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July 18, 2022, 1:44pm EDT
Stipend Summaries
CNSW
Presentation Title: Patient Engagement and Kidney Care (Interprofessional)
Presenter(s):
- Renee Bova-Collis, MSW, LCSW (Engaging Patients in Dialysis Care Plans)
- Melissa Prest, DCN RDN (Health Info and Technology)
- Marissa Argentina, LMSW (Peer Mentoring)
Author: Sarah Billingsly, MSW, LMSW (Barnes Jewish Hospital, St. Louis, MO)
The National Kidney Foundation’s 2022 Spring Clinical Meetings saw a variety of interdisciplinary conversations related to patient care, health disparities, and strategies for collaboration. The COVID19 pandemic has limited our opportunities for in-person interaction and forced us to consider the importance of patient’s engagement in their care. Furthermore, it has stressed the need for centers to adopt innovative strategies to support patient engagement. This session highlighted some of the areas of patient engagement. As a transplant Social Worker, I was especially invested in the ways these areas can be adapted for use in the transplant setting.
Renee Bova-Collins began with a discussion of care plans in the dialysis setting. CMS mandates that centers encourage patient participation in care planning. However, a review of patient case studies shows a variety of missed opportunities for meaningful inclusion of patients in their care plans. Ms. Bova-Collis reviewed the concept of a “Life Plan”, which encourages providers to assist patients with developing a comprehensive plan of their values and goals, and to then create a dialysis care plan from that. She also highlighted the domains of person-centered care planning, of which one is partnership & teamwork. For those patients that transplant is a likely component of their journey, it may be valuable to consider opportunities for collaboration between dialysis & transplant centers in the care planning process. Social Workers are certainly well-positioned to aide in this effort.
Melissa Prest, a renal dietician, continued our conversation with an overview of the use of technology in healthcare, including recent trends and research in mobile health applications. Research demonstrates that while most patients still prefer face-to-face engagement with their providers, many utilize some form of technology to aid in their communication or self-care. The primary aides that are used include wearable trackers (Fitbit, Apple Watch, etc.) and mobile health apps (MyChart, etc.). A growing body of research seeks to evaluate the content & efficacy of these applications, especially for those related to CKD management. An evaluation of one CKD-focused app showed improvement in six-minute walking test and cholesterol, as well as a decrease in overall waist circumference and body fat. However, there continues to be an unmet need of high-quality applications for the CKD & ESRD community. Interestingly, a new application by CareDx - TxAccess - will allow patients to track their status with regards to transplant evaluation and aid them in navigating the waitlist process. Transplant and dialysis centers should consider how new technology - like TxAccess - may enhance patient engagement. That being said, attention must be given to the limitations of technology.
Finally, Marissa Argentina highlighted a valuable resource within the NKF network – NKF Peers. Peer mentorship is shown to be beneficial for both mentors and mentees. NKF Peers matches individuals with CKD, people on dialysis, people living with a kidney transplant, or living donors who are in need of support with a trained peer mentor. NKF Peers is also working to expand their program to offer mentorship to care partners. Mentors & Mentees can be matched based on a variety of criteria including treatment modality, gender, cause of kidney disease, or age. Participation in NKF Peers has been shown to be successful based on positive participant satisfaction scores and improvement in patient activation measures. Many transplant centers offer local mentor programs for their recipients and donors. However, NKF Peers offers an opportunity for engagement at the national level and interaction with individuals that patients may not have otherwise had access to.
A highlight of this presentation was the panel of patients that offered their feedback and insight throughout each topic. It was evident from their testimonies that patients desire engagement with their providers and active involvement in their own care. The panel offered an important reminder to us as renal professionals that we have an obligation to create meaningful opportunities for engagement, and a responsibility to dismantle the systemic barriers that may interfere with that goal.
Presentation Title: Staying Connected in a Pandemic Leadership Challenges
Presenter: Emily Watson, MSW, LCSW Chair: Katherine Merritt LCSW
Author: Jennifer Morales
Many individuals were affected due to COVID 19, but we were not prepared for the challenges it made on the healthcare system. Everything we knew and policies followed were changed as fast as flicking a light switch. Overnight we were told to shelter in place and work from home, but what about our dialysis patient population who still required care? Leadership had to develop ways in which staff felt safe and patients still had hope with reduced fear.
So, what happens two years later in the middle of a crisis as a leader? As a leader one had to come up with mindful and skillful ways to not only reduce fears, but also increase safety. Under safety, PPE, guidance, and new workflows were needed. Safety around PPE was a concern because there was a lack of supply due to shortages. Preservation was needed but making sure there was safety as well. Masks and gowns needed to be worn more than one time.
Under guidance, there was a lot of trial and error. The best way was not always the working way. Workflow also needed to be adjusted. Staff requested to work from home to not only reduce their exposure to patients but also to their families. As an essential employee this was difficult to maneuver. Patients still needed to be served in a safe manner. As a leader, one had to develop new policies. Remote work would be approved due to a positive COVID staff member, exposure, or minor family member being ill. Telehealth visits were warranted for patients who were exposed or staff who was providing care example: nephrologist.
Leaders had to develop new ways to provide regular updates from the CDC and communicate this to staff. This was done by being transparent to staff. Leadership reported to staff any pertinent information that affected the agency directly either through regular meetings or Skype. It was important for staff to be prepared and aware of any issues that were affecting them directly rather than indirectly. It increased safety and reduced fears of the unknown.
