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Objective Scleroderma renal crisis (SRC) is a rare and severe manifestation of systemic sclerosis (SSc). Although it is well documented that Blacks with SSc have worse morbidity and mortality than non-Blacks, racial predilection for SRC is underreported. We examine the association of race and future development of SRC in an SSc cohort. Methods Using the electronic health record of the United States Military Health System, we conducted a comprehensive chart review of each patient with SSc from 2005 to 2016. The final study cohort was comprised of 31 SRC cases and 322 SSc without SRC controls. We conducted logistic regression of SRC as the outcome variable and race (Black vs. non-Black) as the primary predictor variable, adjusted for age, estimated glomerular filtration rate, hypertension and proteinuria at SSc diagnosis. Results Out of 353 patients, 294 had identifiable race (79 Black, 215 non-Black). Thirteen out of 79 Blacks (16.5%) vs. 16/215 (7.4%) non-Blacks developed SRC (p=0.02). On adjusted analysis, Blacks had a significantly higher risk of developing SRC than non-Blacks (odds ratio 6.4, 95% CI 1.3-31.2, p=0.02). Anti-Ro antibody was present in a higher proportion of Black SRC patients vs. Blacks without SRC [45% vs. 14%, p=0.01]. Conversely, older age, thrombocytopenia, and anti-RNA polymerase III antibody at SSc diagnosis were significantly associated with future SRC in the non-Black cohort. Conclusion Black race was independently associated with a higher risk of future SRC. Further studies are needed to elucidate the mechanisms that underlie this important association. This article is protected by copyright. All rights reserved.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

Background: Peritoneal dialysis (PD) management is a fundamental nephrology skill, especially with the recent emphasis on home dialysis. We report a prospective multicentre cohort study of a formative objective structured clinical examination (OSCE) assessing competence in managing PD-associated bacterial peritonitis, using the unified model of construct validity. Methods: The OSCE was developed by the principal investigators and reviewed by two subject matter experts. The test committee (eight nephrologists and one PD nurse) assessed test item difficulty/relevance and determined passing score. There were 22 test items (7 evidence-based/standard-of-care questions). Passing score was 16/22 (73%). No item had median relevance less than ‘important’, and all were easy to medium difficulty. Content validity index was 0.91. Preliminary validation (16 board-certified volunteers): mean score was 19 ± 2, with 94% (15/16) passing. Kappa = 0.85 [95% confidence interval (CI) 0.77–0.94]. Cronbach’s α = 0.70. Results: Eighty-seven fellows (16 programmes) were tested; 67% passed. Fellows scored significantly less than validators: 17 ± 3 versus 19 ± 2, p < 0.001 [95% CI 1.2–3.6]. Eighty-six per cent of evidence-based/standard-of-care questions were answered correctly by validators versus 54% by fellows; p < 0.001. Ninety-three per cent of fellows recognized that sufficient criteria were present to diagnose peritonitis, but only 17% correctly indicated all three. Seventy-seven per cent recognized peritonitis-associated ultrafiltration failure, but only 17% prescribed 21 days of antibiotic treatment for gram-negative peritonitis. Eighty-five per cent of fellows surveyed agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Second-year in-training examination and OSCE scores were positively correlated (Pearson’s r = 0.57, p < 0.00). Conclusions: The OSCE may be used to formatively assess fellow proficiency in managing PD-associated peritonitis.

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Background and objectives An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey. Design, setting, participants, & measurements We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons. Results Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias. Conclusions Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.

Introduction: Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD. Methods: The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was 2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence. Results: At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61–2.37] in ages 18–44 years and HR 1.66 [1.63–1.70] in ages 45–64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68–1.74] in ages 65–84 years and HR 1.69 [1.65–1.73] in ages 85–100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18–44 years and >2-fold higher among veterans aged 85–100 years. Conclusion: The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

Background and objectives In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states. Design, setting, participants, & measurements This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others. Results Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P Conclusions Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Background and objectives Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies. Design, setting, participants, & measurements Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey. Results A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3–4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing “proficiency in ordering” acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format. Conclusions The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_08_CJASNPodcast_19_09_.mp3

Dual kidney transplantation (DKT) is a viable option to increase the donor pool and improve access equity to kidney transplantation. Dual kidneys are procured from carefully selected marginal donors that are not generally acceptable to most transplant centers. This is a narrative review of literature focusing on donor kidney allocation systems and selection of the ideal recipient for DKT. We also discussed surgical approaches for DKTs as well as patient and allograft outcomes. We found that most studies to date showed that DKTs has similar graft survival and delayed graft function rates when compared to single kidney transplants (SKTs). DKT is technically feasible with outcomes that are comparable to expanded criteria donor kidneys (ECD); and has substantial potential in expanding the donor pool. For allograft survival, most studies with strict allocation criteria showed that graft survival was similar in DKT as compared to SKT - ECD transplants.. Our review may encourage transplant centers to review their policies for donor and recipient selection leading to increase in DKT.

