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Providing optimal end-stage kidney disease (ESKD) management requires an adequately trained and sufficiently staffed workforce, including doctors, nurses, and patient care technicians (PCTs). The growing need for ESKD services for a surging population of dialysis-dependent patients has made obvious a workforce crisis affecting nephrology. For a multitude of reasons, the physician workforce supply available to provide dialysis care has failed to expand commensurate with patients need in recent years. Of most importance, fewer US trainees are choosing to enter nephrology, and fewer international medical graduates are available to fill training program rosters. Equally important but less frequently cited are occupational shortages of trained dialysis nurses and PCTs. This article brings attention to this complex workforce shortage and addresses the limited information available regarding how it might constitute a barrier to optimal dialysis care., (© 2020 Wiley Periodicals LLC.)

Although control of chronic glycemia in the population with diabetes and end-stage renal disease (ESRD) has been extensively studied in recent years, the unique problems of short-term glycemic management in acutely ill patients undergoing dialysis have received little attention. Bally et al. evaluated the role of a "closed-loop" (glucose sensor/algorithm tablet device/insulin pump) system in a cohort of hospitalized patients with type 2 diabetes receiving hemodialysis. Compared with usual care, the intervention group had superior glycemic control without increased hypoglycemic events. Additional studies are warranted., (Copyright © 2019 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

The validity of hemoglobin A1c (HgbA1c) is undergoing increasing scrutiny in the advanced CKD/ESRD (chronic kidney disease/end-stage renal disease) population, where it appears to be discordant from other glycemic indices. In the Glycemic Indices in Dialysis Evaluation (GIDE) Study, we sought to assess correlation of HgbA1c with casual glucose, glycated albumin, and serum fructosamine in a large group of diabetic patients on dialysis. From 26 dialysis facilities in the United States, 1758 diabetic patients (hemodialysis = 1476, peritoneal dialysis = 282) were enrolled in the first quarter of 2013. The distributions of HgbA1c and the other glycemic indices were analyzed. Intra-patient coefficients of variation and correlations among the four glycemic indices were determined. Patients with low HgbA1c values were both on higher erythropoietin (ESA) doses and more anemic. Serum glucose exhibited the highest intra-patient variability over a 3-month period; variability was modest among the other glycemic indices, and least with HgbA1c. Statistical analyses inclusive of all glycemic markers indicated modest to strong correlations. HgbA1c was more likely to be in the target range than glycated albumin or serum fructosamine, suggesting factors which may or may not be directly related to glycemic control, including anemia, ESA management, and iron administration, in interpreting HgbA1c values. These initial results from the GIDE Study clarify laboratory correlations among glycemic indices and add to concerns about reliance on HgbA1c in patients with diabetes and advanced kidney disease., (© 2015 International Society for Hemodialysis.)

While hyperglycemia is central to the pathogenesis and management of diabetes mellitus, hypoglycemia and glucose variability also contribute to outcomes. We previously reported on the relationship of glycemic control to outcomes in a large population of diabetic end-stage renal disease (ESRD) patients. Recognizing that ESRD is a risk factor for severe hypoglycemia, we have now analyzed the association between glycosylated hemoglobin A1c (HgbA1c) levels and glycemic variability in those with hypoglycemia. This is a retrospective study of patients with diabetes enrolled in a large hemodialysis program. Hypoglycemia was identified from hospital discharge diagnostic codes. Glycemic variability was assessed by the standard deviation of HgbA1c and glucose levels over time. Hypoglycemia as a discharge diagnosis was documented in 4.1% of patients. Higher baseline HgbA1c was associated with greater risk for hypoglycemia hospitalization, a finding confirmed by time-lagged HgbA1c levels drawn a quarter earlier. Higher baseline HgbA1c categories were also associated with greater variability in HgbA1c levels during the analysis period. Similarly, greater glucose variability was associated with higher mean glucose levels by trend analysis. High, not low, HgbA1c levels are associated with greater risk of severe hypoglycemia, which may derive from glucose variability in the setting of treatment for hyperglycemia. High HgbA1c and glycemic variability are associated with increased risk of hypoglycemia in individuals with diabetes and ESRD., (© 2013 International Society for Hemodialysis.)

