August 2009 Member e–Newsletter

Membership Benefits

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This has been a busy summer for the CAP Listserv with more than 50 entries logged for several months. Topics have included calciphylaxis (with the sharing of some GREAT photos which should inspire patients to take their binders) to a survey of all we do in our practices.

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The CAP newsletter is for YOU!

Please send us comments and suggestions of what you would like to see included or expanded.  In the future, each issue will have a theme and we will be asking you, the members, to share your experiences and expertise.

Please contact
Jane Davis, CRNP
for any newsletter related correspondence.

Upcoming Events

American Kidney Fund Conference October 1
Baltimore, MD

American College of Nurse Practitioners National Clinical Conference
October 7-11
Albuquerque, NM.

ANNA Fall Meeting
October 9-11
Lake Buena Vista, FL

ASN Renal Week
October 27-November 1
San Diego

Spring Clinical Meetings 2010
April 13-17, 2010
Walt Disney Swan & Dolphin
Orlando, FL

Table of Contents

What’s New in Vascular Access?

Beth Adams, PA–C

The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access are published in Journal of Vascular Surgery, Volume 48, Issue 5, Supplement 1, November 2008, Pages S2–S25. A multispecialty panel assembled to develop practice guidelines in arteriovenous access placement and maintenance. This is recommended reading for not just those who place them but also for those who maintain them.

Fistula First: The nationwide rate for fistulas reached 51.9% in February 2009. A year-end goal was set at 66%, which means there is still much work to do. Read more about the initiative at www.fistulafirst.org

  • Until recently, there was a financial disincentive for the placement of AVFs over grafts, but the 2009 Relative Value Unit (RVU) adjustments corrected this. There is a 31% increase over 2008 rates for CPT Code 36821 making AVFs payment equivalent to that of AVGs – so reimbursement discrepancies are no longer an issue.
  • Clinical focus for 2009 Fistula First Initiative:
    • Secondary AVFs in AVG patients (i.e., conversion of an AVG outflow track (vein) to a direct AVF where feasible or an exam and vessel mapping for alternative AVF when outflow vein not suitable).
    • AVF evaluation and placement in catheter patients – evaluation, mapping and placement recommended during initial acute hospitalization. The focus is emphasizing breaking barriers to placement in CKD 4 patients.
    • Monitoring and maintenance – “no fistula left behind” will track new AVFs, especially those failing to mature (i.e., those that have reached 3 months and still cannot be used for 2 needle dialysis at prescribed Qb).
  • The AV Fistula First Breakthrough Initiative National Coalition recommends NOT using PICC lines in patients at risk for or with known mid–Stage 3 CKD, Stage 4 and 5 CKD or ESRD. A small bore central catheter (SBCC) in the internal jugular (IJ) vessels is recommended instead. SBCCs last longer than PICC lines, are easily replaced, and have fewer complications for the period of time needed (Sasadeusz et al, 1999).
  • New details are forthcoming on cephalic arch stenosis – to stent or not.
  • NIH is set to study patient, biological, and process of care factors leading to non–maturation.

Catheter Intervention:

  • New guidelines are available from the Infectious Diseases Society of America (IDSA). Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter–Related Infection: 2009 Update by the Infectious Diseases Society of America can be found in Clinical Infectious Diseases, July 2009, Volume 49, Issue 1, Pages 1–45.
  • Antibiotic Locks: An antimicrobial lock is pending FDA approval but is unlikely to be approved. FDA, in studying these drug–device combination catheter lock/flush solutions, assigned them to the Center for Devices and Radiological Health (CDRH) for review and regulation under the device provisions of the Act. The Agency stated that the adverse event reporting requirements applicable to devices (21 CFR 803) would apply. Sponsors wishing to discuss the regulation of a particular combination drug–device catheter lock/flush solution may contact the Office of Combination Products at 301–427–1934. Alternatively, sponsors may contact CDRH's Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices, at 301–443–8879. Visit the FDA’s web site for more information.
  • Biofilm: Recent studies with RNAIII Inhibiting Peptide (RIP) show promise in decreasing both the adherence of bacteria and formation of biofilm in dialysis catheter especially those made of silicone or polyurethane. A potential application would be to coat dialysis catheters with RIP externally and internally (Kidney International (2003) 63, 340–345).
    • Fibrin sheath: recent studies implicate an association between fibrin sheath development and biofilm formation

Access Monitoring:

  • A Vascular Access Monitoring and Surveillance Flow Chart (VAMP) is available through Fistula First – an excellent resource for managing the permanent access
  • New real–time tools courtesy of updated modules are now available routinely on dialysis equipment where available and when implemented:
    • On-Line Clearance allows at-a-glance determination of clearance (Kecn) and, if tracked, can help identify access flow problems
    • Blood Temperature monitors allows for on-line or on-treatment determination of recirculation percentage.

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AWARDS: Nominate That Special Person or Group

DEADLINE FOR NOMINATIONS: September 15

What person or institution is really making a difference in nephrology? Who represents the best of what we want to achieve and reflects the values and high standards you admire? CAP offers you the opportunity to honor these people with two annual awards.