Presentation Title: Laughter Therapy in Dialysis: Exercise, Activity, and Wellness
Presenters: Paul N Bennett RN, PHD; Brigitte Schiller, MD; Robert Rivest
Author: Berkley French, LMSW, APSW berkley.french@freseniusmedicalcare.com
Laughter therapy has become more prevalent in recent years. Paul Bennett, professor at the University of South Australia, was inspired to start laughter therapy in dialysis units to avoid physical deterioration in patients by increasing movement. Research has shown inactivity in dialysis patients increases with age as well as number of years on dialysis. Dialysis patients self-reported the poorest physical function compared to others with chronic illnesses. A simple activity for dialysis patients to engage in while on treatment is writing the ABC’s or their name with their leg. Hemodialysis patients also reported lower happiness levels than the general population. Laughter is beneficial because it involves all our senses, group behavior, and movement. Laughter has been shown to improve lung function, cardiovascular function, stimulate natural killer cells, and increase pain tolerance. It has also been shown to be beneficial for those diagnosed with breast cancer, neurodegenerative conditions, and diabetes. A typical laughter session starts with stretching, deep breathing, and progresses to laughter while incorporating different movements such as bike riding, swimming, and driving. Robert Rivest walked the live participants through a laughter session. Self-reported happiness ratings of the participants went up after the session. Dr. Schiller discussed her experience with laughter therapy at Satellite Healthcare in California. She created a pilot program Laugh out Loud – Hemodialysis (LOL-HD), which was implemented at 2 dialysis centers in 2017. The pilot showed laughter decreased those who screened positively for depression. Most patients reported laughter therapy had a positive impact on their mood and would recommend it to other patients. Additionally, most patients would like more info about laughter therapy, and most did not have concerns about safety of laughter therapy during dialysis. Staff perceptions during the pilot were also positive. In 2018, they expanded their study to 5 control units and 5 intervention units where patients received weekly laughter therapy for 8 weeks. The study showed an improvement in feelings of achievement, relationships, feeling part of a community, and improvement in depression (not statistically significant). In 2021, they created instructional videos for staff and patients to allow laughter therapy to be available on a larger scale
CRN
Presentation Title: What’s New in CKD-MBD: The Roles of Vitamin D and K
Presenter: Sagar Nigwekar, MD, MMSc
Author: Kendal Burstad, RDN
CKD-mineral bone disorder (CKD-MBD) is a systematic disorder that manifests as kidney disease progresses and abnormalities in mineral metabolism including calcium, phosphorus, and vitamin D ensue. This leads to devastating effects for patients with CKD including cardiovascular events, fragility fractures, decreased quality of life, and mortality. It is critical to understand how these abnormalities contribute to this pathophysiology and what interventions can be implemented to improve these abnormalities. In this session, Dr. Nigwekar explained what’s new in CKD-MBD and specifically focused on the roles of vitamin D and vitamin K.
He first explained the benefits of vitamin D and provided evidence of vitamin D supplementation in randomized controlled trials (RCTs). While epidemiologic studies show evidence of positive associations with improved vitamin D status, this has not been shown across a multitude of RCTs. Further, he presented a systematic review and meta-analysis on the effects of vitamin D on mortality in CKD. In this review, it was concluded that some patients may benefit from vitamin D supplementation, and more evidence from larger RCTs are required to provide concrete recommendations.
In the second half of his session, Dr. Nigwekar discussed the effect of vitamin K on the vasculature and its potential for use in patients with CKD. As vitamin K plays a prominent role in the regulation of blood coagulation and vascular health, supplementation of vitamin K may prevent the detrimental effects of CKD-MBD. Notably, he explains that vitamin K deficiency is more prevalent in dialysis patients with calciphylaxis. Further, RCTs utilizing vitamin K supplementation have been shown to slow the progression of aortic valve calcification, reduce the severity of muscle cramps in hemodialysis patients, and improve vascular stiffness. Importantly, Dr. Nigwekar ended his talk by emphasizing the importance of individualized care and making shared decisions tailored to fit patient needs, treatment goals, and clinical efficacy.
Presentation Title: Moving Beyond Frailty in the Assessment of Functional Status in Kidney Transplant Candidates
Presenter: Golnaz Friedman, RD, CCTD and Ling-Xin Chen, MD, MS
Author: Jessica Collopy MS, RD, CSR
Frailty for kidney transplant is assessed differently between facilities and between providers. Determining frailty status for a pre-transplant patient can help to give an idea of post-transplant outcomes. Some of the popular methods of determine frailty include: Fried frailty assessment, SF-36, short physical performance battery, MoCa, walk test, and stand sit test.
UC Davis transplant center found that each assessment had both positives and negatives and that none of the frailty assessments alone are good sources to determine frailty. The Fried frailty assessment had a small fraction of patients who tested positive to frailty compared to the short physical performance battery. Previous research has found that the walk test, exhaustion, and the stand sit test correlate with mortality. UC Davis decided the best test for their population (which they admit appears healthier than other transplant centers) includes Fried frailty, 6-minute walk, and 30 second sit –stand test. Yearly they do a SF-36 to determine if the patient is still doing well. They conduct the frailty measurements during pre-transplant, upon admission for the transplant, and after the transplant. The data is still new but they are hoping this will provide more consistency between providers and facilities and help to more accurately determine frailty.
Presentation Title: What’s New in CKD-MBD: The Roles of Vitamins D and K
Presenter: Sagar Nigwekar, MBBS, MD
Author: Alexandria Fons, RDN
Researchers have been fascinated with vitamin D and over the past couple of decades have investigated associations with the vitamin to improvement of countless disease states, including chronic kidney disease (CKD). Because of these associations, providers regularly monitor vitamin D levels and recommend supplementation. However, this is often left to clinical judgement rather than standardized practice because of a lack of an agreed upon range for serum 25(OH)D levels; some experts propose 30-80 ng/mL while others argue 25 ng/mL is sufficient.
Despite growing promotion of vitamin D supplementation, clinical investigators have advocated for more clinical trials because most of the studies that have examined vitamin D on health outcomes have been epidemiological. Therefore, in recent years, research in this area has focused on direct impact of vitamin D supplementation on health in human subjects. Through these trials, it was observed that supplementation of vitamin D did not significantly prevent cancer (Manson et al. 2019), cardiovascular events (Manson et al. 2019), diabetes mellitus (Pittas et al. 2019), tuberculosis infection (Ganmaa et al. 2020), or support infant growth during pregnancy (Roth et al. 2019). It appeared that the only health outcome where vitamin D supplementation showed efficacy in clinical research was a study by Chapuy et al. in 1992 that showed positive effects of vitamin D supplementation on bone health.
