SCM23 STIPEND WINNER SESSION SUMMARIES

CNNT SUMMARIES

Submitted by Jennifer Jungemann, BSN
CNNT Stipend Winner 2023

While attending the National Kidney Foundation Spring Clinical Meetings, I had the opportunity to attend many significant courses. One such educational opportunity was Volume Management in Patients on Hemodialysis: Are We Doing a Better Job? This session was led by Sagar Nigweker and Elaine Go. Volume management is a commonly revisited topic within our clinic. Some patients receive the initial education with the occasional follow up on the topic and have great control of their fluid volume. Other patients can receive the same information and struggle with the concept. I was eager to hear what information they had to present to our patients.

The case presentation presented by Dr. Nigwekar was a common patient we would see in clinic that has difficulty with volume management. All the steps that were given in the case matched the very things we have seen and tried with our own patients. Seeing all of the educational opportunities along with the temperature settings, patient positioning, and other protocols gave a better understanding of how everything works when put together in a different manner.  We have added education on

limiting salt intake along with the reduction of weight gains between treatments to ensure patients understand the importance of both when experiencing hypotension episodes during treatments. Rather than focusing on just one topic at a time, we are covering both for those having difficulty managing their fluid volumes. It is important to get an accurate assessment of the fluid status as Elaine Go stated.  So many of our patients take many medications every day. We now educate patients to think about the amount they drink while taking these medications when calculating their fluid intake amounts.

Living in rural America presents its own struggles. We do not have access to fresh foods year-round and a lot of our patients rely on heavily processed foods. Sodium levels in this type of food is exactly what they should stay away from. The dietician takes time to educate patient on reading the nutrition label. As Go explained, adding not only sodium but also the serving size is vital.  When dealing with sodium, Dr. Nigweker encouraged us to expand the discussion to look beyond the fluid and blood pressure management and look at what happens to other organs and clinical outcomes. By expanding the education, our patients have a better overall understanding of the negative effects on the entire system.

Elaine Go discussed ensuring we are getting the accurate readings. Living in the Midwest, many patients arrive with multiple layers on. Staff has received education on removing extra layers of clothing such as sweatshirts and coats when obtaining weights and placing the blood pressure cuff to get the most accurate readings. Patients receive education about the importance of staying warm but ensuring we get accurate numbers also. This multilayer approach to education ensures both staff and patient are working towards the same goal.

Working in a critical access hospital in rural America, funding to attend this caliber of courses is scarce. I would encourage anyone interested to apply for scholarships, grants or other funding as the knowledge gained has not only benefited our staff and patients already on Hemodialysis, but also opened more education for patients with chronic kidney disease not yet on Hemodialysis. I am thankful the National Kidney Foundation gave me the opportunity to attend this year’s conference and I look forward to attending more in the future.

Submitted by Tina Ishcomer, BSN, RN
CNNT Stipend Winner 2023

 As I reflect on what I learned while at the NKF conference in Austin, many things come to mind. This was my first year going and I was amazed at all the information that I was not aware of. In the field of dialysis things are ever-changing.  I also found many resources for my clinic. We are a small independent clinic and education is hard to come by— especially anything that is new. This was like a breath of fresh air for a seasoned nurse like me.  

I learned (or was reminded) to be a good listener and encourager and to focus on the individual strengths my patients have.  I am an advocate for my patients and sometimes we must be reminded of these things. I am their cheerleader and I want to tell them, “You got this.” Sometimes, as dialysis nurses we forget our patients need a cheerleader, and many don’t have any family to be their support. We as professionals need to watch what we say and how we word what we say to the patients.

I also learned that the ones that reject us the most are usually the ones that need us to keep working with them the most.  Our patients are individuals, and each plan of care is individualized as such. We must ensure education and compliance with medications, treatments and so on. 

I was amazed at the newer medications coming out for K+ binder and itching during treatment. I learned about PO medication to help for anemia. There were also best practices with IV iron that I was not aware of. The case scenarios reminded me of the best practices I had forgotten about. I was also reminded, how we approach and word different with our patients can make a difference in their life.

I really liked the session on missed treatments and the factors associated with missed treatments; it was good information to take back to my staff. The outcomes associated with non-adherence to treatments and medications are huge.  It also educates on the ways in which to improve outcomes with our patients. 

I was reminded of the fact that sometimes we need to help motivate patients more. We can get ‘stuck in a rut’. We as caregivers must observe and see how we can do this in a positive, motivational and kind way.  

I want to say thank you from the bottom of my heart. This was an awesome experience and really reminded me why I love my job and my patients.  I cannot tell you how much I needed this conference.  It is an awesome event and the NKF should be very proud of what they are doing in the world of CKD.

 

CNSW SUMMARIES

Submitted by Laura Dameron, LMSW
CNSW Stipend Winner 2023

Missed Treatments: The Challenge We All Face   

Getting patients to attend treatments is a challenge for most dialysis units.  We know the risks patients are taking when they do not follow their treatment prescription.  We also spend a lot of time “telling” patients why it matters.  Why aren’t we more successful conveying this important message?  Several sessions at NKF SCM23 offered ideas that may help us find new ways of communicating on this subject with our patients.

First, are we lecturing our patients about the risks and creating additional barriers to attending in doing so?  Patients having difficulty attending state it is even harder to make themselves show up when they expect a “scolding.”  Let us welcome them and make sure they know we are always glad to have them here instead.

Second, are we only discussing the importance of attending when they are on treatment?  Are they functioning at their cognitive best while receiving treatment?  Some research shows that patients may have temporary reductions in cerebral blood flow during dialysis reducing cognitive function or causing drowsiness.  Can they hear our concern and care over the background noise?  Is there a reason they are missing treatments that is too embarrassing to discuss where others might hear?  Try a variety of teaching methods and venues to engage patients and build collaboration.

Third, have we asked the patient what is most important to them?  Can we help them to see that their participation in treatment is an investment in their future?  Can we help them see that caring for themselves will allow them to care for their loved ones into the future (remember to don your own oxygen mask before helping others)?

Fourth, have we checked again if another modality would make it easier for the patient to get regular dialysis?  Or are they ready to stop treatment, but do not know how to tell their family?

 Fifth, do we have patient champions available to help new patients adjust to the demands of dialysis?  Are we providing information about dialysis, the machine and filter, in small doses with adequate, but not excessive, repetition?  

The answers will be different for each unit, and likely each person within that unit.  However, if we can really look at what we wish to say and how we are communicating this important information, perhaps we can find ways to improve the reception of our message and support our patients to live their best lives possible.

Submitted by Tammy Herrell, MSW, LISW
CNSW Stipend Winner 2023

I had the great pleasure of attending the NKF Spring Clinical Meetings in Austin, TX this year as a CNSW educational stipend recipient.  As a first-time attendee and a relative newbie to nephrology social work, I was quite delighted and honestly a bit shocked at the overall collaborative nature of the conference.  I have been a social worker for 17 years, and throughout my career I have not experienced the level of support, encouragement, and cooperation from other interdisciplinary professionals as I have in nephrology, and more specifically, in the dialysis setting.  So one might imagine the joy I felt throughout the duration of the conference.