The management of hyperglycemia in patients with kidney failure is complex, and the goals and methods regarding glycemic control in chronic kidney disease (CKD) are not clearly defined. Although aggressive glycemic control seems to be advantageous in early diabetic nephropathy, outcome data supporting tight glycemic control in patients with advanced CKD (including end-stage renal disease [ESRD]) are lacking. Challenges in the management of such patients include therapeutic inertia, monitoring difficulties, and the complexity of available treatments. In this article, we review the alterations in glucose homeostasis that occur in kidney failure, current views on the value of glycemic control and issues with its determination, and more recent approaches to monitor or measure glycemic control. Hypoglycemia and treatment options for patients with diabetes and ESRD or earlier stages of CKD also are addressed, discussing the insulin and noninsulin agents that currently are available, along with their indications and contraindications. The article provides information to help clinicians in decision making in order to provide individualized glycemic goals and appropriate therapy for patients with ESRD or earlier stages of CKD., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Dialysis should not be presumed to be the treatment of choice for all elderly chronic kidney disease stage 5 patients. Nondialysis active medical management, as an alternative to dialysis or palliative care, is a reasonable alternative in select cases. Early referral of CKD 5 elderly patients may lead to early initiation of dialysis, which may not be advantageous; it also provides an opportunity to institute active management as a treatment alternative. The informed decision to proceed with dialysis must involve both an assessment of evidence-based outcomes applicable to the patient, and allowance of patient preference. Prognostic tools are increasingly sought to aid in decision-making for elderly CKD 5 patients. Chronological age alone is not a sufficient predictor of benefit from dialysis treatments, according to observational studies and limited clinical trial data. The survival advantage of dialysis appears to be lost in patients with high levels of comorbidity. Establishing patient preference is an imperfect process, and many patients appear to regret their decision to undergo dialysis. With active medical management, efforts shift from prolonging life to emphasis on symptom control, dietary and medical treatment, and quality of life. Patient survival time can be remarkably long., (© 2012 Wiley Periodicals, Inc.)

The disproportionate increase in the prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the elderly is now recognized as a national and global reality. Among the major contributing factors are the aging of the population, a growing prevalence of CKD, greater access to care, and increased comorbidities. The utilization of renal replacement therapy in the geriatric population has concomitantly increased. It is imposing enormous challenges to the practice of ESRD care, the largest of which may be to determine the best application of clinical performance targets to a population with limitations in life expectancy. Concurrently, increased focus on quality of life will be required. The effective dialysis practitioner will need to adapt to the aging ESRD demographics with an increased focus on physical and mental well-being of the geriatric patient., (© 2012 Wiley Periodicals, Inc.)

Background: Patient groups associated with disparities in health care are usually defined on the basis of race, gender or geographic location. Social Adaptability Index (SAI), calculated based on education, marital status, income, employment and substance abuse, has been strongly associated with clinical outcome in other patient populations and may be used to identify individuals at risk. We used data from the United States Renal Data System to evaluate the role of SAI in survival of patients on dialysis., Methods: We used Cox model analyses to study the association between SAI and patient survival in patients with ESRD on dialysis, as well as in the subgroups based on age, race, sex, comorbidites and diabetic status., Results: We analyzed 3396 patients (age of ESRD onset 56.9 ± 16.1 years, 54.2% males, 64.2% white, 30.3% African-American). Mean SAI of the entire population was 7.1 ± 2.5 (range 0-12 points). SAI was higher in whites (7.4 ± 2.4) than in African-Americans (6.5 ± 2.5) (analysis of variance, P <0.001) and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) (t-test, P <0.001). In a Cox model adjusted for potential confounders, SAI was associated with decreased mortality [hazards ratio of 0.97 (95% confidence interval 0.95-0.99), P = 0.006]. Subgroup analysis demonstrated an association of SAI with survival in most of the subgroups. Potential limitations of the study include reverse causality, possible misclassification and retrospective design., Conclusion: We demonstrated that SAI is significantly associated with mortality in dialysis patients. SAI could be used to identify individuals at risk for inferior clinical outcomes.