Because those with CKD often experience bone and mineral disorders, the proposition of utilizing vitamin D supplementation in CKD patients has still been thought to be effective, especially after a study conducted in 2005 by Leclair et al. found that only a small percentage of the CKD population had sufficient 25(OH)D levels. However, given the great discrepancies of findings between epidemiological and clinical evidence on the efficacy of vitamin D supplementation, much remains unknown. Therefore, ongoing investigation is warranted to understand the effects of vitamin D on health outcomes, especially in patients with CKD.
Presentation Title: What’s New in Vitamin D & K
Presenter: Sagar Nigwekar, MD, MMSc
Author: Wendy Hermes, MS, RD, CSR
Vitamin D and K deficiency are linked with adverse outcomes in people with CKD. The Majority of people with CKD are insufficient/deficient. High rates of CVD and mortality have spurred studies regarding vit D and K supplementation and survival in CKD.
For every 10 unit increase in serum Vitamin D (25 (OH), there is a 20% drop in all-cause mortality. Repletion protocols to correct lab values are available and effective however data from these interventions to support routine usage is lacking. The goal of treatment is to correct low vitamin D in the context of other labs i.e. high PTH or hypocalcemia. Treatment forms include cholecalciferol, ergocalciferol, calcidiol, calcitriol and synthetic forms (Zemplar® and Hectorol®).
Decisions regarding supplementation should be made on an individualized basis focusing on treatment goals and clinical efficacy. Observational studies show improvements in population data which could not be repeated in Randomized Controlled Trials for mortality risk or even fracture risk in CKD. Additionally, studies looking at cardiovascular risk and vitamin D in CKD pts with normal calcium and PTH also showed no difference between placebo.
The KDIGO-MBD guidelines were revised in 2017. Changes in recommendations for the risk for hypercalcemia were identified. Avoidance of therapies linked with soft tissue calcification is deemed a priority. Use of vitamin D analogues in pre-dialysis are not recommended primarily because of imaging studies showing emergence of calcification before CKD stage III. The protocol is to monitor abnormalities associated with MBD every three months when there is low calcium, hyperparathyroidism or vitamin D deficiency.
Calciphylaxis is also associated with vitamin K deficiency and warfarin therapies. Deficiency is also linked to Cystic Fibrosis, biliary disease, malabsorption, bariatric surgery and antibiotic use. Furthermore, traditional renal diet recommendations may have inadvertently increased deficiency risk as plants and whole grains rich in potassium and phosphorus are also rich in vitamin K and osteocalcin. Several trials examining Vitamin K supplementation via menaquinone and phylloquinone show decreased calciphylaxis by inhibiting MGP carboxylation. However, studies are inconclusive on dose response and further research is needed to provide adequate evidence in the reduction of CVD risk in CKD.
Presentation Title: How to Reduce bias to practice culturally sensitive nutrition care (RD ethics)
Presenter: Kate Garener Burt PhD, RDN
Author: Holley Holloway RDN
It’s important to ask ourselves: do we practice culturally sensitive nutrition care? Cultural competence is learning about other cultures so that you may serve patients of this culture more effectively. Cultural humility builds on this by adding self-awareness. It is important to understand our own attitudes, the awareness of our relative position in society and profession as these impacts how culturally humble we may or may not be. Diversity is the range of human differences. Inclusion is understanding that not only are the differences present but they are valued, heard and respected. We must identify and eliminate biases, stereotypes or barriers that may limit full participation in our profession and that may limit full cooperation and engagement with our patients.
Despite our efforts, people are not eating any healthier. A closer look at the population served shows a large number of disparities, and one of the reasons people are not eating healthier may be due to the fact that we are not meeting people where they are. It requires us to adjust our approach to better meet the needs of our clients and patients.
It is not possible to be culturally humble without being diverse. Diversity and inclusion mean that we have different identities who can speak to experiences to help the decision-making process. Dietetics is not diverse. We are 80% white, 96% females and above 95% able bodied;
this is limiting the effectiveness of our care. We have a history of discrimination bias in dietetics education and practice going back 100 years. We as dietitians use forms of invisible bias when we give diet advice, and these are biases that are interwoven into society norms. Consider the Mediterranean diet. It is accepted as the gold standard ‘healthy diet’. It really has nothing to do with the Mediterranean - many of the foods in this ‘diet’ do not come from the Mediterranean region and many cultures do not identify with this way of eating. My plate is another example of invisible bias: a lesson on a nine-inch dinner plate while not every cultural group uses a 9-inch dinner plate. What this is suggesting is that if you are not using a 9-inch dinner plate, your diet is not as good as those who do. If people cannot see themselves in the resources, we are providing then they are not likely to use them.
Dr. Burt reviewed the dietetics profession privilege assessment tool. This is a tool to help one understand their relative privilege compared to other professionals. Privilege is one's relative social advantage. It is a system, and it exists when one group has more social advantage over another. The dominant norms become the norms of society. The dietetics professional privilege tool is a tool to use and discuss with your colleagues. The academy will promote this as a cultural humility tool for all practice groups. They plan to add this to the academy web page within the next 6 months. Use this tool to help identify your covert privilege as it aligns with your life environment, to assess your own biases, to use critical thinking to understand the ways that dominate groups hold the power in dietetics, to learn deeply about other cultures from people who identify with that culture, to embrace indigenous knowledge, and to acknowledge the limitations of our 'evidence base'. It is important to improve our profession's cultural humility. Listen. If you have privilege, listen more than talk and reflect on what you learn. Act; vote, participate, and lead. Find a group you identify with and be active in it. Research. Dr. Burt encouraged all to start a conversation about dietetics professional privilege assessment tool. You can both love your profession and want it to change at the same time.