Introduction Renal biopsy is a valuable tool for determining diagnosis, management, and prognosis of intrinsic kidney diseases. Indications for biopsy depend on the clinical presentation. Within the military, renal biopsies also enable medical review boards to make military service fitness assessments after diagnosis of a kidney disease. There are no recent studies evaluating kidney disease diagnoses and clinical outcomes after renal biopsy at military treatment facilities. Additionally, no studies have examined overall healthcare and military career outcomes following renal biopsy. Materials and Methods We retrospectively reviewed all native renal biopsies performed on active duty beneficiaries at the Walter Reed National Military Medical Center from 2005 to 2020. We determined the prevalence of those who progressed to end-stage kidney disease (ESKD), kidney transplantation, doubling of serum creatinine, nephrotic-range proteinuria (NRP; proteinuria >3.5 g/day), medical evaluation board (MEB) outcomes, and death. The Armed Forces Health Longitudinal Technology Application and the Joint Legacy Viewer electronic medical record systems were used to access clinical and laboratory data at the time of biopsy and subsequent outcomes. Death data were collected using the Defense Suicide Prevention Office database. Results There were 169 patients in the cohort, with a mean follow-up of 7.3 years. Mean age was 32 years; 79% male; 48% white; and 37% black. Sixty-seven percentage of them were junior or senior enlisted. The most common indication for renal biopsy was concomitant hematuria and proteinuria (31%). The most common histologic diagnoses were immunoglobulin A (IgA) nephropathy (23%), followed by focal segmental glomerulosclerosis (FSGS; 17%) and lupus nephritis (12%). Eleven percentage of them progressed to ESKD, of whom 87% received a kidney transplant (10% overall). Thirty percentage of the patients progressed to NRP and 5% died. Forty-seven percentage of our patients underwent MEB after diagnosis, and of these, 84% were not retained for further military service. Although IgA nephropathy was the most commonly diagnosed condition, FSGS and lupus nephritis diagnoses were significantly more likely to result in MEB. Conclusions and Implications Immunoglobulin A nephropathy was the most frequent histologic diagnosis in active duty service members undergoing renal biopsy between 2005 and 2020. Despite being largely young and previously healthy, 11% progressed to ESKD and 5% died. A confirmed histologic diagnosis was associated with separation from the service and the end of military careers for 84% of the patients in the cohort who underwent MEB.

BACKGROUND: FSGS is a heterogeneic glomerular disease. Risk factors for kidney disease ESKD and the effect of immunosuppression treatment (IST) has varied in previously published cohorts. These cohorts were limited by relatively small case numbers, short follow-up, lack of racial/ethnic diversity, a mix of adult and pediatric patients, lack of renin-angiotensin-aldosterone system (RAAS) inhibition, or lack of subgroup analysis of IST. METHODS: We compared demographics, clinical characteristics, histopathology, and IST to long-term renal survival in a large, ethnically diverse, adult cohort of 338 patients with biopsy-proven FSGS with long-term follow-up in the era of RAAS inhibition using data from the US Department of Defense health care network. RESULTS: Multivariate analysis showed that nephrotic-range proteinuria (NRP), eGFR

Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy.Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy.58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018.Fellowship training year and clinical scenario.Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed).Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario.Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions.Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS.The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Racial disparities in kidney transplant outcomes are well documented and are attributed to biologic differences ( e.g. , gene variants in APOL1), immunologic factors, and other barriers, including lower socioeconomic status (SES), nonadherence to immunosuppressive medications, reduced access to care