The Nostradamus Award and the Tim Poole Memorial Award recognize these outstanding people or groups. CAP members are encouraged to nominate people or institutions which they want to honor.

The Tim Poole Memorial Award will be given to a CAP member who portrays dedication and service to patients, families and community. This person exemplified the heart and soul of the advanced practitioner and provides a role model to emulate. Look across your desk or into your community and put into writing why this fellow CAP member is deserving of this award. Tim Poole was a dedicated, outstanding practitioner whose memory will be honored with this award.

Nephrology is supported by people or institutions outside the field who promote advanced practitioners. The Nostradamus Award recognizes these contributions. The recipient can be a politician, dialysis manager, educator or anyone who has helped position advanced practitioners for the future of nephrology. A short essay describing what this person has done and how this has helped advanced practitioners is all that is needed.

These first-ever awards will be presented at the 2010 NKF Clinical Meetings in Orlando. For details, please see CAP’s Awards web page. Barb Weis at Barbara.weis@ucdenver.edu will be glad to answer any questions.

Remember, your writing skills are not as important as your heart-felt feelings. Please nominate today.

DEADLINE FOR NOMINATIONS: September 15, 2009


RESEARCH GRANTS

October 15, 2009   LETTER OF INTENT DUE
December 1, 2009   GRANT PROPOSAL DUE
Jan & Feb 2010 Council Research Grant Committee review
March 2010 Awards announced
July 1, 2010 Approved project begins through June 2011

CAP will award research grants for the first time in the spring of 2010. Research adds to the nephrology body of knowledge and is one of the purposes of CAP.

MicroscopeTo be eligible, an applicant should be:

  • A CAP member
  • Have at least two years experience as a nephrology advanced practitioner
  • Have written approval from the facility where the research is to be conducted
  • Be a resident of the United States or territories
  • Have prior experience with research

The areas of interest include, but are not limited to, basic or applied research in nephrology, early intervention and treatment of renal failure, development and evaluation of patient education and demonstration projects.

For further information, please contact CAP’s Research Chair, Peter Juergensen, PA–C.


STEP UP TO THE PLATE!

Nominations for CAP’s First Elections Due: September 4

The first CAP elections are coming. Open positions include Chairperson, Chairperson–Elect and Secretary–Treasurer. Visit the NKF Council Elections site for more information. Nominations are due September 4. Please note, as we are still a small council, we have not divided into regions similar to the other NKF Councils.

Online Elections take place October 15–November 15

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Chair’s Corner

by Kim Zuber, PAC, MSPS

Spring has been a busy season for CAP. We are feeling like a ‘real’ council with sub–committees and projects and such! Our major projects continue to be CM10 planning, the CAP CKD education program “Nephrology Essentials”, in addition to elections, awards and the CAP Survey for 2010. Taking each one in turn:

CM10 planning started with a bit of a glitch when Laurie Benton, CME chair extraordinaire, developed pancreatitis, complicated by a reaction to dye, and missed the Orlando planning meetings. Since she had a strong and capable committee, they stepped up to the plate (thank you Tricia and Carol), went to Orlando and plans are on track. Laurie is feeling better (although, as usual, she is overdoing it!) and we are incorporating your ideas and suggestions for the AP track at NKF’s 2010 Spring Clinical Meetings in Orlando.

Lisa Farris continues to work on the CAP CKD education program, “Nephrology Essentials”. We plan to discuss the program more at the CAP luncheon in Orlando.

The first CAP elections are getting off to a slow start. Since we have no previous ‘official’ committee, anyone is eligible to run for any position this year. We have had only a few members fill out an election application (and I admit, I am running but I have not applied yet!!), and the deadline is September 4. Visit the NKF Council Elections site to apply for a position today!

The CAP awards will be given in 2010. Senator Blanche Lincoln (D–Ark) has been nominated for the Nostradamus award. She is the author of S 432 which was the Senate bill authorizing the pre–dialysis (CKD 4) language that was incorporated into MIPPA. Speaking of MIPPA, the CAP sub–committee reviewing the CKD 4 program has finished their work and we are just waiting for the “Your Treatment, Your Choice” slide deck and DVD to be issued by NKF this fall. Thank you to everyone who helped.

The CAP Survey is on track to be sent out in December 2009 and will be open until the spring of 2010. This will be the first nation–wide survey of job descriptions, salary and benefits for nephrology APs ever done. The sub–committee is developing the questionnaire now. We are taking our cue from the NKF’s Council of Nephrology Social Workers (NKF–CNSW) and will allow any AP to participate in the survey (CAP member or not). This will allow us to get the best and most comprehensive. If you participate, you will receive the synopsis of the results. But…if you are a CAP member, you get the synopsis along with full breakdown of all results including statistical evaluation. The Committee will need beta–testing volunteers this fall. If you are interested in helping, contact me ASAP!