Presentation Title: Healthier Kidneys Through Your Kitchen: Early Nutrition Intervention for Chronic Kidney Disease
Presenter: Rebecca Schlueter, RD, LD
Author: Jill Hoyt, RD, CD hoyt.jill@mayo.edu
For National RDN Day this year, I was gifted a coffee mug with the phrase, “I’m a dietitian. What’s your superpower”? While appreciated, I must admit I thought it was a bit cheesy. I mean, a dietitian, a superpower? Really?
If there was a theme at the SCM22, it was earlier CKD intervention, which includes referrals to a kidney dietitian. Can we be the superheroes? I attended the session ‘Healthier Kidneys through Your Kitchen: Earlier Nutrition Intervention for Chronic Kidney Disease’, presented by Rebecca Schlueter RD, LD. This session highlighted the significant knowledge gap between how many people have CKD and how many are actually aware of it. The National Kidney Foundation estimates that 37 million Americans have chronic kidney disease. But, sadly, an alarming 90% do not know they have it. We must, then, ask ourselves, if one is unaware of his disease and how diet modification could benefit it, how does they have a chance to make any changes, if so desired?
Rebecca acknowledged this gap and developed a class for patients with chronic kidney disease. The class included the following: explaining CKD stages and lifestyle changes that slow progression, teaching how to monitor protein intake, controlling blood pressure and blood sugar, and healthy cooking demonstrations. These classes helped to bridge the gap between talking about making healthy food choices and making them happen at home. It supported behavior change with hands-on practice of reading a recipe, cooking, tasting, label reading, meal planning and social connection. Patients had the opportunity to try new recipes and ultimately increase their confidence for cooking at home. These combined learning modalities are more effective for success. A class like this takes medical nutrition therapy to the next level, helping patients put into practice what they have learned.
The data supports the need for earlier CKD intervention, especially MNT. Dietitians have the knowledge and skills to change millions of lives and change the trajectory of CKD. To all the dietitians out there, be the change. Be the superhero. Consider developing a class like ‘Healthier Kidneys Through Your Kitchen’.
Presentation Title: What’s New in CKD-MBD: The Roles of Vitamins D and K
Presenter: Sagar Nigwekar, MD, MMSc
Author: Julius S. Navarro, RD, CSR, CNSC, LD
Julius.Navarro@ucsf.edu
Vitamin D
Bone abnormalities that lead to disease are among the most common complications among patients with chronic kidney disease (CKD) on dialysis.1,2 There is disequilibrium in the diseased kidney's mineral and endocrine functions that significantly affect the initial bone formation, structure, and function.1 Numerous factors impact the prevalence of this condition among CKD on dialysis.
Kidney Disease Improving Global Outcomes (KDIGO) defined CKD-Mineral and Bone Disorder (CKD-MBD) as a manifestation of one or a combination of the following: 1,2
- Laboratory abnormalities (calcium, phosphorus, PTH, and Vitamin D metabolism)
- Abnormal calcification of vascular or other soft tissue calcification, and
- Bone disease (resulted from abnormal bone turnover, mineralization, volume, linear growth, or strength).
The manifestation of CKD-MB is linked to clinical outcomes such as bone pain, fractures, secondary hyperparathyroidism, progression to end-stage renal disease (ESRD), cardiovascular events, hospitalization, and mortality.1
For decades, it has been known that the pathophysiology of secondary hyperparathyroidism is one of the CKD-MBD trademarks. Three core abnormalities that trigger the synthesis of parathyroid hormone that eventually contributes to developing secondary hyperparathyroidism are hypocalcemia, hyperphosphatemia, and hypovitaminosis D. After discovering fibroblast growth factor 23 (FGF23) in the year 2000, the understanding of phosphate homeostasis and bone mineralization has grown exponentially.3 FGF23 is secreted primarily by the osteocytes and osteoblasts in the skeleton, promoting phosphaturia and calcitriol production in the kidney.1,3 As kidney disease progress, the increased level in FGF23 is not sufficient to maintain normal phosphate levels, thus may hurt the cardiac or skeletal system.1 FGF23 alteration was revealed to be the first biochemical manifestation of CKD-MBD in the early stage of CKD, preventing the rise of phosphorus with the help of PTH, followed by 1,25 dihydroxy vitamin D parathyroid hormone and phosphate.1
Common reasons for altered vitamin D metabolism in CKD are deficiency of calcidiol and calcitriol, and calcitriol resistance. Therefore, supplementation is vital in preventing deficiency using either nutritional vitamin D or active vitamin D analogs. However, there are controversies on the definition of Vitamin D deficiency in both normal individuals and the kidney disease population. Based on the Institute of Medicine (IOM) recommendation ten years ago, the values are as follows: sufficient 30-80 ng/ml, insufficient 20-30 ng/ml, deficiency <20 ng/ml, and toxicity >80 ng/ml. The interpretation of Vitamin D levels should always be made in the context of other parameters or abnormalities such as PTH, phosphate, and calcium. The main goal is not solely for repletion but to treat some consequences of low Vitamin D, either secondary hyperparathyroidism or hypocalcemia. Clinicians should interpret the levels of Vitamin D in the context of abnormalities of the CKD-MBD paradigm, not only individual levels.1
According to Nigwekar et al.2012, it is important to identify the right group of patients that would benefit from Vitamin D replacement both in CKD and long-term dialysis populations including those with high PTH levels and low calcium levels. The revised 2017 KDIGO CKD-MBD Guideline’s main goal is to prevent or minimize the therapy that can increase the tendency of hypercalcemia.1 Also, routine use of Vitamin D analog and calcitriol is not recommended.1
A longitudinal cohort study published in 2020 by Hall et al. on the Trends in Mineral Metabolism Treatment Strategies in Patients receiving Hemodialysis in the United States revealed the following information:
| Increasing Trend | Decreasing Trend |
|---|---|
| No mineral metabolism medication | Vitamin D + binder |
| Binder alone | Vitamin D alone |
| Cinacalcet |
The summary of the study showed that the change in clinical practice is primarily due to changes in reimbursement coverage. This resulted in decreased use of mineral metabolism medication. 1
Vitamin K