I was asked to write a reflection about one of the workshops I attended.  While it was a difficult decision to choose which one among so many inspiring and informative presentations, I want to summarize what I learned in “Missed Treatments:  Strategies for Reduction and Patient Engagement” led by Vernon Silva, LCSW, FNKF.  Missed treatments is obviously a concern to dialysis clinics as we know patients ultimately do better and reduce their risk of hospitalization and mortality if they attend every treatment and complete them in their entirety as prescribed by their nephrologist.  Additionally, from a business operations perspective, missed treatments impact revenue from health insurance reimbursement, clinical performance measures, and scheduling/staffing needs.

So, what made Mr. Silva’s presentation stand out to me so much?  It is because he proposed a paradigm shift in the way that social workers, in particular, approach this topic.  He discussed how we are taught a more traditional approach using strengths-based, optimistic interventions that value patient self-determination, provide multiple options, offer supportive counseling, and view the patient as the most important member of the team.  None of these things are wrong or go against our social work values and ethics.  However, Mr. Silva suggested that we consider building upon and, in some cases, replacing or rejecting aspects of this traditional approach with a more directive one.  Yes, of course we social workers will continue honoring a patient’s right to self-determination and utilizing the strengths perspective, but Mr. Silva challenged the audience to take a more reality-based, trauma informed approach when talking about missed treatments and the reasons behind them with our patients rather than falling back on our tendency to “sugar coat” the dialysis experience.  In this shared power and decision-making framework, social workers are asked to consider being more directive and persuasive, viewing the renal professional as the expert of ESRD and the patient as expert of self.  The words we use with patients can be fine-tuned to reflect this approach without compromising who we are as social workers.

I started thinking about how I could better approach my patients when discussing missed treatments.  First, I want to work on rapport building and gaining my patients’ trust.  Second, I want to be “real” with them.  Affirm their feelings and acknowledge that life on dialysis is hard and can be really awful at times.  However, I do not want to just stop there.  This is when I can reach into my social work toolbox and utilize interventions such as Motivational Interviewing, Cognitive Behavioral Therapy, grief processing, etc., to dig deeper into the reasons behind the missed treatments, understand their motivation for coming to treatments when they do attend, and work collaboratively with the patient to build their coping skills and help them problem-solve to address the issues impacting their ability to attend treatments.  I want to flip the script that I use and focus on the benefits of dialysis and how it can contribute to their overall quality of life rather than the more threatening, fear-provoking approach of the consequences of missing treatments.  Even though patients may feel like so many things in their lives are out of their control, my hope is to remind patients that what they can control is investing in their health now in the hopes of having more positive outcomes in the future.  

In conclusion, I left this workshop feeling hopeful about how I can better understand the reasons why my patients miss treatments as well as tap into my social work knowledge and skills to provide the mental health support they may need to adjust to life on dialysis, collaboratively and creatively problem-solve to address issues impacting their attendance, and ultimately live their best life.  Nephrology social work is a unique field of practice, and I would like to express my heartfelt thanks to NKF for making this conference possible and to CNSW for providing the financial support that allowed me to attend SCM23 and leave feeling inspired and refreshed for the future.

Submitted by Kelly Seifert, LCSW
CNSW Stipend Winner 2023

Presentation Title: Interprofessional: Many Miles to Go to Reach People Who Are Uber Marginalized
Speakers: Tiffena Pierce, DSW, LMSW, NSW-C, FNKF, Tessa Novick, Lilia Cervantes/Katie Rizzolo

This session focused on three marginalized groups that all had kidney disease, including incarcerated individuals, individuals with unstable housing, and undocumented immigrants. It was eye opening to hear that individuals receiving their first-time medical care was when they were incarcerated and the number of inmates that have a diagnosis of kidney disease. One of the biggest concerns is the lack of a detailed after-care plan once the inmate is released. The session discussed how coordinated and detailed a hospital discharge is vs. a prison discharge, which outlined the extensive work that is arranged for hospital discharge patients. The suggestion is to link people to healthcare services post release to help improve the health and well-being of those who are incarcerated and those with a history of incarceration. 

Kidney care delivery for people experiencing unstable housing appears to be very challenging, but there are several considerations discussed that attempt to address the barriers. It makes sense when one of your basic needs like shelter/housing is not being met, that some of your other needs are not necessarily prioritized as they would be if all of your basic needs were being met. I liked hearing about the idea of completing a sensitive housing screening survey to discover which patients may be experiencing unstable housing and then be able to offer the needed resources/support to address this concern. The session also covered how important being aware of a patient’s housing situation impacts their labs, appointments, medications and supplies. 

The path towards providing kidney care for undocumented immigrants described the distinctive policy barriers for undocumented people with kidney disease, how policy in healthcare can further inequities, and ways to improve access to equitable care for undocumented people with kidney disease.  This session discussed how emergency Medicaid can provide some coverage and how this can vary depending on the state. It is important to ensure kidney failure is included as a condition for emergency Medicaid. It appears money is saved in the end with adding kidney disease to emergency Medicaid. There appears to be very few states that have included kidney failure as a condition for emergency Medicaid. The speaker suggested writing letters to your state Medicaid directors to help advocate to have kidney failure included. 

Submitted by Anthony Stallworth, LMSW
CNSW Stipend Winner 2023

Unpacking “isms’ and Privilege in Dialysis Facilities to Improve Patient and Provider Outcomes

What can I say about the NKF Spring Clinical Meetings in Austin, Texas? One word, WOW. It was amazing to be a part and around so many professionals who share the same passion, learning, and urge to change the circumstances of so many people impacted by kidney failure. I had the privilege of being awarded a stipend and conference registration to attend this meeting. There were so many great sessions with so many great leaders in the roles of doctors, nurses, social workers, and dietitians.

The session that stood out to me was by social worker, Elanderia Rowe. I had the pleasure of meeting her at the opening reception and talking to her about my experiences in the area of nephrology and where she pictures the role of the renal social worker heading. Her session in unpacking “ism’s” and privilege brought me back to why I entered the field of social work. One of the reasons I entered the field of social work is to help people who are impacted by the way of the world. It is also to help them cope and thrive with the privilege and many “ism’s” of the world and society we live in. This topic she spoke on is foundational social work, and she broke it down so simply. No matter what field of social work you are in, you will encounter privilege and its impact on marginalized communities and more specifically our patients in the dialysis facility. With the discussion and demonstration of what privilege we encountered in our own lives, we become more informed. With this information, we can provide better service and intentional care to our patients.

Lastly, I am grateful for this opportunity and happy about all of the people and connections I made to educate myself and be a more impactful social worker in this profession of social work and the community of nephrology. This opportunity has lit a fire to continue to advocate and use my voice to enhance the lives of the patients we encounter. I want to say thank you to the National Kidney Foundation for the opportunity to be able to listen, learn, and be a part of life-changers for the empowerment of the people we serve daily. 

Submitted by Jennifer Sumner, LMSW
CNSW Stipend Winner 2023

New Nephrology Social Workers: Tools, Techniques, and Strategies for a Successful and Effective Practice

I had to opportunity to come to the 2023 NKF Spring Clinicals as my first clinical conference as a nephrology social worker.  I have worked as a pediatric social worker for a year and a half.  This population is one that I never could have imagined.  The medical complexities and quality of life of our patients is overwhelming.  

This particular workshop addressed the ins and outs of best practice for nephrology social workers and how to incorporate the information into my work with children.  To be in a setting with other nephrology social workers, who understand the work, was amazing.  We discussed the case management aspect of nephrology social work; building trust and being “where the client is” during interactions with patients.  I received more background on the ESRD Network and validation on the stress my patients and their families endure.  