Background and Objectives: The optimal time of dialysis initiation is unclear. The goal of this analysis was to compare survival outcomes in patients with early and late start dialysis as measured by kidney function at dialysis initiation., Design, Setting, Participants, & Measurements: We performed a retrospective analysis of patients entering the U.S. Renal Data System database from January 1, 1995 to September 30, 2006. Patients were classified into groups by estimated GFR (eGFR) at dialysis initiation., Results: In this total incident population (n = 896,546), 99,231 patients had an early dialysis start (eGFR >15 ml/min per 1.73 m(2)) and 113,510 had a late start (eGFR ≤5 ml/min per 1.73 m(2)). The following variables were significantly (P < 0.001) associated with an early start: white race, male gender, greater comorbidity index, presence of diabetes, and peritoneal dialysis. Compared with the reference group with an eGFR of >5 to 10 ml/min per 1.73 m(2) at dialysis start, a Cox model adjusted for potential confounding variables showed an incremental increase in mortality associated with earlier dialysis start. The group with the earliest start had increased risk of mortality, wheras late start was associated with reduced risk of mortality. Subgroup analyses showed similar results. The limitations of the study are retrospective study design, potential unaccounted confounding, and potential selection and lead-time biases., Conclusions: Late initiation of dialysis is associated with a reduced risk of mortality, arguing against aggressive early dialysis initiation based primarily on eGFR alone.

Background and Objectives: The benefits and risks of aggressive glycemic control in diabetes mellitus complicated by end-stage kidney failure remain uncertain but have importance because of the large patient population with inferior overall prognosis. Recent large observational studies with differing methodologies reached somewhat contrasting conclusions regarding the association of hemoglobin A1c with survival in diabetic chronic hemodialysis patients., Design, Setting, Participants, & Measurements: This study supplements the authors' previous analysis (which found no correlation) by extending the follow-up period to 3 years and using time-dependent survival models with repeated measures. Among 24,875 nationally distributed study patients, 94.5% had type 2 diabetes, allowing additional analysis in the subset with type 1 diabetes. Data were collected at baseline and every quarter to a maximum of 3 years' follow-up., Results: Adjusted standard and time-dependent Cox models indicated that only extremes of glycemia were associated with inferior survival. There was no effect modification by serum albumin levels, a marker of protein nutrition status, and no trend associated with random glucose measurements in a post hoc analysis. In type 1 diabetic patients, upper extreme hemoglobin A1c values indicated lower survival risk., Conclusions: Sustained extremes of glycemia were only variably and weakly associated with decreased survival in this population. In the absence of randomized, controlled trials, these results suggest that aggressive glycemic control cannot be routinely recommended for all diabetic hemodialysis patients on the basis of reducing mortality risk. Physicians are encouraged to individualize glycemic targets based on potential risks and benefits in diabetic ESRD patients.

Both in the United States and many regions of the world, chronic kidney disease and end-stage renal disease (ESRD) in patients with diabetes mellitus have reached epidemic proportions in recent years. The large prevalent diabetic ESRD population in the US involves remarkable risk in African Americans and an increasing population of elderly diabetic patients, including many octogenarians. In the US and globally, over 90% of diabetic ESRD patients have type 2 diabetes. The multinational epidemic of diabetic ESRD has been linked to increases in the prevalence of diabetes in many populations, related to obesity, ageing, and physical inactivity. It is anticipated that the worldwide prevalence of diabetes over the next 20 years will reach a level twice that of the year 2000. The excessive morbidity and mortality of the diabetic ESRD population are well documented. However, the growth in incidence and prevalence rates for diabetic ESRD has remained somewhat stable in the US in recent years, and new data suggest that the incidence of ESRD expressed per diabetic population may finally be declining, suggesting that proven therapies are making "progress on progression."