Cardiovascular disease is the primary cause of death among the dialysis population. This is primarily due to the 70% potential risk of crucial coronary artery and aortic calcification.1 As FGF23 levels increase, the risk of cardiovascular mortality also increases. Interestingly, matrix Gla Protein (MPG) is also being studied for its link to vascular calcification and mortality. MGP is a protein synthesized in the endothelial cells that depends on vitamin K for its activation.1,4 Its primary function is to inhibit vascular calcification, which is common among CKD dialysis patients.1,4 An imbalance between calcification inhibitors and promoters will result in calciphylaxis. According to Nigwekar 2022, calciphylaxis is a disorder of microvascular calcification and occlusion involving subcutaneous adipose tissue and dermis, leading to a painful lesion (50-80% one-year mortality).1 Potentially, there is a link between warfarin and calciphylaxis since the former works as an antagonist of vitamin K. Therefore, the activation of MGP will be affected if warfarin is present.1
Two studies that were presented highlighted calciphylaxis and its link to other factors such as warfarin and vitamin K.1 One of those studies was conducted by Nigwekar et al. in 2016, which showed that a dialysis patient on warfarin has three times the risk of developing calciphylaxis compared to those not on the drug. Another study by Nigwekar et al. 2017 revealed that patients who have developed calciphylaxis have a high prevalence of vitamin K deficiency and significantly low level of MGP.1 Other factors that effect Vitamin K status should be considered, such as deficient intake, gut microbiome, fat malabsorption, and gastric bypass surgery. Hemodialysis patients may experience a vitamin K deficiency due to their restrictive diet of potassium-rich foods containing vitamin K1 (phylloquinone) and phosphate-rich foods containing vitamin K2 (menaquinone).
In the general population, supplementation of Vitamin K1 showed evidence of slowing the progression of pre-existing coronary artery calcification.1 Vitamin K2 supplementation improved arterial stiffness in healthy postmenopausal women. However, despite a high dose of menaquinone, which improved MGP activity, the overall metabolism of this vitamin is affected due to a uremic state.
Conclusion:
Data from interventional trials using vitamin D or vitamin K in general therapy are still lacking. Therefore, clinical judgment and individualization should always be the top guiding decision to prevent adverse health consequences among patients with CKD.
References:
- Sagar, N. (2022). What’s New in CKD-MBD: The Roles of Vitamins D and K [1-88]. National Kidney Foundation Spring Clinical Meetings
- Improving Global Outcomes (KDIGO) CKD–MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD–MBD). Kidney International 2009; 76 (Suppl 113): S1–S130.
- Huang, X., Jiang, Y., & Xia, W. (2013). FGF23 and Phosphate Wasting Disorders. Bone research, 1(2), 120–132. https://doi.org/10.4248/BR201302002
- Bjørklund, G., Svanberg, E., Dadar, M., Card, D. J., Chirumbolo, S., Harrington, D. J., & Aaseth, J. (2020). The Role of Matrix Gla Protein (MGP) in Vascular Calcification. Current medicinal chemistry, 27(10), 1647–1660. https://doi.org/10.2174/0929867325666180716104159
Presentation Title: Palliative Care in Advanced Kidney Disease
Presenter: Hesham Shaban, MD, FRCPC
Author: Kristen Nonahal, RD
Learning Objectives: The learning objectives for this session focused on the definition and understanding of palliative medicine, discussion of palliative care needs of patients with advanced kidney disease, and a description of a Palliative Care delivery model for patients with advanced chronic kidney disease.
Palliative Care is a subject that has long been discussed in ESRD and CKD but is just now shining in the forefront. Palliative Care, as defined by the CAPC (Center for the Advancement of Palliative Care), “..is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve the quality of life for both the patient and the family.” From this definition Dr. Shaban expanded on the barriers and achievability of delivering and providing such care to patients. The role of Palliative medicine in specifically CKD was discussed in relation to pain and symptom management, dialysis decision making, advanced care planning, along with support and care of the patient and family. Kidney supportive care includes interdisciplinary team support with all working together for a common goal. Common symptoms of ESRD were discussed along with assessment and measurement. These include pain, sleep disorders, uremic pruritus, restless leg syndrome, nausea, dyspnea, depression, fatigue, and anorexia. Approaches to management of these were also reviewed in detail with pain being of high prevalence and severity in symptom burden. A model of a Palliative Nephrology Clinic was discussed and shared by Dr. Shaban. The Comprehensive Care Nephrology Clinic (CCNC) encompasses care of the CKD stage 4-5 patient not yet on dialysis and a patient centered shared decision-making approach. Patients are required to come with a support person or someone who they would choose to be their substitute decision maker. Every patient goes through Full Frailty Assessment, Cognitive Assessment, Advanced System Assessment: using IPOS, and Goals of Care and Advanced Care. Visits are typically 60-90 minutes. MA’s are trained to give frailty questionnaire and a chair stand test. Patients understanding of their renal disease is also assessed in addition to discussion regarding the patient’s prognosis and advanced care planning. Follow-up visits are with the NP and focus on advanced care planning. Any CKD issues or symptoms are also followed-up on at this visit…overall CKD care. The option of palliative care whether an ESRD patient on dialysis or a CKD clinic patient, needs to be an option for all our renal patients. In this type of setting patients are educated on their condition and prognosis which makes them an integral part of the decision making of their path forward
CNNT
Presentation Title: Conservative Management in CKD/ESRD
Presenter: Hasham Shaban, MD, FRCPC
Author: Deborah Halinski, RN, BSN, CNN, CPHQ
Understanding the meaning of conservative management in CKD/ESRD is an important aspect of care. In this session, Dr. Shaban provided an excellent overview for attendees. His clear and easy descriptions of many components was refreshing. I went into this session thinking that I had a pretty good understanding of what conservative management was, who is qualified for this service and what the goals would be in ESRD. My understanding was pretty accurate but Dr. Shaban was able to breakdown this service into pieces that were easy to understand.
