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.
Laura Troidle, PA
Metabolism Associates, New Haven, CT
Home hemodialysis (HD) therapy has gained popularity for patients with kidney failure. The advent of home HD has provided significant opportunities for patients to do HD treatments more frequently and for longer sessions, which results in significant benefits such as improved phosphorus and blood pressure control as well as an improved quality of life. Yet, despite these advantages, home HD is not for all. Some patients are either unable to perform such therapies safely at home or lack the support. Other patients prefer a dependent, in-center environment to meet their HD needs.
No studies have shown that any particular type of hemodialysis, including today’s home HD, offers a significant improvement in mortality. Yet, we do know that hyperphosphatemia, hypertension and cardiovascular disease can contribute to the high mortality observed among HD patients. Traditional thrice-weekly, four-hour, in-center HD does not adequately address these factors in all patients for a multitude of reasons, primarily the difficulty of achieving homeostasis in a limited period of time.
Thus, alternative in-center HD therapies have been sought to improve the quality of life and health of hemodialysis patients. The most extensive study has been observed among HD patients in Tassin, France. Laurent et al. (1998) reviewed their experience with 876 patients maintained on 8-hour, in-center, thrice-weekly HD and noted that the mortality was two to three times less than the standardized mortality ratios observed in the U.S.1 This group also noted that after three months of longer sessions, the mean arterial pressure decreased from 119 (162/98) to 100 (136/82) mmHg. The blood pressure improvements were then associated with a reduction in antihypertensive medication usage.
It is not surprising that the longer HD sessions were associated with a reduction in mortality rates. Marshall et al. (2006) of the Australian and New Zealand registry noted that, after adjusting for demographics and co-morbidities, a session length of 4.5 to 4.9 hours was associated with a lower mortality compared to patients with adequate Kt/V urea and similar co-morbidity on a shorter time.2 And, a reanalysis of DOPPS data showed that treatment times of greater than 240 minutes were associated with a 19% lower relative risk of all-cause and a 16% risk of cardiopulmonary death as compared to similar patients maintained on HD for less than 240 minutes.3 The DOPPS study also noted that an ultrafiltration rate of more than 10 mL/h/kg was associated with a significant increase in mortality. One can postulate that improvement in a variety of factors, including blood pressure and phosphorus control, which are intrinsic to HD therapy, may have contributed to the improved mortality observed in these studies.
My group in Milford, CT, implemented a thrice-weekly, in-center, 8-hour nocturnal HD treatment in May 2005. A total of 24 patients were enrolled. The patients were younger and with significant less co-morbidity factors than patients in the general kidney failure population. The average age was 47.7 +/- 13.2 years and the mean Charlson Comorbidity score was 4.7 +/- 2.1.
We noted an improvement in several clinical and psychosocial parameters in patients who were maintained on the 8-hour therapy.4 Serum phosphorus values decreased from 5.3 +/- 1.27 to 4.4 +/- 1.1 mg/DL (p=0.049) within six months of starting the nocturnal program. Phosphorus binder usage was noted to be reduced, but not significantly at six months. The average time to resume usual activities (2.5 +/- 3.2 hours) following each treatment was also faster than the typical six hours it takes a general HD patient to recover after a treatment. The average ultrafiltration rate was consistently less than 10 mL/h/kg at an average of 6.4 +/- 2.7 mL/h/kg.
We further analyzed the kinetics of the phosphorus removal in addition to beta-2-microglobulin (B2M). Phosphorus clearance was sustained through the entire 8 hours of therapy and averaged 136 +/- 13 mL/min, similar to the creatinine clearance of 143 +/- 27 mL observed in the same study (in press). B2M clearance was 55.1 +/- 40.3 mL/min. Additional studies are underway to determine if the clearances were improved based on higher blood flow rate of 400 cc/min used in our study.
