Highlights From Days 3 & 4 of the National Kidney Foundation Spring Clinical Meeting

Recapping Days 3 & 4 of the 2022 NKF Spring Clinical Meeting

Catch up on some of the latest updates to come from Days 3 and 4 of the 2022 National Kidney Foundation Spring Clinical Meeting.

Dilemmas When Clinical Practice Guidelines Do Not Support Patient-Centered Care

The session titled, “Dilemmas When Clinical Practice Guidelines Do Not Support Patient-Centered Care,” featured a panel of experts who presented research and clinical cases centered around the benefits of and barriers to patient-centered care. One of the panelists was nurse practitioner Ms. Jo Ann A. Otts, who shared key considerations for optimizing chronic kidney disease (CKD) care.

Ms. Otts began by defining patient-centered care as care that’s respectful of and responsive to individual patient preferences, needs, and values in addition to ensuring that these elements guide all clinical decisions. 

When it comes to patient preferences, Ms. Otts noted that they vary according to each patient’s personal beliefs, goals, and expectations.

To help nephrologists discover and consider the preferences of each individual patient, Ms. Otts provided the following four steps to utilizing shared decision-making (SDM) in practice:

1. Inform the patient that decisions need to be made
2. Discuss the available options as well as the benefits and risks of each option
3. Discuss the patient’s values, goals, and preferences
4. Support the patient in making or deferring decisions and make follow-up plans

Now,  there are a few barriers to patient-centered care that can affect both patients and providers. For patients, the complexity of CKD, health literacy, and limited availability of information can be challenging, while providers often struggle with incentives, time, interdisciplinary care models, and decision support tools.

Another barrier Ms. Otts noted is the fact that clinical practice guidelines don’t always align with what matters most to patients. Clinical practice guidelines, by definition, are statements that include recommendations intended to optimize patient care that is informed by a systemic review of evidence and an assessment of the benefits and harms of alternative care options.

But clinical practice guidelines have some key limitations that nephrologists should be aware of, including:

• Elderly patients may be excluded from clinical trials that help inform the guidelines
• Guidelines often focus on a single disease or condition without taking common comorbidities into account
• Guidelines are population-based, meaning the unique values and preferences of the individual patient are not recognized

Ms. Otts concluded that while clinical practice guidelines are a critical component of CKD management, they should not be the only consideration when caring for patients. Clinical practice guidelines, SDM, and patient-centered care are the key ingredients that comprise quality patient care and—by extension—improved outcomes and quality of life for patients with CKD.

The Challenge of Expanding Home Dialysis Utilization

Since home dialysis remains underutilized compared to incenter hemodialysis, the session titled “The Challenge of Expanding Home Dialysis Utilization” featured four presentations that all shared strategies for improving the uptake of home dialysis. One presentation in particular, which was led by Ms. Akilah King (MSW, LCSW), zeroed in on increasing peritoneal dialysis (PD) utilization among racial and ethnic minorities and disadvantaged populations.

To stress the importance of this topic, Ms. King began by sharing that 24 percent of Black and 10 percent of Hispanic/Latinx patients start on PD. Additionally, Black patients are four times more likely to develop the end-stage renal disease (ESRD) while Hispanic/Latinx patients are 1.3 times more likely.

Some factors behind these troubling statistics include psycho-socio-economic disparities, like housing, fear, and denial related to dialysis, lifestyle, and safety, and even structural barriers, such as misconceptions, mistrust in the healthcare system, and a lack of education on kidney disease.

This challenge was only exacerbated by the COVID-19 pandemic given that Black patients are more likely to be diagnosed with the virus and less likely to have access to the resources to treat it. And while the pandemic did have a positive impact on home dialysis utilization as there was increased interest in PD among both patients and providers, was that interest equal across all patient groups?