I found it very telling in one of the slides, a word cloud, that listed what patients described as being very important in their life. If you are unfamiliar with a word cloud, it is a technique to see how many times a word appears, the more it appears the larger it becomes. In this instance, the most important things to our patients: quality of life, family, lifestyle, health and life, to name a few.
Dr. Shaban shared some very useful tools that could be used when assessing patients for symptoms and frailty. He referenced two symptom measures tools, the ESAS-R and IPOS-R. The use of such tools can help guide the physician and patient develop a plan that meets their needs. Additionally, he stressed the importance of including the patient care-giver in these discussions.
He ended the session discussing the importance for advance care planning. There are guidelines for practitioners to use when helping patients and families decide on the appropriateness of dialysis. The RPA was instrumental in developing a tool for practitioners to use, “Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis.” He provided some of the recommendations that should be considered in these cases. I feel this guide should be added to every dialysis team’s library of resources.
As our patients continue to age it is important to consider conservative management, where appropriate, and Dr. Shaban provide some wonderful building blocks to help providers.
CAP
Presentation Title: Improving the ADPKD Management Paradigm: Integrating Dietary and Pharmacologic Options to Improve Patient Quality of Life
Presenters: Neera Dahl MD/PhD, Kristen Nowak, PhD, MPH, Craig Gordon MD
Author: Ashley Kelley NP
I especially enjoyed this session. The first part of this session provided helpful information on assessing risk of progression and why assessing risk matters. There was a good discussion about the special needs and challenges for patients with PKD. The second speaker focused on dietary intervention strategies and current dietary guidelines. There was interesting information provided on the role that obesity plays in PKD along with other dietary interventions like low calorie diets and intermittent fasting. Lastly, Dr. Gordon discussed pharmacologic interventions for PKD including Tolvaptan and other novel therapies. Novel therapies included Lixivaptan, HCTZ added to V2 antagonist, Metformin, Bardoxolone, and Vengulstat. I appreciated his discussion on the “step wise approach” to ADPKD management. In my clinical practice, I take care of patients with PKD. This was a very helpful talk.
Presentation Title: Understanding Urinalysis and Diuretic Use
Presenter: Denise Link, PA (urinalysis) and Catherine Wells, FNP (diuretics)
Author: Jennie Feiger, MS, MA, PA-C
Being relatively new to nephrology and attending my first NKF conference, I was daunted by the sheer number of sessions offered and worried that the content would be over my head. So, I was relieved (haha-get it?) by the practical presentation title “Understanding Urinalysis and Diuretic Use”. Both halves of the session covered the basics at just the right level, and they provided a lot of pearls for the practicing nephrology APP. Both presenters were clear, energetic, and funny and there was a great vibe in the packed room.
Here are some random pearls from the urinalysis talk:
- When you see sterile pyuria, think interstitial nephritis. Causes of interstitial nephritis include allergic, drugs (think PPIs), infection (such as TB and CMV), Lupus or malignancies.
- Glucose is positive in urinalysis when serum levels are greater than 180. You should expect to see glucose in the urine in a patient taking a SGLT2 inhibitor. High levels of vitamin C will give a false negative.
- Don’t forget that only albumin is being measured in urinalysis. Non-albumin proteinuria can be caused by overflow (amyloidosis, monoclonal gammopathies), glomerular dysfunction (pregnancy, Lupus, IgAN, MCD, malignancy, familial) or tubular (drugs, toxins, Fanconi syndrome)
- Pathognomonic casts include WBC (interstitial nephritis), muddy brown (ATN such as myoglobinuria, ischemia, contrast, necrosis), fatty (nephrotic syndrome).
- Here are some random pearls from the diuretics talk:
- CKD is a progressive, worsening diuretic-resistant state. This is due to decreased nephron mass, renal blood flow, and bioavailability (low albumin limits drug delivery to kidney), as well as competition for the co-transporters with other drugs.
- Don’t forget that thiazides are considered first line treatment, but their effect may be lost as CKD progresses. Chlorthalidone has the longest half-life.
- Loop diuretics are the most efficient. Risks include ototoxicity and contraction alkalosis if hypokalemic. If a patient has a sulfa allergy, use ethacrynic acid. Furosemide is the least predictable of the class.
- The braking phenomenon is when naturesis is impaired despite therapeutic diuretic dose. To prevent compensatory sodium reabsorption, we often need to dose the diuretics twice daily and/or use multiple drugs to do a sequential nephron blockade.
- Sodium retention makes diuresis harder. Medications that can promote Na retention include estrogens, vasodilators, and NSAIDs.
- “Sick day rules” are a great way to counsel patients on when to hold diuretics if any decreased PO intake, fluid loss through sweating, fever, etc. I will be sure to use this term when educating patients.
Presentation Title: Treatment Updates of Diabetic Kidney Disease Based Upon 2020 KDIGO Guidelines
Presenter: Denise K. Link, MPAS, PA-C, FNKF
Author: Julie Glace Boggs
Ms. Denise K. Link, MPAS, PA-C, FNKF utilized a power point presentation to enhance her lecture. She documented her association with the Consulting and Advisory Board for Bayer Pharmaceutical. She provided the OBJECTIVES for the lecture.
She discussed the fact that Diabetes Mellitus is a global epidemic quantifying the percentages in each continent and projections for the future. She discussed diabetic complications such as Heart Disease (Myocardial Infarction, Cardiac Failure); Nephropathy, Neuropathy, Retinopathy, Stroke, and Peripheral Vascular Disease.