Thus, for our patients maintained on thrice-weekly, in-center, 8-hour HD, there appeared to be advantages. Serum phosphorus values improved with a reduction in binder usage. Phosphorus and B2M clearances were noted to be enhanced and sustained throughout the 8-hour session. The ultrafiltration rate was consistently less than 10 mL/h/kg. Patients also stated they felt better and most resumed usual activities shortly after the longer session.
However, our study is limited by its small patient size. Is there any data demonstrating a survival advantage for patients maintained on these longer treatments? Dr. Ercan Ok of Izmir, Turkey, presented several studies suggesting that this may be the case.5 His group compared 224 patients on 8-hour HD and 224 patients on 4 hour conventional HD who were age matched and with co-morbidities adjusted to each group. He demonstrated a significant reduction in mortality rates (1.29 versus 6.03 deaths per 100 patient years, p<0.01) among the patients maintained on the 8-hour sessions as well as a significant reduction in hospitalization rates (5.0 versus 19.2 days per 100 patient months, p<0.05). Other benefits noted among the patients maintained on the longer 8-hour sessions included lower progression of coronary artery calcification scores 10 months after starting the longer sessions and a significant improvement in arterial stiffness at 12 months. The Turkish data provided striking evidence that longer therapies ought to be considered part of our dialysis repertoire offered to HD patients.
Despite the benefits observed among the several studies, some patients decided to not continue the 8-hour therapy in my particular center.1,4 One-half of the patients who initially enrolled in the 8-hour program left the program. Fifty percent of those patients left because of psychosocial reasons including trouble sleeping and intolerance of the lengthy 8 hour treatments. Ramkumar et al. (2005) analyzed the patient preferences for in-center HD.6 These investigators noted that one-half of the patients cited inadequate time for self and family as barriers to receiving HD for eight hours three or six times per week. Only 20% of the patients interviewed would even consider in-center, thrice-weekly, 8-hour HD.
In conclusion, longer and more frequent HD therapies provide several advantages for patients maintained on HD including improved phosphorus and blood pressure control and an improved quality of life. In-center, thrice-weekly, 8-hour HD treatments are yet another option for HD patients in need of an alternative to conventional HD for whom home therapies are not an option. Further multi-centered studies should be undertaken to explore the benefits of these lengthy treatments.
CAP’s First Elections
CAP’s first-ever elections will take place online from October 15-November 15. We will be voting on three elected positions of the CAP Executive Committee: Chair, Chair-Elect and Secretary/Treasurer. For this election, all CAP members are eligible to run for open positions. Online nominations are due September 4. Descriptions and nomination forms are now available online.
A salary survey is being designed to send to CAP members. Information gleaned from the responses will show national industry statistics and will be valuable to members as they negotiate with employers. Look for this in your inbox this winter.
By the Numbers
NKF’s 2009 Spring Clinical Meetings in Nashville, TN, were a great success, with more than 2,000 attendees. Approximately 179 Advanced Practitioners were in attendance and took full advantage of the 38 Advanced Practice Track Programs, including five pre-conference classes.
CAP will present its first annual awards at the 2010 NKF Spring Clinical meetings in Orlando. The Nostradamus Award will be given to a person or organization which has promoted and supported advanced practitioners in nephrology.
The Tim Poole Memorial Award will be given to a CAP member who best exemplifies the heart and soul of the advanced practitioner. This is a person whose dedication and service to patients, community and family gives us a model to emulate. Please think of potential recipients for these two awards and nominate them to be recognized for excelling in their profession. For awards criteria and to make a nomination, visit CAP’s Awards and Research web page.