We discussed signs of trauma – physical, social, mental, emotional, and behavioral – and how social workers can support families through these stages.  I learned about the nephrology social work skills, including identifying the issues – medical, ethical, legal, mental health, boundaries, etc.  I was reminded to use the patient’s strengths and to make sure the medical team knows the strengths of our patients and families.  I was reminded of trauma informed care principles and how it’s different than traditional care.

Another aspect of this meeting I found helpful was information on documentation and progress notes – what is important and what verbiage is most beneficial.  

Overall, I came back from the Spring Clinical Meetings refreshed and informed as a newer nephrology social worker.  It helped me understand why certain methods are implemented with nephrology patients and it served as a reminder of why I do what I do.  Thank you for the opportunity!

 

CRN SUMMARIES

Submitted by Shannon Bares, RD, CSR, LD
CRN Stipend Winner 2023

2023 SCM Addressing Eating Disorders in Renal Disease

Eating disorders and disordered eating (ED/DE) aren’t mentioned often in renal nutrition, and research in ED/DE and CKD is lacking. Amanda Hays, MS, RDN, LD, addressed the prevalence and complications of ED/DE at the 2023 NKF Spring Clinical Meetings and how registered dietitians (RDs) working with CKD/ESKD patients can identify disordered eating patterns and involve the interdisciplinary team to address the ED/DE and barriers to patients getting treatment for their ED/DE.

In the United States, 9%, or 28.8 million Americans, will have an eating disorder in their lifetime. ED/DE do not discriminate, impacting all races, genders, and sexual orientations, with LGBTQIA populations at increased risk and incidence. RDs are often most familiar with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), which was more recently given its own diagnosis in the Diagnostic and Statistical Manual- 5 (DSM-5); however, “Other Specified Feeding and Eating Disorders” (OSFED), replaced the previous category of “Eating Disorders Not Otherwise Specified” (EDNOS) and includes atypical anorexia nervosa (AAN), night eating syndrome (NES), purging disorder, binge eating disorder of low frequency or limited duration, and bulimia nervosa of low frequency or limited duration. AAN is more common than AN despite the name and includes the typical criteria for AN with exception to low weight/BMI status. Orthorexia nervosa is not currently a diagnosis in the DSM-5, but is often linked to AN. If the patient is more concerned about moralistic aspects of diet and is not concerned about body shape or size, this can also lead to malnourishment and significant psychosocial problems. An important question to ask is, “Are you doing these behaviors out of respect and care for your body, or are you doing them in order to make your body worthy of respect and care?”

The majority of those with ED/DE do not seek treatment for many reasons, including shame/stigma, lack of insurance coverage for treatment, or lack of time or difficult schedule (for example, someone on hemodialysis 3x/week). Though RDs cannot diagnose ED within their scope of practice, they can identify signs and symptoms and can use the Nutrition Care Process nutrition diagnosis of disordered eating and refer to the MD to get appropriate psychological treatment. The social worker is also a crucial part of the team and can help address barriers to getting ED/DE treatment. 

The risks for renal health in eating disorders include chronic dehydration and hypokalemia, metabolic alkalosis from chronic vomiting, hyperchloremic acidosis from laxative abuse, nephrolithiasis, chronic rhabdomyolysis, and nephrocalcinosis and hypercalciuria. Particularly with AN/AAN, >5% will develop ESKD after 21 years. Chronic dieting in BED and NES is associated with metabolic syndrome and higher HgbA1c, blood pressure, and circulating inflammatory marker levels.

So, how do RDs identify ED/DE and best support these patients? Building rapport so that patients are willing to share their eating habits and thoughts surrounding food and weight is always most important or an ED/DE may be overlooked. Focusing on behaviors and not weight is an important strategy. Keeping a weight-neutral stance, encouraging regular meals, and intuitive eating can help promote a healthy eating pattern, but the psychological aspects should be addressed by a mental health professional to truly overcome their ED/DE. The presentation reviewed several case studies, including one of a higher-weight patient with AAN, where instead of finding symptoms of ED/DE, health professionals had been encouraging the patient to continue weight loss. Let’s ask more open-ended questions and use our motivational interviewing skills to elicit information from our patients so that their ED/DE does not fly under the radar, and we can optimally treat our CKD patients who struggle with eating and their body image.

Submitted by Christine Benedetti, MS, RDN, CSR, CCTD, LD, FNKF
CRN Stipend Winner 2023

A Summary of “Simple and Realistic Cooking Techniques for Kidney Disease”

Welcome to the future of nutrition education! This presentation demonstrated how a visual and hands-on approach can help improve outcomes, confidence, and overall success in our patients meeting their recommended nutrition needs.

Certainly, cooking can come with many barriers. Our patients may have never had the opportunity to cook before. They may not know what tools they need or have the means of getting these tools. They may not feel well enough or have enough energy due to their disease process, medication side effects, co-morbidities, being under-dialyzed, or even due to a recent hospitalization. Their lack of appetite, cravings, and overall perception of a kidney-friendly diet can also be barriers. Our patients can feel discouraged by the idea of diet restrictions and find it difficult to track various nutrients. How can we as clinicians break down these barriers and help our patients thrive?

Jackie Termont, a renal dietitian for DaVita Kidney Care, provided an adult-oriented perspective for simplifying meal prep. Meeting our patients where they are and helping them make slow, simple, realistic goals was the common theme. Having our patients drive the conversations can help them incorporate different habits moving in the direction of using less processed, whole foods. For those patients who may already cook, she proposed the idea of the 25% rule. Reduce certain ingredients in your recipe by 25% to reduce nutrient content. Recipe substitutions and portion control on favorite food items are additional options to promote healthier habits without the feeling of missing out. When our patients are new to cooking, find simple, culturally relevant recipes and offer to print or email them. Start a conversation about where they shop! This can provide insights into what’s available and further meet them where they are. For instance, shopping at gas stations and food pantries may present different options and barriers versus a dollar or grocery store. Looking for steamer bags, low sodium convenient items, and foods that may keep longer can be helpful depending on their needs. How can we assist in reducing overwhelmed feelings to maintain good habits once they start, and why do they make certain choices? Are they looking for the cheapest option, trying to think “healthy” or going for convenience? As clinicians, we cannot assume our clients know certain things that may be second nature to our own habits, like reading food labels or how to season foods. Reviewing flavor preferences can help us focus on what spices and staples to purchase to make the best use of their time and money. Getting them to take pictures of their pantries can help us see what’s already in place to work from. Then, focus on the most versatile products from there. We can also review how to use leftovers to reduce waste and provide realistic meal combination ideas. Portioning their recipes and freezing leftovers can make an easy grab-and-go meal on a day when cooking isn’t an option. Meal combinations can offer a variety of options to pull from, which continues to allow our clients to maintain control of their choices. Lastly, Jackie showed us that DaVita offers a variety of creative educational and cooking videos, which demonstrate food comparisons and making easy recipes. In our clinics, we can make creative bulletin boards, show plates with food pictures, or show pictures breaking down a recipe prep step-by-step. Making each step of the process simple, easy, and manageable for anyone.