She specifically discussed the altered metabolism and pathological lesions of Diabetes Mellitus Nephropathy as well as results of microalbuminuria in Chronic Kidney Disease and Diabetes Mellitus. She did discuss nonspecific findings: near normal histology and typical diabetic nephropathy. She also spoke to both normal and totally destroyed glomeruli, severe arterioliohyalinosis and tubulointerstitial fibrosis.
She provided KDOQI’s definition of diabetic kidney disease. She discussed severe albuminuria as >/= 300 mg./g. or moderate albuminuria (microalbuminuria 30 – 299 mg./g. in the presence of diabetic retinopathy and type one diabetes mellitus of at least 10 years duration. She discussed the relation between Diabetes Mellitus Neuropathy and Retinopathy – proliferative Diabetes Mellitus retinopathy. She reported that all cause mortality of Diabetic Kidney Disease is not ESRD but Stroke, Myocardial Infarction, Heart Failure & Sudden Death. Albuminuria is a risk factor of Cardiovascular Disease. Patients with Type II Diabetes Mellitus with severe albuminuria are more likely to die than develop ESRD.
She reported that diabetic nephropathy treatment focus has dual goals: Prevention of Cardiovascular events and Prevention of ESRD. ACE inhibitors and ARB(s) slow progression of Diabetic Kidney in hypertensive Type II Diabetics. She discussed EMPA REG Outcome Study involving Empaglifozin, cardiovascular outcomes & mortality in Type II Diabetes Mellitus. She reported Sodium – glucose cotransporter 2 inhibitors (SGLT2 Inhibitors). SGLT 2, once in the segment of the proximal tubule reabsorbs 90% of glucose. She discussed the CREDENCE Study which looked at Albuminuria & effects on GFR. She reported DAPA – CKD study; EMPA – Kidney Study involving Cardiovascular Outcomes Trial in Type II Diabetes Mellitus; Class Effect of SGLT 2 Inhibitors on CKD outcomes.
She reported the 2020 Clinical Practice Guidelines for Diabetes Mellitus Management in CKD involved Comprehensive Care – controlling risk factors including RAS Blockade in those with albuminuria remains part of standard of care; lifestyle interventions; glycemic goals based upon A1c and glucose levels; anti-hyperglycemic treatment options; & approaches to management of patients. All of theses aspects are discussed in detail.
Recommendation 2.2.1 individualized HbA1c target ranging from <6.5 to <8.0% in patients with Diabetes Mellitus and CKD who are not treated with Hemodialysis. Diabetic Ketoacidosis risk involve those with low pancreatic reserve. The FIDELIO – Diabetic Kidney Disease is discussed. The CONFIDENCE Trial is discussed.
She included all the questions left unanswered: RAS Blockade and SGLT2 inhibitor and NS MRA; How low of eGFR can SGLT2 inhibitors safely be used; difference in treatment between Type One Diabetes Mellitus and Type II Diabetes Mellitus.
Presentation Title: Right to Live or Right to Die: Ethical Consideration with Starting and Stopping Dialysis
Presenters: Susan Wong, Aaron Wightman, MD MA; Catherine Butler, MD MA, and Alvin Moss, MD, FACP, FAAHPM
Author: Denise Jones MSN FNP
Chronic Kidney disease is a progressive disease that result in patients requiring a type of dialysis therapy to survive. Health care providers must take the time to explain to patients and to their families that there may come a time when a patient may decide to no longer receive dialysis therapy. It would be beneficial if dialysis healthcare professions could develop a standard approach for engaging patients to explore their beliefs about death. Patient support groups for dialysis patients should be a part of this systematic approach to discussing their beliefs about death to make it less frightening. Patients must be engaged into discussing their thoughts, beliefs, and fears about death. From my experience of talking with new dialysis patients, death seems more a reality to them ever before when starting dialysis. Why not take advantage of the opportunity and have that discussion on the right to die?
Advance directive is a topic discussed with patients during a hospital visit and when patients are signing their admission papers for dialysis therapy. I think conversations about advance directives should be occurring every month with patients. It may help to lay the foundation to empower patients to become more comfortable in exploring their end-of-life decisions. There must be an established standardize format that all healthcare disciplines can utilize to engage patients into discussing advance directives. It is vital to remember that one discipline may be better prepared into having those discussion with patients such as a social worker. From my own experience as advance practitioner patients sometimes feel more comfortable with discussing certain things with me then they do with their nephrologist. I have more frequent encounters with them, which helps to develop a trusting relationship with them.
Policy makers for the right to live or die must address every aspect of a patient’s well-being. This must include a patient’s current and future potential healthcare needs to make these policies realistic and effective. Patients and families deserve compassion and empathy when making right to live and right to die decisions.
Presentation Title: Chronic Kidney Disease-Associated Pruritus (CKD-aP) in Non-Dialysis Patients: Awareness and Effective Treatments Bring Relief.
Presenter: Dr. Tariq Shafi
Author: Lidia Dalessandro, APRN, DNP
Dalessandro.lidia@mayo.edu
Pruritis is a multidimensional sensitive, cognitive and motor phenomenon associated with poor quality of life. The best way to assess itching in patients with CKD is to ask whether they are bothered by itch. About 1 in 4 CKD patients have moderate to severe itching.
Pruritis is an unpleasant sensation evoking a desire to reflex to scratch, acute itch is an alarmin signal, chronic itch can be compared to chronic pain. It serves no biological purpose. Several factors such as xerosis and inflammation are common in patients with CKD; immune cells and microangiopathy can contribute to pruritis. After activation of the pruritus receptors, sensation is carried by the nerve fibers through the spinal cord to the brain. Systemic diseases, medications are often thought to be the culprit of itching. Additionally, in nephrology, the toxins are believed to cause pruritis. Several studies explored the association of toxins with uremic pruritis; however, the findings were inconclusive.