To find out, a qualitative study was conducted in which 23 Black patients with chronic kidney disease (CKD) who hadn’t yet reached ESRD that required renal replacement therapy (RRT) were interviewed. Through these structured interviews, researchers were able to assess patients’ knowledge and beliefs about CKD, ESRD, and the following RRT methods: incenter hemodialysis, PD, home hemodialysis, and transplant.

After collecting participants’ responses, the results showed PD was the least known and the least preferred modality. When it came to choosing a modality, researchers also concluded that RRT education and physician guidance were the primary facilitators.

Based on the above research, Ms. King provided the following strategies to increase PD uptake:

• Diversify peritoneal training to accommodate learning styles
• Provide early modality education to patients
• Include family (biological and surrogate) in a patient’s care
• Consider transitional units and urgent PD start
• Incorporate social workers and dietitians in treatment planning
• Create quality improvement initiatives for RRT referrals in ambulatory and inpatient settings to assess areas requiring improvement

And when it comes to assessing which patients might be right for PD, Ms. King recommended the Method to Assess Treatment Choices for Home Dialysis (MATCH-D) screening tool. This tool is comprised of three columns, each with a list of factors denoting whether patients are good candidates for PD, whether certain barriers need to be addressed before recommending PD, or if patients need an involved partner to help them with PD.

With these tools and strategies in place, nephrologists can help increase the utilization of PD among racial and ethnic minorities and disadvantaged patient populations.

COVID & Dialysis: Where We Have Been and What Now?

The COVID-19 pandemic has had an impact on every aspect of medicine, especially for our immunocompromised patients. For patients on dialysis, the pandemic has led to many unexpected challenges. In a session titled “The Michael J. Lazarus Distinguished Lecture - COVID and Dialysis: Where We Have Been and What Now?” Dr. Daniel Weiner, a nephrologist and Associate Professor of Medicine at Tufts University School of Medicine shares what questions remain about dialysis and explores how we can translate lessons learned from the COVID-19 pandemic to improve kidney care moving forward.

Dr. Weiner began with a look at the current state of dialysis, and explained that hemodialysis patients forced into a congregate setting to complete their dialysis puts them at increased risk of contracting COVID-19, and shared key steps to mitigate that risk:

• Make efforts to dialyze clinically stable in-center HD patients in outpatient dialysis facilities
• Implement screening and isolation processes in hemodialysis facilities
• Increase COVID-19 testing in hemodialysis facilities
• Observe personal protective equipment (PPE) practices

Dr. Weiner focused on one key step in particular: implementing home dialysis as opposed to in-center dialysis. He then dove into a study titled “Epidemiology and Outcomes of COVID-19 in Home Dialysis Patients Compared with In-Center Dialysis Patients,” assessing the safety of in-center dialysis compared to home dialysis during two different periods of the pandemic: Phase 1 (February 22, 2020 – September 30, 2020) and Phase 2 (October 1, 2020 – December 31, 2020). Phase 1 assessed patients in 35 home programs and 68 in-center programs, and Phase 2 assessed patients in 58 home programs and 113 in-clinic programs. The results of the study were as follows:

• In phase 1, 46 of 1,024 (4.5%) patients on home dialysis were diagnosed with COVID-19
• In phase 2, 99 of 1,547 (6.4%) patients on home dialysis were diagnosed with COVID-19

The results show that the incidence rates of COVID-19 were much smaller in patients receiving at-home dialysis, and according to Dr. Weiner, these results indicate a greater need for these programs.

Beyond these at-home dialysis programs, there are a few other ways we can help keep our dialysis patients safe, including physical distancing, masking for vulnerable patients, and treatment with tixagevimab-cilgavimab. But one of the most beneficial ways to prevent COVID-19 in these patients is to encourage them to get vaccinated.

Dr. Weiner concluded by emphasizing how challenging the COVID-19 pandemic has been for dialysis patients, and explained that vaccinating in a trusted environment and taking steps to bring the vaccines to your patients can make a big difference. Dialysis patients especially can benefit from a third vaccine or a booster shot, so Dr. Weiner encourages them to get vaccinated.