Paige Vondran and Elisha Pavlick discussed their successful interventions on this topic in pediatric populations at Children’s Hospital of Philadelphia (CHOP). Meet Paige Vondran, their Medical Chef Educator promoting kidney health through culinary medicine. Vondran brings a novel approach through experience as a trained Chef and Speech Language Pathologist. Elisha Pavlick, their pediatric renal dietitian, helps incorporate the renal diet specifications. Together, their collaboration helps patients and families visualize and practice incorporating changes into their daily routines, making it a reality. CHOP applied for grants to fund this unique role and utilized interns to develop specialty diet recipes. Funding sources could also come from your company or nephrology divisions, if available. Pavlick outlined nutrient specifications, like sodium per serving of 35-140 mg, a 12 mg phosphorus/g protein ratio while avoiding phosphorus and potassium additives and keeping potassium <200 mg per serving. They determined what the most popular recipe requests are, like finger foods, school lunches, feeding therapy on-the-go, and desserts, and looked for budget-friendly ingredients that can still meet different renal goals. They tested recipes, created handouts that are available for patients in the clinic, educated staff, and made recipes and videos available on the CHOP website, along with newsletters for those interested. Once you have a variety of recipes created, Vondran recommends putting them together to create a cookbook which you can then offer for free or for sale to cover the expenses of your endeavors. They utilize a videographer to demonstrate cooking techniques and to reiterate the nutritional benefits of following their diet recommendations in a visually creative, quick format. CHOP also provides a variety of in-person or virtual cooking events and demonstrations throughout the year, like Nephrotic Syndrome Day and day camps utilizing their teaching kitchen. As CHOP is a teaching hospital, they have also developed a curriculum for residents who are interested in Culinary Medicine. Even without a medical chef educator at your facility, Vondran outlined how to implement the concept of culinary medicine at your center. You can start by using pre-developed recipes from websites or other centers, provide patients with local resources, provide virtual cooking classes, and consider getting your ServSafe Certification. Those lucky enough to attend the session in person were able to sample Vondran’s own no-bake recipe for “Energy Bites”, incorporating rolled oats, macadamia nuts, coconut milk and flakes, and dried dates. She offered variations of the recipe, like adding egg and baking to make a muffin or using different seasonings and spices, like honey, cinnamon, vegetables, or fruits. When it comes to recipe creation, the sky is the limit!

This patient-centered learning trend promoting the hands-on experience and skill development of cooking can help our patients and families gain the confidence needed to promote healthier, more sustainable eating habits. This can help them meet their laboratory goals and outcomes, but most importantly help them feel better, improve their quality of life, and promote longevity.

Submitted by Alexis Briley, MS, RDN
CRN Stipend Winner 2023

CKD-MBD: Old Problem

Chronic kidney disease metabolic bone disorder (CKD-MBD) is defined as abnormalities of calcium, phosphorus, intact parathyroid (iPTH) or vitamin D metabolism, and FGF-23. It’s multifactorial leading to further complications such as, increased bone fractures, secondary hyperparathyroidism, vascular calcification, progression of renal failure, cardiovascular disease, and mortality. 

Mr. Juergensen began his presentation on this topic by discussing a case study about a patient of his who experienced these complications related to CKD-MBD. He then went on to discuss the importance of understanding the normal physiology of bone mineral metabolism as it relates to calcium, phosphorus, and iPTH homeostasis while explaining the metabolic pathways of each. He then discussed each mineral and how it’s affected when the kidney starts to fail.  KDIGO 2017 recommendations were reviewed regarding appropriate bone mineral metabolism lab values, use of calcitriol and vitamin D analogs, initiation of calcimimetics, and surgical options to treat abnormal levels of calcium, phosphorus, and iPTH in non-dialysis and dialysis patients. Mr. Juergensen reviewed ways to treat bone and vascular disease according to the KDIGO 2017 recommendations, by 1) controlling iPTH and phosphorus levels; 2) using supplementation of vitamin D when appropriate for non- ESRD and ESRD patients; 3) treating acidosis; and 4) encouraging CKD patients to maintain an active lifestyle using weight bearing exercises to help reduce further complications. He also discussed refractory hyperparathyroidism which is the persistent and progressive elevation of iPTH levels greater then 800pg/ml. Surgery is indicated for pre-transplant patients but emphasized the importance of preparing the gut 1 to 2 weeks prior to surgery with calcitriol to reduce hungry bone syndrome and acute hyperkalemia. 

New Solutions  

Mr. Juergensen reviewed new research findings related to CKD-MBD abnormalities. One study found that the initiation or increase use of statins can potentially increase calcification and serves no clear benefit for kidney patients. Another study found that increased supplementation of magnesium did not slow the progression of vascular calcification. Researchers also found that hyperphosphatemia can contribute to more DVT’s and fistula clots due to poor circulation among dialysis patients. The latest research study has found that there is no correlation between having elevated phosphorus levels and itching but more research is warranted on this subject. Lastly, researchers found that higher levels of directional range phosphates were associated with a higher risk of all-cause mortality among hemodialysis patients. 

Unfortunately, close to 80% of kidney failure patients are unable to consistently achieve the recommended target guideline for serum phosphate levels with current therapy of phosphate binders and diet education. However, a new medical treatment for elevated phosphorus called, tenapanor (Xphozah), reduces intestinal phosphate absorption. Early results have indicated that tenapanor has a future place in managing hyperphosphatemia in ESRD patients, but more studies are warranted. Mr. Juergensen went on to discuss the importance of making sure a kidney patient’s bicarb level stayed above 22 to preserve kidney function and prevent damage to the bone. Finally, he ended the first part of the presentation by urging interdisciplinary team members to understand the disease state and the individual patient to educate and encourage them to be compliant with medications, diet, and treatment. He also stressed the importance of working with a registered dietitian to educate patients on dietary sources of organic and inorganic phosphates to improve phosphorus knowledge and compliance with a low phosphorus diet.

Anemia

Mr. Juergensen went on to start the second part of his presentation on anemia in CKD. Chronic anemia is associated with worse Quality of Life (QoL) outcomes and higher risk of left ventricular hypertrophy (LVH) among CKD and ESRD patients. He reviewed the primary causes of anemia, KDIGO treatment recommendations for erythropoietin stimulating agents (ESAs) and iron dosing among CKD and ESRD patients.

So, what’s new for anemia management in CKD and ESRD? First, he discussed the metabolic pathway of HIF-polyhdroxylase for the treatment of anemia in ESRD. Unfortunately, the FDA recently rejected Akebia therapeutics’ anemia drug, Vadadustat, for use in CKD patients due to concerns with vascular access complications and liver toxicity. However, the FDA did approve an oral drug called Daprodustat, which raised and maintained hemoglobin levels between 10-11 gm/dL for CKD adults who have been on dialysis for greater than or equal to 4 months. Initial use is for patients who are hyporesponsive to ESAs and thus are on a high dose of ESA therapy. In addition to a boxed warning, the most common side effects include elevated blood pressure, thrombotic events, dizziness, abdominal pain, and allergic reactions. Mr. Juergensen concluded that the management of anemia in CKD is very complex. However adequate anemia treatment during CKD stages 3-5 and dialysis are important to improve quality of life and clinical outcomes. He urged IDT members to administer iron when necessary and to follow appropriate dosing guidelines from KDIGO. 

Submitted by Angela Jacobs, RDN, LD
CRN Stipend Winner 2023

1.  Outline resources for how to implement and/or utilize culinary medicine.

2. Articulate how most foods can be incorporated into a kidney-friendly diet.

3. Discuss barriers to cooking for kidney patients.

After speakers’ presentations, followed a Q & A session and a brief cooking demo along with an offered tasting of Energy Bites.  Recipe available via the link below. 