Is there a question affecting your practice you would like to pursue? Or perhaps a project you want to implement? If so, a CAP Research Grant may be just what you need. Peter Juergensen, PA-C, CAP’s newly appointed Research Chair, is already hard at work on CAP research grants. These will be awarded to CAP members for projects that will advance nephrology. For more details, visit CAP’s Awards and Research web page.
by Kim Zuber, PAC, MSPS
What a wonderful time we had in Nashville! If you were there, I am sure you would agree. The Continuing Education Committee, under Laurie Benton and Elaine Go, put together a wonderful collection of talks and speakers. Laurie not only went under budget, but had such incredible speakers that the physicians want to ‘borrow’ them from us next year. The hotel was fantastic and had everything you would ever need on site. Peter Juergensen and Beth Ramenofsky judged the poster session for CAP and did a spectacular job. It was so gratifying to see such professionalism in our representatives to NKF. Lisa Farris and Peter dragged us out for a night at the Grand Old Opry, where we saw the Gaitlin Brothers and Loretta Lynn. Seeing such a legend perform on her home stage was truly a chance of a lifetime. Forty to fifty other NKF meeting attendees were there and everyone was blown away.
NKF was thrilled with the attendance of CAP members - at our first ‘official’ CAP networking luncheon, we had over 150 attendees. We ate, gossiped, laughed and shared. The time went by so fast but there was so much that we all learned from each other. Laurie collected a list of suggested topics for the 2010 Spring Clinical Meetings (April 13-17, 2010 in Orlando) and is still asking for topics and speakers. You can email her at firstname.lastname@example.org since she REALLY wants the AP tract to reflect what we want and need. This year, we welcome a new CE Co-Chair, Carol White from Tennessee, who brings energy, experience and humor to the role. She can be reached at CarolWhite@Nephassociates.com and would love to hear your ideas or CME suggestions.
Research, awards and elections are the thrust of the Executive Committee’s work this year. Peter Juergensen is presently writing up the criteria for CAP research grants. He recruited two Committee members while in Nashville but welcomes input and participation from anyone interested. Barb Weis spent much of last year developing (with many opinions from us all) the 2 awards that CAP will present each year: the Nostradamus Award for that person or institution that helps position NPs and PAs for the future and the Tim Poole Memorial Award for the CAP member who most exemplifies all that we hold dear in our lives and practices.
CAP will hold its first elections this fall. The current acting Executive Committee was appointed by NKF in order to get CAP up and running. All CAP members are eligible to run for open positions. To view open position descriptions and make a nomination, visit NKFs Professional Council Elections page.
NKF’s “Your Treatment, Your Choice” program is still on our radar with 5 of the 6 lectures already reviewed by CAP volunteers. The program should be available this summer in its final form. Thank you to the wonderful reviewers who have put many hours and much thought into their comments. NKF appreciated our help and Marilyn Swartz, NKF/KLS Director, met with the CAP Executive Committee to give us a progress report and thank us for our input.
CAP awarded its first educational travel stipends to assist members in attending the meetings in Nashville. We gave stipends to three members and want to make sure that we have more applicants in 2010. So, remember, we’d love to help sponsor your trip to Orlando and we hope to see you in sunny Florida in April 2010!!
As a physician assistant student, this was my first time to attend a professional conference. Leading up to the Spring Clinical Meetings, I had the opportunity to spend three weeks on a nephrology elective rotation, getting a chance to practice managing kidney failure and CKD patients, while familiarizing myself with the ins and outs of the field.
In the days preceding the conference, I felt a great deal of anxiety as well as excitement. Despite having immersed myself in the world of the kidney, three weeks is far from sufficient to understand the principles, let alone the complexities, of how this organ works. I feared that the conference presentations would be over my head and that I would struggle to interact with the participating clinicians.
To my surprise I was met with open arms and great enthusiasm. I quickly came to realize that everyone in attendance was most interested in finding ways to become a better clinician; whether it was through learning about the latest advances in diabetes management, implementing strategies to improve renal dietary compliance, or making their patients more comfortable during dialysis treatments. It was very encouraging to see the enthusiasm with which people exchanged ideas and personal tricks of the trade, all in the hope of improving their practices.
