Ask the Doctor
Questions about kidney disease? Risk factors? Signs and symptoms? Are you concerned about yourself, a friend or family member? Ask Dr. Spry.
Carol Dahl, RN, CRNP
University of Alabama at Birmingham Division of Transplant Nephrology
Approximately 2 to 10 percent of patients diagnosed with human immunodeficiency virus (HIV) have renal disease. Persons of African-American ethnicity are disproportionately affected, suggesting that genetic factors play a role in development of HIV nephropathy. Of those diagnosed with the condition, approximately 95 percent are young black men. HIV nephropathy occurs most commonly in patients whose CD4 count is less than 200/uL. The clinical presentation may include findings of nephritic or non-nephrotic range proteinuria, microscopic hematuria and elevated serum creatinine, along with radiologic findings of increased echogenecity and renal hypertrophy. The most common form of HIV nephropathy is collapsing focal segmental glomerulosclerosis. There are numerous other causes, including, but not limited to, acute renal failure, amyloidosis, interstitial nephritis, immune complex glomerulopathy and membranous glomerulonephritis (such as seen in patients with concomitant infection with hepatitis C).
Traditionally, human immunodeficiency virus (HIV) has been considered an absolute contraindication to undergoing renal transplantation. Since the introduction of highly active anti-retroviral therapy (HART) in 1996, and subsequently the wide availability of such therapy, HIV has become, for many affected patients, a chronic condition with manageable associated co-morbidities. As a consequence of improved longevity and wellness among this population, renal transplantation has evolved as a viable alternative for those who have reached end-stage renal disease.
Inclusion criteria are being determined to optimize outcomes and may include:
In patients who are co-infected with hepatitis C and/or hepatits B, there must be no evidence of cirrhosis clinically and on radiographic imaging. In addition, the patient must meet all standard inclusion criteria as required for patients with non-HIV associated kidney failure; this includes a demonstrated history of medical compliance. Once a patient is listed for transplantation, HIV viral load and CD4 count should be monitored every three months. Special challenges encountered following transplantation are unique to the HIV patient population, including managing complex drug-drug interactions relating to HAART therapy and immunosuppressive agents. Some data suggests that outcomes in this population are improved versus those maintained on dialysis; allograft survival was estimated at 75 percent at one year and 71 percent at two years.
Kumar, et al. Safety and success of kidney transplantation and concomitant immunoppression in HIV-positive patients. Kidney International 2005; 67:1622-1629.
Rose, Burton D., MD, Appel, Gerald B., MD. Collapsing FSGS and other renal diseases associated with HIV infection. October 2009; UpToDate
Tankersley, Martha, CRNP. Renal and Pancreas Transplantation Update, September 2009.
Tebas, Pablo, MD. Solid organ transplantation in HIV-infected individuals. September 2009; UpToDate
Windus, David. The Washington Manual: Nephrology Subspecialty Consult, Second Edition. page 173
Hollywood has the Oscar, TV has the Emmy and Broadway has the Tony Awards. But these pale in comparison to CAP's Nostradamus Award and Tim Poole Memorial Award. Your Executive Committee is pleased to announce the winners and to present them with an impressive award they will be proud to display in their home or office. Awards will be given on Wednesday, April 14, during the CAP Networking Luncheon at the NKF Spring Clinical Meetings in Orlando.
The Tim Poole Award will be presented to Lynn Poole, FNP-BC, CNN (no relation). She has been involved in nephrology since 1983. Since her early days at the University of Virginia, she has had an ongoing commitment to improving the care of individuals with CKD and to developing programs in the areas of CKD and ESRD. She has also had an active voice in CKD/ESRD legislation. In acceptance of the award, she stated she was "flabbergasted and awed by the award" and hoped she could do credit to Tim Poole and his loved ones.
The Nostradamus Award was accepted by Blanche Lincoln, U.S. Senator for Arkansas, for her proposal of the Medicare Improvement for Patients and Providers Act (MIPPA) CKD education bill. Senator Lincoln is the youngest woman ever elected to the Senate and currently sits on the Senate Finance Committee. She is very proactive on healthcare issues. She will accept her award at the Senate Building in Washington, D.C., on World Kidney Day (March 11) from CAP Chair Kim Zuber and CAP Chair-Elect Barbara Weis-Malone. A videotaped message will be shown at the CAP luncheon.
Each fall, educational stipends are made available to CAP members to help defray the cost of attending the NKF Spring Clinical Meetings. Recipients receive $500 each towards travel expenses and complimentary general meeting registration, and are required to attend CAP program sessions and write an article summarizing a session or their overall experience at the SCM10 meeting.