The first speaker, Jackie Termont, is a registered dietitian with DaVita who talked about how to assist patients in overcoming barriers to following a kidney-friendly diet and ways to address patient concerns.  She identified barriers such as lack of appetite, salty food cravings, bland diet, fatigue and difficulties with tracking nutrients.  She suggested keeping it simple by just moving to more whole foods and less processed foods.  Importance of involving the patient by helping them drive the conversation.  Start slow by first establishing what exactly the patient/family is looking for.  What’s their goal and/or needs? Be sure to consider patient’s favorite foods, how they could adjust their favorite recipes, and incorporating cultural preferences.  Add in discussions of new trends like plant-based proteins. She mentioned that it could also be beneficial to find out how & where your patient is grocery shopping.  Questions to ask include:  Are they using food/grocery shopping apps?  Are they buying convenience foods for cost or as cooking aids?  Ask where they do they grocery shop; gas station, dollar store, food pantries or grocery stores.  Think about specific ingredients and explore more spices.  Don’t forget to discuss food safety.  Use bulletin boards as a way to show recipe steps, plates with food pictures, or a ‘This vs That’ food choices display.   Finally, promote short education videos that demonstrate cooking recipes such as DaVita Eats.

The next speakers, Elisha Pavlick, RD and Paige Vondran, chef, both work for Children’s Hospital of Philadelphia (CHOP) and talked about how culinary medicine impacts clinical care. They explained that culinary medicine has been around for a very long time and referenced traditional Chinese medicine as an example.  CHOP has invested in a new kind of program that utilizes a collaborative team approach to develop projects that “Let Food Be Thy Medicine”. The main team members include a Dietitian and a Medical Chef Educator who is a trained chef with a special interest in nutrition and the medical field but is not an official expert in either.  The program’s main goal is to develop and provide recipes in a variety of formats.  These tested & analyzed recipes are then used to produce recipe handouts, a recipe website, and publications for the hospital magazine and e-newsletters. These recipes are also for creating cookbooks (in which proceeds help fund the program) and professionally made short cooking videos along with conducting cooking events and demonstrations.  They have even created a popular cooking camp for families.  Check it out at: https://www.chop.edu/kidney-friendly-recipes-kids.

Submitted by Lauren Kline, RDN/CD
CRN Stipend Winner 2023

While I attended many highly educational sessions at the National Kidney Foundation Spring Clinical Meeting 2023, the Alkaline Diet Considerations in CKD session with Melanie Betz, RD, “The Kidney Dietitian”, was the most impactful for me as a new dietitian.

Summary

• Brief refresher on the kidneys’ role in managing pH levels and what acidosis is in CKD and why it is undesirable (leads to CKD progression and death)

• Fact-checking information about alkaline diets from Dr. Google and what our patients see

  • Some incorrect information regarding an alkaline diet listed on Google includes recommendations to buy organic foods, drink alkaline water, test your pH level, avoid high sodium foods, avoid milk, avoid peanuts and walnuts, and eat only raw foods

• What an alkaline diet actually is

  • An alkaline diet is plant-based and low in non-dairy animal protein. It consists mostly of vegetables, fruits, beans, nuts seeds, and legumes but does include small amounts of acidic foods such as meat, poultry, eggs, fish/seafood, and grains.

• Provided an equation to calculate the Potential Renal Acid Load, or PRAL, of food using protein, phosphorus, potassium, magnesium, and calcium

• Potassium and how much is absorbed from plant v. animal v. processed foods

  • When reducing potassium in diet from plant foods, also reduce fiber, alkali-producing foods, vitamins, minerals, antioxidants, and phytochemicals

  • Other factors influence potassium such as meds, residual kidney function, hydration, acid-base, glycemic control, adrenal function, catabolism, GI (vomiting, diarrhea, constipation, bleeding), PA, and fiber intake

  • Focus on glucose control, preventing constipation, improving acidosis

  • Reduce intake of very highly concentrated sources of potassium such as juices, sauces, enhanced meat products, supplements, and large portions of high-potassium foods

I have always practiced from a whole food, plant-based perspective but this session gave me much more insight into how beneficial this diet is for patients with CKD. I can now confidently recommend an alkaline diet for my pre-transplant patients and, should they want more information, explain to them the exact benefits of the diet. Simultaneously, I feel more certain about the benefits of including fruits and vegetables even if they do have potassium in them since potassium intake does not necessarily increase serum potassium levels, especially when there is fiber and glucose intake involved. Thank you, Melanie, for a very impactful talk!

Submitted by Julius S. Navarro, RDN, CSR, CNSC, LD, FAND
CRN Stipend Winner 2023

Presentation: Kidney Failure in Older Adults: All You Wanted to Know but Were Afraid to Ask
Presenters: Bernard Jaar, MD, MPH; Susan Wong, MD, MS; Christine Corbett, DNP, APRN, FNP-BC, CNN-NP, FNKF

The prevalence of end-stage kidney disease (ESKD) among the elderly has significantly increased by 107% since 2000, according to the 2022 USRDS Annual Data Report. The adjusted prevalence by race/ethnicity is significantly higher among the Black and Hispanic populations. While the adjusted prevalence by age showed that older adults 65-74 years old and 75 years and older have higher reported cases than other age groups.

In 2020, there was a substantial increase in in-center hemodialysis as the choice of modality among older adults >75 years of age. In contrast, home hemodialysis was significantly low among the elderly population with ESKD. The significant increase in in-center hemodialysis is related to late referral to a nephrologist for pre-ESKD care. The 2022 USRDS reported that almost 50% of older adults had not seen a nephrologist for more than 6 months before starting renal replacement therapy (RRT). Late referral results in insufficient time for the patient to be prepared for RRT or conservative care options, leaving them with no choice but to start in-center hemodialysis.

Older adults have several comorbidities that need to be considered before choosing in-center hemodialysis as a treatment option. The common comorbidities are diabetes (50%), hypertension (90%), and cardiovascular disease in any form (>80%). These comorbidities significantly affect the five-year survival probability in this population. The data showed that 75 years and older have no more than a 20% rate of survival related to several comorbidities.

The decision about dialysis treatment must be patient-centered. The patient and family should know different factors to consider beyond dialysis, including survival, quality of life (QoL), satisfaction with care, financial issues, and burden to the family. Below are the ESKD treatment options.

Figure 1. Adapted from the lecture of Dr. Bernard Jaar: Burden of Kidney in Older Adults¹

Dialysis has limitations and is not universally beneficial. This treatment has limitations in restoring one’s health. Most of the patients who started dialysis did not have health improvement. Instead, it even worsened the case.  Limits to maintaining function: Within a year after starting dialysis, most patients over 80 start becoming dependent and eventually die. End-of-life care: Patients treated with dialysis are more frequently hospitalized, receive intensive procedures in the final month of life, increased in-hospital death, have palliative consultation, and receive hospice care. There is significant evidence that for some patients, dialysis does not add longevity or QoL beyond what can be achieved in conservative kidney management. Also, median survival in patients with CKD 4 or 5 and significant comorbidity reported no difference between conservative and dialysis. A systematic review of the QoL trajectories shows positive results in overall QoL, mental well-being, physical well-being, and psychological symptoms in 8-24 months follow-up of conservative patients. Hence, conservative kidney care may be considered a viable option among this group of individuals. Dialysis is the default treatment for advanced CKD in the US despite evidence of the positive outcomes of conservative care among the elderly.  Also, those patients who do not want to pursue dialysis have difficulty gaining support for their decision.