Fortunately for me, my preceptor for my nephrology rotation was Kim Zuber, CAP Chairperson. So, in addition to attending the conference, I was able to attend the Executive Committee meetings and learn how a Council is run from the inside.
I also had the opportunity to judge the posters with Peter Juergensen, which was an education in itself. This gave me a chance to look at the research behind studies and also the importance of communication through presentation.
Even though I anticipate graduating from my program in August, the conference served as an important reminder that no matter your current level of understanding or command of a subject, the learning never stops. The conference was an apropos end to my nephrology elective. Thank you, CAP, for your generosity and for allowing me to participate in this year’s event.
I was absolutely delighted to find that I was given a $500 educational travel stipend by the National Kidney Foundation to attend the Clinical Meetings. I am a new member to the NKF and have found this organization and its benefits outweigh those of any other professional organization I have ever joined. I am an Adult Nurse Practitioner student from Stony Brook University, Long Island, NY, with plans to graduate in May 2009. I decided to attend this meeting back in December to broaden my knowledge of kidney disease. At the time, I was not sure of my career path, but knew that I was certainly interested in this field. Just prior to coming to Nashville, I signed on to work with two nephrologists based in Kingston, NY, after graduation. After attending this spring meeting, I feel more prepared to face the various pathologies and pharmacological challenges I will be encountering in the coming months as I start my new career.
I arrived in Nashville a day before the conference officially started to take advantage of an opportunity to attend Nephrology 210, a full day of lectures which sounded interesting to me. During the general session, I attended 11 or 12 additional lectures. After attending the polycystic kidney disease lecture on Thursday morning, I went into information overload. I had gotten up at 4:30 AM to attend a breakfast lecture prior to that and had not gotten much sleep the night before. I found it necessary to go to the gym for a half-hour run on the treadmill to decompress. After that I was renewed and ready to start learning again. I have to admit that many of these classes had information that I found to be over my head.
Some of the speakers were more engaging than others but I found the quality and quantity of speakers to be amazing. Of all the lectures, my favorite was a session on proteinuria by Dr. Harvey Feldman, held during Nephrology 201.
My experience was outstanding. I met many interesting people and felt welcome in an organization that is filled with people with so much more renal experience than I have. I plan on attending the next conference in Orlando in April 2010. My one bit of advice? Apply for that educational travel stipend.
A paragon is a model of excellence or perfection. The Paragon award from The American Association of Physician Assistants (AAPA) recognizes individuals in six categories who have distinguished themselves in their contributions to their patients, community and profession. CAP’s own Laurie Benton, PA-C, is one of this year’s recipients of the coveted award. She will be recognized, along with Dr. Charlie Foulks, for the PA-Physician Partnership Award. Laurie is the Continuing Education Chair for CAP and one of the original CAP planning committee members. The award will be presented in May at the AAPA annual meeting in San Diego.
In 2005, Benton and Foulks, then at Scott & White in Central Texas, asked what at first seemed to be a simple question: Why were so many people who were seeing internists and general practitioners, having late referrals to nephrologists, often when renal replacement was imminent? The answer was deceptively simple—a lack of recognition of impaired renal function on the part of medical practitioners. They linked this to a general lack of knowledge of CKD which was not unique to just their area but is an international problem.
Together, Benton and Foulks embarked on an educational program to heighten awareness of kidney disease among practitioners and also to increase the number of nephrology advanced practitioners. Among their projects, they have been formulating and producing educational material for patients and providers and distributing a guide for nephrology practitioners. As a result of their hard work and devotion, many patients are being diagnosed with CKD and treated earlier and might possibly avoid the need for renal replacement.
The PA-Physician Team Partnership Award recognizes and honors those relationships which exemplify all that is good in a PA-Physician relationship. Benton and Foulks’ partnership represents a synergy between two outstanding and devoted professionals who put their patients and professions at the forefront.
All of CAP congratulates Laurie and Dr. Foulks for all of their achievements and work to come.