There is no diagnostic testing to diagnose itch in a similar manner as other measurable units including touch, pain, temperature, etc. The presentation of the pruritis in CKD can be highly variable in severity, timing, distribution, exacerbating factors and accompanied skin conditions. The scales to assess itch are unidimensional including visual analog scale, numeric rating scale, and verbal rating scale.
In nephrology and CKD literature, most of CKD itching assessments come from MDRD symptoms questionnaire and KDQOL-36. They are categorized as multidimensional scales. The presenter advocated asking the patients the following question to assess their itch: “Are you bothered by itch?”. Protocolizing itch assessment can be worthwhile.
Pruritis is more prevalent in patients with CKD 3b, CKD 4 and 5. The severity of the symptoms is slightly increasing with CKD progression. Additionally, people with more advanced stages of CKD have higher prevalence of moderate to severe symptoms over the years. Quality of life is lower in patients with pruritus due to reported depressive symptoms. Severe itching was associated with more severe depression and worse mental health. The frequency of hemodialysis did not show reduction in pruritic symptoms. There was some improvement of symptoms after renal transplantation.
Presentation Title: Understanding and Effectively Addressing Inequities in Health
Presenter: David R. Williams, PhD, MPH
Author: Sarah Wagner, PA-C Sarah.wagner@deaconess.com
Racial inequities in renal disease include higher burden and faster progression of CKD, and greater ESRD burden among African Americans as compared to whites. Life expectancy for whites is greater than that of their non-white counterparts even when adjusting for education and income level. To drive this home, consider the fact that in 1950 the life expectancy for whites was 69.1 years but only 60.8 years for blacks. Not until four DECADES later did blacks achieve the life expectancy of 69.1 years that whites enjoyed in the 1950s. Race drives disparities even within the same socioeconomic level. As an example, for every dollar the average white person makes, Hispanics, American Indians, and African Americans make 73 cents, 59 cents, and 59 cents, respectively. Income is not the only driver of socioeconomic status, however. For every dollar of wealth white Americans have, Hispanics and African Americans have 12 cents and 10 cents, respectively. Racism as defined by a system that “categorizes, ranks, devalues, disempowers, and differentially allocates opportunities or resources” for a subset of the population based on their race leads to prejudices, stereotypes, and discrimination by individuals and social institutions. In the United States, institutional racism led to policies such as segregation and red lining which ultimately became the driver of the racial and ethnic disparities we see today. Segregation itself can be linked to lower health outcomes for communities of color; we also know that racism on the individual level contributes to poor health outcomes as well. Racial bias on the part of health care providers, whether implicit or not, leads to poorer outcomes for patients of color. What can be done to help alleviate these disparities? We can work to gain access to health care for all. We should work to increase the number of health providers of color in order to make those providing care better reflect the racial makeup of the communities they serve. Cultural competence training should be included in every provider’s training. Finally, we must advocate to address upstream issues that directly impact the patients we serve.
Session Title: Debunking Common Myths About Patient Eligibility for Home Dialysis
Presentation Title: Physical Barriers to Peritoneal Dialysis: Prior Abdominal Surgery and Obesity
Presenter: Rob Quinn, MD, PhD, FRCPC
Author: Shawnna Read, MSN, APRN, FNP-BC, ACNP-BC
In the featured session “Debunking Common Myths About Patient Eligibility for Home Dialysis” two barriers, prior abdominal surgery and obesity, are discussed in relationship to patient candidacy for peritoneal dialysis (PD).
Many clinicians presume prior abdominal surgery clinically correlates to intra-abdominal adhesions. Using the same reasoning, providers deduce adhesions translate to PD catheter dysfunction, ultimately resulting in preemptive PD exclusion. However, research has failed to identify any association that prior abdominal surgery poses an increased risk of adhesions, infectious complications, or mechanical failure of the PD catheter.
Obesity is another common clinical issue with 48% of the US population overweight utilizing BMI measurements alone. PD concerns include metabolic consequences such as weight gain, inadequate clearance, and increased risk of infection. With initiation of dialysis, a median weight gain of 0.5 kilograms occurs in the 1st year, with a transition from lean body mass to fat mass. Adequacy becomes a concern as patients fail to meet adequacy targets as fat mass does not contribute to urea distribution.
The North American PD Catheter Registry investigated these concerns and followed outcomes in 855 patients for 1 year following catheter insertion. They noted 23% of patients with a prior abdominal surgery had a complication, and 18% of patients with no history of surgery had a complication, reaching no clinical significance. Additionally, there was no relationship between an increased number of abdominal surgeries and outcomes. They noted that central adiposity was more of a concern and acknowledged a critical step in determining appropriate adequacy when calculating the Kt/V, where V is based on ideal body weight versus actual body weight. They also established a clinically insignificant absolute infection risk of 1 episode in 14 years.
Ultimately, 1 in 5 patients will experience PD interruption or termination regardless of prior surgical history, and a history of prior abdominal surgery or obesity should not prohibit or influence decision making for PD as a modality option. In summary, there was no meaningful difference clinically with prior abdominal surgery or obesity that should affect patient modality candidacy.
Title: Survey: Advanced practitioners manage more hospital coverage, home dialysis and telehealth
Author: Sofia Thomas, DNP, MHA, AAPRN, FNP-C, CNN-NP, CPH, FNKF, FCDC sofiathomasdnp@gmail.com.
Presentation Title: Controlling Hyperkalemia for Optimal Cardiorenal Protection
Author: Hilary Bays, APRN
Hyperkalemia is a known complication of CKD and is prevalent in this population. Many providers will avoid prescribing medications that may contribute to high potassium levels. This may not be best practice.
For example, ACE-I and ARB medications are often used for cardiorenal protection. These medications are known to increase the risk of hyperkalemia; however, there are many benefits to using them.
There are now many ways to manage hyperkalemia. The use of medications such as Lokelma may be used while allowing the patient to benefit from the cardio-renal protection of ACE-I and ARB medications.
This lecture was very informative, and I feel it will likely help improve patient outcomes.