Barriers to Consider in Kidney Disease Management²

System	Provider
Lack of training, research, and education	Fear of doing nothing
Lack of clinical practice guidelines (focus predominantly on dialysis)	Fear of taking away hope
Financial incentives	Fear of practicing “outside of norms”
The technological imperative	Acting on best interests and moral distress
	Practice inertia

 

Shared Decision-Making

A proactive and collaborative approach to decision-making should have a strong foundation that rests on patient and clinician rapport, an equal perspective from patient and medical or clinician, a deliberative decision style, and bonded by strong communication. Good communication is associated with greater patient care satisfaction, greater patient medication adherence, reduced litigation against clinicians, and reduced clinician burnout. Communication frameworks can help reach goal-concordant treatment decisions as it gets you to the patient’s perspective.

Conservative Kidney Management

Conservative kidney management is a reasonable alternative to dialysis for some of our patients.

Older adults with kidney failure should be evaluated appropriately to know if dialysis would provide a survival advantage—different factors such as age, comorbidities, frailty, functional impairment, cognitive impairment, and malnutrition should be considered. Functional Screening and Prognostic Tools such as Karnofsky of score <40 or Charlson Comorbidity Index (CCI) >8 scores are poor candidates for dialysis.

Those who may benefit from dialysis withdrawal:

• Self-expressed poor QoL

• Limited life expectancy

• Uncontrolled pain or other debilitating symptoms

• Progressive disease

• Difficulty with dialysis (vascular access issues)

• Frequent hospital admissions

• Patient wishes.

In conclusion, dialysis works for some but not for all; therefore, conservative kidney care management may be reasonable for some.

References:

1. Jaar, B. (2023). Burden of Kidney Failure in the Older Adult [1-21]. National Kidney Foundation Spring Clinical Meetings

2. Wong, S (2023). Promoting goal concordant treatment decisions. [1-]36 National Kidney Foundation Spring Clinical Meetings.

3. Corbett, C (2023) Conservative Management is a Viable Option! [1-43] National Kidney Foundation Spring Clinical Meetings.

Submitted by Amber Parisie, RDN, CSR
CRN Stipend Winner 2023

Presentation Title:  The Future of Telehealth
Chair:  Lauren Levy, MS, RDN, CSR
Speakers:  Marsha Schofield, MS, RD, LD, FAND; Ingrid Knight, RDN, LD

The Future of Telehealth was a very timely presentation for RDNs providing telehealth, considering the public health emergency (PHE) due to the Covid-19 pandemic has ended. Marsha Schofield and Ingrid Knight both provided a wealth of knowledge to fulfill the objectives of the course and prepare the RDN for the future of telehealth. 

Marsha started the presentation by discussing legal and regulatory matters surrounding telehealth services provided by RDNs for patients with CKD. She shed light on the different definitions of telehealth and who regulates policies for use. We learned how to determine where to look for information on telehealth policies, which is different depending on the payer. Medicare rules are regulated at the federal level, whereas Medicaid and commercial payers are regulated at the state level. Self-funded commercial plans are exempt from state laws.

We went on to learn about Medicare rules for providing telehealth prior to the pandemic, the restrictions lifted during the pandemic, and what will change when the PHE ends. For those who are providing Medical Nutrition Therapy (MNT) via telehealth and billing Medicare, the Consolidated Appropriations Act of 2023 will allow continuation of some aspects of telehealth to continue until the end of 2024. The telehealth flexibilities that will continue until the end of 2024 are: additional services, audio only services, and location flexibilities. One item the Consolidated Appropriations Act of 2023 does not cover is Hospitals Without Walls. At the time of this education session there is still a need for further information on how telehealth provided through Hospitals Without Walls will be handled after 5/11/23 when the PHE ends.

Marsha then discussed the Value Proposition. The Value Proposition has two overall goals, which are better health and improved economy. There are five steps in the Value Proposition that RDNs can connect the dots between, in order to illustrate the value we bring. The steps are: improved patient experience, better outcomes, lower cost, clinician well-being, and health equity. 

Ingrid Knight then presented five different services that an RDN can provide and add to their portfolio. The five areas are: nutrition services, coaching, remote patient monitoring, body composition, and care management. She elaborated on how each of these services provides value. For example, nutrition services can be billed directly by the RDN such as when providing MNT for CKD and using 97802 for an initial assessment and then 97803 for follow-up assessments. Alternately, services such as Intensive Behavioral Therapy for obesity include the RDN and are billed incident to physician. 

Ingrid also discussed the hot topic of licensure considerations during the pandemic with telehealth rules relaxed. A common confusion around pandemic relaxed telehealth rules is that an RDN can practice anywhere. She stressed the importance of reviewing the rules for state licensure where the patient is located, the RDN should be licensed in their own state, and payment is not related to licensure. We learned a little bit about the future compact that the Academy of Nutrition and Dietetics is working on. There will be some information by 2024 but it will take many years before anything is put into practice. 

Marsha then discussed some of the differences between billing and using a patient’s MNT benefit vs using preventative benefits. A patient’s deductible and copay may apply when billing the MNT benefit. When billing a preventative visit, deductible and copay may not apply. The exception is Medicare, in which deductible and copay do not apply when billing MNT. 

Marsha discussed the importance of needing to look beyond fee for service to fully leverage the value an RDN provides. We discussed alternative payment models, which apply to Medicare. She described Value Pathways that focus on kidney health, and encouraged RDNs to look at them. RDNs are often already assessing some of the areas that focus on kidney health in our day-to-day practices. By reporting on them, we can add value in addition to the rate per unit that Medicare reimburses.

Finally, we discussed advocacy. Advocacy is something we all can participate in and is going to prove extremely important for the future of telehealth. Medicare wants more data before determining how to proceed post Consolidated Appropriations Act of 2023. RDNs can provide value by tracking outcomes in order to demonstrate the impact we have on those outcomes. Outcomes equal opportunity. If you have studies, publish. If you are able, advocate with stakeholders at any level. Stakeholders include physicians, practice managers, healthcare administrators, federal and state legislators, federal and state agencies, patients, and payers. RDNs can tie their message to the Value Proposition, pick your audience, and speak to them on things they value. The future of telehealth depends on it!

Submitted by Nicolle Piernak, RDN
CRN Stipend Winner 2023

Presentation Title: Counseling Techniques for the Renal RD: Setting Realistic Goals
Presenters: Rebecca J. Johnson, PhD, ABPP and Kathy Schiro Harvey MS RDN CSR

This presentation highlighted that patients with chronic kidney disease (CKD), especially those on dialysis, face cognitive deficits due to disease processes, physical fatigue, and a decline in social-emotional health. Understanding these can better help clinicians address behavior change.  

Rebecca Johnson, a pediatric psychologist, started the presentation by defining adherence as the extent to which a person’s behavior (such as taking medications and following diet) corresponds with the provider's recommendations.  It is preferred to use “non-adherent” as opposed to the term “non-compliant”, to avoid reproachful language that is dismissive of the total context of why the patient did not do the prescribed treatment.  Non-adherence is common, and estimated rates for pediatric populations are roughly 50% and between 31- 68% in adults.  It was repeatedly emphasized to assess why the patient was non-adherent, stating that too often this question gets missed. Johnson gave an example of a patient that was struggling to take their medications, in which it was found that the patient was prescribed an insurmountable 40 pills; but in part, this was due to dose increases from not taking their pills.  Johnson stated that for everyone adherence declines as the complexity of the treatment regimen increases (for example 1 pill is easier than 2 or 3 daily), and this is especially true for those with CKD given the challenges of their disease state.