Persons with diabetes mellitus whose kidney disease progresses to end-stage requiring dialysis have poorer outcomes compared to nondiabetic patients who commence maintenance dialysis. In the diabetic patient without renal failure, sustained strict glycemic, lipid, and blood pressure (BP) control can retard or thwart diabetic complications such as retinopathy, neuropathy, coronary disease, and peripheral vascular disease. Achieving these outcomes requires multidisciplinary collaborative care. Best care of the diabetic person requires a dedicated clinician who knows the patient well, who closely follows the course of clinical problems, who provides frequent assessments and interventions, and who also directs care to other agencies, clinics, and specialized clinicians who provide expert focused evaluations and interventions aimed at specific clinical concerns. Diabetic patients who reach end-stage renal disease (ESRD) have even greater clinical need of a dedicated principal care clinician than the diabetic patient who has minimal or moderate kidney disease. The diabetic patient with ESRD exhibits greater fluctuations in glucose and BP due to dialysis-related diet patterns and fluid balances and has more active cardiovascular problems due to the combined influences of calcium, phosphorus, and lipid imbalances. These problems warrant exceptional care that includes frequent surveillance and monitoring with timely interventions if patient outcomes are to be improved. We present here a quality improvement model for optimizing care of the diabetic dialysis patient that relies on a dedicated practitioner who can evaluate and intervene on the multiple variables within and beyond the dialysis clinic that impact the patient's health. We present three detailed clinical care pathways that the dedicated clinician can follow. We believe that patient outcomes can be improved with this approach that provides customized problem-focused care, collaborates with the dialysis-provider team, and extends and directs diabetic self-care, home-care, and specialized clinical care in the challenging areas of cardiac and peripheral vascular disease, glycemic control, lipid control, infection prevention, and BP management.

As kidney function declines, chronic kidney disease (CKD) becomes an increasingly systemic disorder. Most patients with CKD eventually develop subclinical or clinical abnormalities in bone and mineral metabolism. Recent observational and basic scientific studies have led to a new emphasis on the changes in phosphorus and calcium metabolism, parathyroid hormone, and vitamin D that lead to this complex systemic bone/mineral disorder (CKD/BMD). At the center of the disorder are relationships among all 4 factors that conspire to create a perfect storm, leading to secondary hyperparathyroidism (SHPT). Some key current issues that are reviewed here are as follows: (1) factors promoting SHPT, (2) the role of fibroblast growth factor-23 in CKD/BMD, (3) molecular mechanisms of SHPT, (4) mechanisms of vascular calcification, and (5) medical management of the disorder, including calcimimetics. Current therapies directed at correcting the primary abnormalities (ie, improve conditions to an imperfect storm) and minimizing the consequences of CKD/BMD are discussed.

Health-care insurance is the key to health-care access, yet the number of uninsured in the United States grows by a million persons per year and consists, in large part, of those who are financially unable to obtain medical coverage. Their unpaid medical bills add significantly to the cost of health insurance for those who do pay. Those without insurance receive care on a sporadic basis, and the risk of poor health-care outcomes is well established. The end-stage renal disease (ESRD) uninsured face unique problems related to chronicity of care and the system of chronic dialysis-care delivery. This article addresses the growing challenge of the ESRD uninsured in the United States and describes how the current system copes with the ESRD uninsured. More broadly, it discusses who the uninsured are (including undocumented immigrants), the health-care consequences of being without coverage, and how their care is currently financed. It also presents a health-care reform measure in Massachusetts designed to provide affordable insurance to those without coverage.

The new Medicare benefit, medical nutrition therapy (MNT), came into effect January 2002-the product of a lengthy legislative process. Over several years, evidence-based advocacy by groups such as the American Diabetic Association and the National Kidney Foundation led to a legislative product that was introduced and passed by Congress. More recently, the legislation entered an implementation process, including the most recent Coverage Determination phase. The definition of MNT and the scientific evidence supporting it are presented. Evidence-based nutrition now enters a new phase of implementation and additional analysis., (Copyright 2002 by the National Kidney Foundation, Inc.)