Dates to keep on your calendars:

  • The US Transplant Games will be held in Madison, WI July 30th to August 4th, 2010. Volunteers are needed in every capacity. Visit the USTG web site for more information. You must have a Wisconsin license to volunteer as a PA or NP.
  • World Kidney Day is March 11th, 2010. CAP is co–sponsoring a KEEP screening in Washington D.C. for that day. We would love to have any CAP members come and help. ☺ More details to follow.
  • NKF 2010 Spring Clinical Meetings are going to be Orlando April 13–17th. Hope to see you in sunny Florida in April 2010!!

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Experiences from the 2009 NKF Spring Clinical Meetings in Nashville

Linda Mixter, MSN, APRN, BC

The 2009 Spring Clinical Meetings of the National Kidney Foundation held in Nashville were excellent. With the many sessions available to select from, there is something for everyone. An outstanding event networking luncheon open to advanced practitioners. Meeting new people, exchanging ideas and making new professional contacts from all over the country that extend well beyond the meeting is something very special. Many new ideas are created from these networking contacts with other advanced practitioners.

The preconference session “Integrated Peritoneal and Hemodialysis Course,” presented many different facets of both peritoneal and hemodialysis that one must consider in the management of patients undergoing these types of renal replacement therapy. There was also an interactive session which highlighted points for use with patients. I found this very thought provoking and put me in the patients’ place to know better how they think and feel at this time.

Sessions on acute kidney injury, amyloidosis and multiple myeloma provided a better understanding of the disease process and treatments. I learned information that is directly applicable to a number of patients seen in my practice and I now have a better idea how to direct their care. The session on CKD/ESRD and anticoagulation provided new insights on better management of patients who need to be started on anticoagulation and for those patients already on anticoagulation. Maintaining a therapeutic INR is an ongoing challenge with our population.

The workshop on electrolytes was very thought provoking and gave a variety of case studies which were discussed in detail. Evidence and critical reasoning were discussed with each decision.

At other sessions, including those on diabetes mellitus, secondary hypertension, tubulo-interstitual diseases, research evidence was presented that validated current treatments practices. Pulmonary hypertension/vascular disease update and urine analysis sessions were very interesting as tests and the interpretation of results were discussed and I gained a better understanding of the significance of the findings.

Overall, the spring meetings are a wonderful learning experience to update and clarify my practice as well as learn new evidence and research. The networking luncheon allowed me to exchange ideas, practice methods with other advanced practice professionals. The new contacts I made there are already proving a benefit since several of these contacts are in the Metropolitan Detroit area, a definite plus.

Kirsten Jensen, MS, ANP, CNN

This was not my first experience at a national conference, but it was my first time attending the NKFs Spring Clinical Meetings. It was also my first meeting as a nurse practitioner. I chose to attend this conference for several reasons: the wide variety of session topics was highly applicable to my new practice, the meetings gave me an opportunity to talk with other practitioners who have already traveled this road, and, finally, I cannot leave out the added bonus that it was located close to my hometown and allowed me to visit with some old friends!

Overall, this meeting far outperformed my expectations. I received a warm welcome from NKF–CAP members as soon as I arrived. Everyone I met was incredibly friendly and more than willing to share their experiences as advanced practitioners. I not only learned about the various responsibilities, but also picked up a few tips that will make my job easier.

The educational sessions were informative, occasionally humorous, and, at times, challenging. I had a few “Aha” moments and made notes about several things to research further in the future. The sessions offered ranged from basic to advanced and allowed participants to choose from multiple topics without being overwhelmed. And while there were some presentations I had to miss due to conflicts, I was happy to hear that slide presentations would be available online to allow me to review the materials at home.

This was a very positive and energizing experience for me. I am looking forward to attending this meeting again in the future and catching up with the wonderful people I met this year. I would also encourage others to consider coming, as they will not be disappointed. Thank you all!

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The Kidney Song Deserves a Grammy

He Needs a Kidney

Kidney donation received the national spotlight during this season’s finale of “30 Rock,” NBC’s Emmy Award–winning sitcom. In the episode, Jack Donaghy, played by Alec Baldwin, tries to find a kidney for his father when he learns that he himself is not a match. To raise funds and awareness for the cause, Donaghy puts together a star–studded benefit concert featuring such well known performers as Sheryl Crow, Mary J. Blige, Cyndi Lauper, Beastie Boys and Clay Aiken who sing a specially–created song, “He Needs a Kidney”.

NKF was actively involved as producers scripted the episode, providing background information on organ donation so that the portrayal would be realistic and accurate while still fitting in with the show’s comedic format.

To make sure the show’s message lives on beyond the season finale, producers made the song available on iTunes.com for six months after the segment's airing on May 14, 2009. One hundred percent of the proceeds of the sales (99 cents per download) will be donated to NKF. Within the first two months, the song was downloaded more than 6,000 times and more than 2,000 web surfers on NBC's “30 Rock site” visited kidney.org for more information on organ donation. Additionally, the iTunes version of the song featured an organ donation public service announcement recorded by Tina Fey, writer, star and executive producer of “30 Rock.”

If you missed the segment back in May, tune in to the rerun on September 3. To support NKF by downloading “He Needs a Kidney” visit www.kidney.org for the direct link to the song on iTunes.com

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