Neurocognitive deficits begin in CKD and can worsen when on dialysis as proteinuria, abnormal blood pressure, and anemia have all been associated with poorer mental performance for both children and adults.  Johnson reported that studies demonstrate fluid intelligence, which governs problem-solving, thinking and acting quickly, memory, and adapting to new situations is much more affected by biological influences such as CKD, as opposed to crystallized intelligence, which is our accumulated verbal knowledge and skills which are influenced by our education and cultural experiences.  Those with CKD scored lower in intellectual functioning than healthy controls; even transplant patients who improved from CKD levels still scored lower than the healthy controls.  Less executive function in CKD can impair a patient's ability to organize tasks, remember details, manage time, and solve problems.  This illustrates that the complex regimens of diet, medication, and dialysis schedules are not easily achievable for patients and all patients need ongoing support to facilitate effective treatment.  Social emotional health is impacted for children with CKD compared with healthy kids due to lifestyle restrictions, missing school and social activities which results in lack of social learning with peers, less self-efficacy, internalizing symptoms, more inattention, developing depression often when progressing to dialysis, and having problems with peers.  For adults, depression is common with the highest rates for those on dialysis.  This again relates to the inability to participate in social activities, either physically or with role limitations, due to not being able to fully fill the role that you envision for yourself at your particular life stage (parent, grandparent, etc).  Depression is often a barrier to completing treatment goals also.

The first step in promoting behavior change is to assess adherence, as there is unintentional non-adherence such as forgetting or misunderstanding the instructions, or intentional non-adherence (or adaptive non-adherence) where patients attempt to treat themselves to minimize their side effects or believe that a change in regimen will be helpful.  Adaptive non-adherence often happens when the treatment does not fit the patient’s lifestyle, or the patient feels burdened by disease and is seeking relief from a poor quality of life.  Often to improve adherence, patients may need to have depression treated first in order to make behavior changes.   Johnson also suggested when relying on patients’ memory or self-report, it is important to be specific in questioning- to ask only about a certain time frame such as yesterday or the past 2 days to enhance recall. It can be helpful to ask about where the patient was at meal times, or to use phone diaries for patients to take pictures of their meals as part of a 24-hour recall to share with the provider and improve understanding of patients’ adherence.  Another imperative to optimize patients’ self-report is to provide a nonjudgmental response free of reprimands for non-adherence, as a provider’s negative reaction to their honesty can reinforce lying (especially with children).   Additional strategies for behavior change are rewards for meeting goals, focusing on one area of adherence at a time (diet or medications- not both), and discussing behavior contingencies with an example of starting with a very achievable goal and progressing to increasing the new behavior.

Kathy Harvey furthered the discussion of effective behavior change strategies by reiterating that knowledge alone does not promote change, and that clinicians need to reach both the emotional and rational sides of patients for effective change to happen.  Harvey described how the rational, thinking brain can become overwhelmed and unable to find a solution to a problem by constantly ruminating on it.  Conversely, the emotional brain can overtake the rational brain.  To begin, Harvey emphasized that counseling patients starts with building a relationship with the patient and getting to know them, their concerns, hobbies, joys, and “what makes this person tick”.  Adding that you need to “make sure the patient likes you, as they are more likely to listen to you”.  She described a patient who was referred to her and was minimally answering questions until she started asking the patient about their jewelry.  As Harvey continued to ask about her daily routine, she discovered that the patient mostly had four Pepsi sodas while watching TV, and so suggested Diet Pepsi instead- one small actionable change that the patient was willing to try (rather than meal plans that the patient had not followed in the past).  In other examples where the solutions-based strategies had failed to help the patient avoid large fluid gains or elevated phosphorus, Harvey switched to motivating the emotional brain by “looking for the bright spots” or telling the patient everything they are doing right.  She said to the patients a version of, “Your other labs are all consistently great, you are doing a good job, so quit beating yourself up”, and in subsequent months those patients ended up making a change with labs or fluid gains trending down.  Another important factor in behavior change is to “break down the change so that it doesn’t spook the emotions”, by using small specific steps.  Helping patients think through the change and plan what will be needed to implement it is key.  Harvey noted that “what looks like a people problem is often a situation problem”, meaning that by changing the environment and removing obstacles (such as junk food or not having binders near you at meals), then behavior change can then take place.  Harvey ended with, “For change to happen, somebody must act differently- it could be you, the patient, or the team.”

This was an excellent presentation with the overall message being to listen to the patient to determine what their understanding is of what they are being asked to do- making sure to always ask why to get the big picture of what's going on with patients.  Clinicians can discuss recommendations, but must also address behavior change planning with patients and breaking change into smaller achievable goals.

Submitted by Ann Pittaoulis, RD LDN
CRN Stipend Winner 2023

Probiotics and Transplant

Jessianna Saville, MS, RDN, LD, CLT, who founded the Kidney Nutrition Institute, and Alex Rogers, PharmD,  Kidney Pancreas Senior Clinical Pharmacist and Team Leader in Solid Organ Transplant at Houston Methodist, were the presenters of this session.  They discussed the pros and cons of probiotics in transplant patients.  The goal was to provide participants with information to help guide decision-making when it comes to the use of probiotics.

Jessianna started the presentation by stating that gut health impacts transplant outcomes since gut health impacts the immune system.

Digestive health products, which include a large percent of probiotics, is a $47.8 billion market.  11% of the US population suffers from a digestive disease.  Digestive diseases are a signal that the immune system may be compromised.  Gut health has been associated with mental health, kidney disease, cancers, Alzheimer’s, heart disease, diabetes, and most other chronic diseases.

The three types of oral probiotics/prebiotics discussed were defined by Alex as such:

• Prebiotics are non-digestible carbohydrates that in the intestines are the nutrition for the bacteria flora

• Probiotics are live microorganisms used to replace or support the normal healthy flora

• Symbiotic are the combination of the 2

Jessianna explained that after kidney transplant it is not uncommon for immunosuppressant drugs to often cause GI symptoms.  High use of antibiotics post-surgery definitely impacts the gut.  This can set off a reaction that it may be an infection and sometimes antibiotics may be prescribed.

Immunosuppressant drugs in the long term are linked to CV disease, DM Hyperlipidemia HTN, and malignancies; but is it the drugs or the altered Gut status of our transplant patients, she asked.

Animal studies show a potential benefit from probiotics to induce tolerance, reduce rejections and prevent ischemic reperfusion injury- all of these observations suggest positive outcomes with the use of probiotics.  However there very few human studies.

One important concept that was explained was the kidney-gut axis and how it works.  As kidney function declines along with other factors like co-morbidities and low dietary intake, including low fiber, medications, and constipation, GI function can be altered.  These factors will:

• Decrease GI motility

• Decrease protein absorption

• Decrease absorption- which can lead to edema

This will then cause:

• An increase in proteolytic bacteria flora

• Toxin generation (NH3/NH4+ , thios, indoles, amines. pre-cresol)

 This disruption leads to:

• GI mucosal injury

• translocation (bacteria and toxins) along the GI tract where it does not belong

• inflammations (cytokine release)

• immune suppression

With all of this decreased kidney function and increase in uremic toxins, endotoxemia develops.   Endotoxemia is a condition where endotoxins or lipopolysaccharides (by-products of bad bacteria) enter the blood system and cause systemic inflammation.  The endotoxins are able to enter into the blood system because of intestinal permeability (leaky gut).  It is important to understand this connection since many CKD patients present with compromised microbiomes.