This year's recipients are: Sandra Abrahamson, ARNP; Linda Doeckel, PA-C; Elaine Go, RN, NP, MSN, CNN; Catherine Groeger, MN, NP-C; Valerie Pompey, MS, ANP-BC; Lynne Poole, FNP-BC, CNN; and Jason Tiede, PA-C, MHS.
The seven recipients were all first time awardees of the stipends and wrote meaningful requests for travel monies. They will also be recognized at the CAP Networking Luncheon. We look forward to meeting these fortunate recipients and learning their stories! Be sure to apply for a CAP educational stipend for next year's meeting in Las Vegas.
Sydney, our traveling kidney is up and running again. Last year Syd went to Texas, Colorado and Washington, D.C. After a holiday break in North Carolina, traveling Syd is anxious to get back on the road! If you want Syd to visit you, please contact his travel agent, Deb Hain at firstname.lastname@example.org. Syd brings kidney health information, a traveling journal and love. Coming soon: Visit the CAP web page to learn more about Sydney's travels!
Kim Zuber, PAC, MSPS
I can't believe it is a New Year already! I hope everyone had great holidays and 2010 is peaceful and productive for all of us. After our first election, we welcome the new CAP leadership who officially take office in April 2010 (they look a lot like the old leadership since positions were unopposed...the next election will be in the fall of 2011).
Unfortunately, we rang in the New Year without Maritza Owens, who was a driving force at NKF behind the formation of CAP and who has guided us for almost two years. It was Maritza who planted the seed which has grown to be CAP and we will truly miss her. We say thank you from the bottom of our hearts and wish her the best.
The NKF Spring Clinical Meetings are on the horizon in Orlando in April. The program looks wonderful. Congrats to the CME committee for putting together a wonderful program: Laurie Benton, Carol White, Tricia Howard and Barb Weis. We will be having the 2nd annual CAP reception following Nephrology 201 on Tuesday, April 13 from 6:00-7:00pm. Join us even if you are not attending Nephrology 201. The CAP Networking Luncheon will be Wednesday April 14 from 12:00-2:00pm. The new CKD training for APs will be introduced along with CAP 2010 award winners. Planning of CME for 2011 in Las Vegas will get started at the luncheon (with your input!) and we are looking especially for west coast volunteers to help!
Your Treatment, Your Choice, NKF's slide deck and DVD for the CKD Stage 4 education program is ready! The program is FREE, but NKF requests a donation. Visit: www.kidney.org/ytyc to order.
Remember: Use CPT code G0420 for 1 patient/1 provider at bill at 85% of $108.18 (no incident to), and CPT code G0421 for a group class and 85% of $25.60/patient up to 20 patients/class.
The CAP Survey is underway! It is the first nation-wide survey of job descriptions, salary and benefits for nephrology APs ever done. It is completely anonymous and open to all APs, CAP member or not. This will allow us to get the best and most comprehensive evaluation done. Results should be available summer 2010. So anyone who is planning to negotiate a contract, data is coming!! If you haven't already, please take the survey here.
Important Dates to Watch:
Troy Zimmerman, NKF Vice President for Government Relations
Congressional Leadership and the White House are engaged in health reform negotiations, with the hope for a final vote in February. While the outcome of various major issues were in question as we went to press, including how to finance the legislation, many provisions in the House and Senate versions of the legislation are identical or similar. The final bill undoubtedly will include a prohibition against preexisting condition discrimination in insurance coverage, subsidies to assist individuals to purchase insurance, requirements or incentives for employers, and elimination of annual and lifetime caps on benefits. Revenue provisions in the legislation will be effective as early as 2010 or 2011, but many benefit improvements and reforms will not be effective until 2013 or 2014 (eliminating preexisting condition restrictions is expected to be effective sooner).
In December, Congress approved legislation to fund multiple federal departments and agencies for fiscal year 2010. An NKF priority, the CKD program at the Centers for Disease Control and Prevention (CDC), received a $100,000 increase. CDC plans to support kidney screenings under the ongoing demonstration project in up to four additional states. NKF is the lead contractor for the demonstration project.
Outlook for 2010
Coupled with "fatigue" from major issues such as health reform and the expected emphasis on job creation, legislative opportunities will be hard fought in the upcoming session of Congress. NKF priorities will include supporting various provisions under our End The Wait! organ donation initiative, continuing support for the CDC kidney program and participating in Kidney Care Partners initiatives including quality care issues. At the executive branch level, priorities will include encouraging the utilization and monitoring of the new Stage 4 pre-dialysis education benefit and the development of the Medicare Improvements for Patient and Providers Act's (MIPPA) Quality Incentive Program for dialysis services. All of these are aided by the active participation of our Professional Council members, and we look forward to your assistance!