiratory failure, cardiac failure, and acute kidney injury, technologies are used to facilitate recovery in those that would have assuredly passed away years ago. Some of these advancements include extracorporeal membrane oxygenation and continuous kidney replacement therapy. In this article, we review the literature regarding the history, technology, indications, and outcomes of synchronous extracorporeal membrane oxygenation and kidney replacement therapy.
Accurate assessment of intravascular volume status in critically ill patients remains a very challenging task. Recent data have shown adverse outcomes in critically ill patients with either inadequate or overaggressive f...Accurate assessment of intravascular volume status in critically ill patients remains a very challenging task. Recent data have shown adverse outcomes in critically ill patients with either inadequate or overaggressive fluid therapy. Understanding the tools and techniques available for accurate volume assessment is imperative. This article discusses the concept of fluid responsiveness and reviews methods for assessing fluid responsiveness in critically ill patients.
Continuous kidney replacement therapy is commonly used in the critically ill population. Despite the recent development in continuous kidney replacement therapy technology and clinical informatics, many aspects of contin...Continuous kidney replacement therapy is commonly used in the critically ill population. Despite the recent development in continuous kidney replacement therapy technology and clinical informatics, many aspects of continuous kidney replacement therapy delivery are still not fully standardized, and quality assurance programs for the provision of continuous kidney replacement therapy are not fully developed. This is in part explained by practice variations, suboptimal integration between machine and clinical data, and the lack of validated continuous kidney replacement therapy quality indicators that are feasible for measurement and monitoring. The further development and sustainable implementation of quality assurance systems that support continuous kidney replacement therapy delivery rely on the collaborative work of the critical care nephrology community and the continuous evolution of clinical informatics. In this article, we describe the present status of information technology and quality assurance systems for continuous kidney replacement therapy delivery and provide a framework for technology development and implementation which is in the pipeline of enhanced continuous kidney replacement therapy delivery.
Acute kidney injury (AKI) is a common complication of critical illness and is associated with adverse short- and long-term health consequences. Survivors of critical illness and AKI experience poor kidney, cardiovascular...Acute kidney injury (AKI) is a common complication of critical illness and is associated with adverse short- and long-term health consequences. Survivors of critical illness and AKI experience poor kidney, cardiovascular and quality of life outcomes, along with increased mortality. Yet, many patients surviving AKI are unaware that there is a problem with their kidney health, and post-AKI nephrology follow-up occurs at very low rates. Although there is a paucity of evidence-based studies to guide post-AKI care, attention to risk factors such as hypertension and albuminuria are requisite. There are several ongoing or planned studies which are expected to help inform specific management in the future. Until then, a multidisciplinary approach is warranted to address areas such as quality of life, physical rehabilitation, dietary modifications, and medication reconciliation.
Preeclampsia is a multisystem progressive disorder of pregnancy that can be potentially catastrophic for the mother and the fetus. It involves complex perturbations of the kidney and systemic physiology, along with long-...Preeclampsia is a multisystem progressive disorder of pregnancy that can be potentially catastrophic for the mother and the fetus. It involves complex perturbations of the kidney and systemic physiology, along with long-term effects on vascular and kidney health. Thus, the nephrologist plays a key role in the peripartum and long-term management of preeclampsia. Recent translational research has improved our understanding of its pathophysiology, and there is hope for novel therapies. In this review, we discuss the evolution of diagnostic criteria and dilemmas in the diagnosis of hypertensive disorders in pregnancy. We summarize the advances in the pathogenesis and prediction of preeclampsia. We describe the management and prevention of preeclampsia focusing specially on the forthcoming strategies from the nephrologist's perspective. We address the evidence regarding long-term outcomes for the mother and the child. We end with exploring areas warranting future research.