Seven studies were cited that showed evidence that using probiotics actually altered CKD patients’ microbiomes positively.

So why the concern in transplant?  Typically, transplant clinicians are worried.  Since probiotics heighten immunity, would that cause rejection?   Evidence shows most concerns are theoretical; partly because we do not completely understand how the immunosuppressant drugs work and there is not true evidence behind this.

Since we don’t completely understand the mechanism of action, could this be hypothetical.  She showed a number of studies that all stated that the mechanism of how probiotics work is “unclear” in the conclusions.  There is a fear that a catastrophic infection from live micro-organisms could occur and there is still concern over the efficacy of probiotics, specifically with the large variety of strains available.

 Jessianna also reviewed how our immune system works.

The innate immune system is the first to come out to defend.  These are the dendritic cells, macrophages, and the gran negative team – eosinophils, neutrophils and basophils.

The innate team gives instruction to the adapted immune system cells or the lymphocytes.  The lymphocytes, (CD8, B cells, Regulatory T cells, and CD4 T cells) are given instructions on how to act out. These are the inflammation masters and if they are balanced, they work well.

A “Probiotic and The Immune System” review illustration was provided to explain what probiotics are capable of doing, such as:

• Attach to membrane receptors of macrophages and dendritic cells which instruct the adapted immune system.  Certain strains of probiotics can skew the adapted immune system cells – the naïve T cells – to produce more non-inflammatory cytokines.

• Activate B cells to become IgA-producing plasma cells; we need a good level of Secretory IgA in our gut lining because you have a better tolerance to invaders (anything foreign) in the GI tract.

• Modulation of Natural Killer Cells- creates a balance of these Killer cells

• Alter intracellular immune pathways through activation and suppression of transcription factors and cytokines- again keeping balance in the immune system

• Probiotics will cause a positive systemic response

So, what studies do we have on probiotics and transplant?  Most studies on probiotics and transplant are on hematopoietic stem cell transplant (HSCT).   HSCT involves complete transplantation of the immune system.  One probiotic strain in particular, Lactobacillus GG, has shown efficacy, feasibility and safety in preventing graft vs. host disease in stem cell transplant.

Using a Shannon diversity index used to identify the diversity of strains in the gut of people post kidney transplant, those patients that had more diarrhea had a lower abundance of diversity in the microbiome than those patients without diarrhea. And unfortunately, if antibiotics are given this will actually make the diversity even more compromised.

Five RT studies on gut microbiome in Solid Organ transplant (SOT) with the use of probiotics, prebiotics and symbiotics, had “uncertain effects”.  It was concluded that there was low-quality evidence and a high risk of bias.  But the focus of the studies was on the gut and not the immune system.

Looking at kidney-specific studies of eight RCTs in CKD patients, strains of probiotics of Lactobacillus and Bifidobacterium were related to decreased urea, BUN, ammonia levels, plasma p-cresol and plasma indoxly sulfate, decreased cytokine and endotoxin concentrations, and increased IL-10 (an anti-inflammatory cytokine).  Symbiotic supplements also caused positive results.

Core fundamental strategy for transplant is to prepare the gut microbiome with an abundance of diversity to reduce the incidence of diarrhea.  Other proven effective strategies include:

1. Diversity in the GI tract is key to a healthy gut

2. Lactobacillus is safe and effective against C difficile in post-lung and liver transplant

3. Oral Lactobacillus GG shows efficacy in preventing graft vs host in stem cell transplant

4. Fecal transplant restores microbiome diversity with reoccurring c diff

Currently, there are no recommendations from KDOQI/KDIGO for probiotics in post-transplant.  Practice varies by center with regard to using pro and prebiotics.  One suggestion, as a better way, is to build foods in place of probiotics into the diet: yogurt, kefir, allowed cheeses, kombucha, true brine sauerkraut and pickles, miso, kimchi, and tempeh- if it contains vinegar, it is not a true probiotic food.  Also consider nurturing the microbiome with natural prebiotics: chicory root, Jerusalem artichoke, jicama, garlic, onion, leeks, green bananas, oats, and flaxseeds.

Jessianna concluded with:

1. Work on the gut before transplant- focus on diversity to prevent post-transplant diarrhea

2. After transplant get a specific probiotic for what is needed but do your research with the strains

3. Prebiotics are the perfect starting point before introducing probiotics other than probiotic foods

4. Remember: The use of some probiotics may increase GI symptoms and may not be the way to go

_____________________

Alex started his presentation more on the subject of caution with probiotics.  He acknowledged that the prevalence of probiotic use in hospitals has grown and is continuing to grow.  There are a massive amount of probiotics in the marketplace and various strains which may be overwhelming both to our patients and healthcare professionals. One important factor in choosing a probiotic is to look for the USP/United States Pharmacopeia logo, which stands for good manufacturing processes.

Following transplantation, there are many factors that will change the microbiome of a patient.  This includes anesthesia, dietary changes, changes in meds including immunosuppressant drugs, and lifestyle changes including the correction of renal dysfunction.  Dysbiosis, which is a disruption in the microbiome, is common in post-transplant. Dysbiosis is the imbalance of bad bacteria to good bacteria within the GI tract.  This is a major factor that contributes to leaky gut, as well as:

• Loss of diversity- more risk of opportunistic pathogens to take hold (i.e., C diff)

• Loss of commensal bacteria- commensal bacteria help with creating a protective barrier, which can prevent leaky gut.

The goal of probiotic use is to mitigate infectious complications in patients and re-establish the microbiome. But, he asked, should we be cautious in post-transplanted patients?

One study was discussed looking at the use of a probiotic green banana powder in post-transplant recipients.  It was a Randomized Control Feasibility Study (27 /29 control) for a total of 56 participants. The study showed a decrease in the Gastrointestinal Symptoms Scale Score in the prebiotic group vs. the control.  It was significant. 

In a Cochrane Review of probiotic/prebiotic use in Solid Organ Transplant, there were five studies that included a total of 250 patients that were reviewed.  One study was kidney transplant and four were liver transplants. It was concluded that the overall quality of evidence was poor, there was a high risk of bias, and overall there is a lack of high-quality RCT studies.

Alex also presented a case study on a 60-year-old post-kidney transplanted patient who was readmitted to the hospital one week after transplant with an infection.  He had developed perihepatic fluid with Lactobacillus casei.  This matched with one of the stains in a probiotic that the patient had been taking.

Cohen and colleagues (2016) looked at patients (n = 3799) that had HSCT (stem cell transplant) who were also using probiotics.  24% of the patients had some form of infection.  Lactobacillus was isolated in 95% of the cases.   There was only one case of a prolonged positive culture (25 positive cultures tested) but there was no mortality in any of the patients.

Alex concluded with the following:

• There is a lack of sufficient studies on probiotics in transplant

• Lack of standardized and regulated products on the market

• Not completely understanding the effects on the immunosuppressant drug metabolism

• Potential risk of a strain becoming infectious in an immunocompromised patient

My takeaway on this presentation is that food is always best. There are numerous pre- and probiotic foods that are safe and that aid in keeping the GI tract healthy.  Keeping a healthy gut prior to transplant is key and should be an important concern prior to transplantation.