Introduction In recent years, data have emerged on the outcomes of living kidney donors who develop end-stage renal disease (ESRD). We aimed to evaluate mortality rates in kidney donors who had initiated dialysis compared with a propensity-matched cohort of dialysis patients without previous kidney donation. Methods We used the United States Renal Data System (USRDS) and abstracted 274 previous living kidney donors between 1995 and 2009. There were 609,398 individuals on dialysis without kidney donation. We used propensity score matching to identify 258 donors and 258 nondonors. The time-dependent Cox proportional hazards model was used to compare survival between the 2 matched cohorts. Results In the propensity score−matched cohort, mortality was lower in donors compared with nondonors (19% vs. 49%; P < 0.0001). The time-dependent Cox proportional hazards model demonstrated that donors had significantly lower mortality compared with nondonors 0 to 5 years since start of dialysis (hazard ratio [HR]: 0.17; 95% confidence interval [CI] 0.11−0.27; P < 0.0001) and with nondonors 5 to 10 years on dialysis (HR: 0.34; 95% CI: 0.19−0.63; P < 0.001). We were unable to estimate the difference between the 2 groups after 10 years on dialysis with any precision (HR: 0.51; 95% CI: 0.18−1.42; P = 0.20) due to the small sample size. Conclusion We observed a lower mortality rate in living kidney donors with ESRD compared with matched nondonors. This data should guide clinicians in the informed consent process with prospective donors.

Objective.Systemic sclerosis (SSc) is a disease of autoimmunity, fibrosis, and vasculopathy. Scleroderma renal crisis (SRC) is one of the most severe complications. Corticosteroid exposure, presence of anti-RNA polymerase III antibodies (ARA), skin thickness, and significant tendon friction rubs are among the known risk factors at SSc diagnosis for developing future SRC. Identification of additional clinical characteristics and laboratory findings could expand and improve the risk profile for future SRC at SSc diagnosis.Methods.In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the demographics, clinical characteristics, and laboratory results at SSc diagnosis for 31 cases who developed SRC after SSc diagnosis to 322 SSc without SRC disease controls.Results.After adjustment for potential confounding variables, at SSc diagnosis these conditions were all associated with future SRC: proteinuria (p < 0.001; OR 183, 95% CI 19.1–1750), anemia (p = 0.001; OR 9.9, 95% CI 2.7–36.2), hypertension (p < 0.001; OR 13.1, 95% CI 4.7–36.6), chronic kidney disease (p = 0.008; OR 20.7, 95% CI 2.2–190.7), elevated erythrocyte sedimentation rate (p < 0.001; OR 14.3, 95% CI 4.8–43.0), thrombocytopenia (p = 0.03; OR 7.0, 95% CI 1.2–42.7), hypothyroidism (p = 0.01; OR 2.8, 95% CI 1.2–6.7), Anti-Ro antibody seropositivity (p = 0.003; OR 3.9, 95% CI 1.6–9.8), and ARA (p = 0.02; OR 4.1, 95% CI 1.2–13.8). Three or more of these risk factors present at SSc diagnosis was sensitive (77%) and highly specific (97%) for future SRC. No SSc without SRC disease controls had ≥ 4 risk factors.Conclusion.In this SSc cohort, we present a panel of risk factors for future SRC. These patients may benefit from close observation of blood pressure, proteinuria, and estimated glomerular filtration rate, for earlier SRC identification and intervention. Future prospective therapeutic studies could focus specifically on this high-risk population.

Biotin (vitamin B7) is a dietary supplement that can lead to falsely abnormal endocrine function tests. The impact of biotin on both 25-hydroxyvitamin D [25(OH)D] and intact parathyroid hormone (iPTH) have not been previously described in end-stage renal disease (ESRD). A woman with ESRD on hemodialysis taking biotin 10 mg daily had a 25(OH)D spike from 25 to >100 ng/mL and an iPTH decrease from 966 to 63 pg/mL. After discontinuation of biotin, her 25(OH)D and iPTH returned to baseline. Biotin can cause erroneous 25(OH)D and iPTH results in ESRD that could adversely affect patient care.

Direct renin inhibitors (DRIs) block the activation of the alternative complement pathway in vitro and could be a treatment option for refractory hypertension in atypical hemolytic uremic syndrome (aHUS). A 20-year-old male presented with primary aHUS complicated by end-stage renal disease and refractory malignant hypertension despite being on five antihypertensive medications at maximum dose. Only a partial response was achieved with aliskiren and eculizumab, but after increasing aliskiren to a supratherapeutic dose, antihypertensive medication was reduced, platelets increased, C3 increased and epoetin alfa requirement decreased. DRI may be an adjunct treatment for malignant hypertension associated with aHUS.

Background Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. Methods The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than ‘important’. The content validity index was 0.91. Ninety-five percent of positive-point items were easy–medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46–51], κ = 0.68 (95% CI 0.59–0.77), Cronbach’s α = 0.84. Results We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43–45); 36% passed the test. Fellows scored significantly less than validators (P

Introduction: Biopsy of the allograft is the gold standard for assessing kidney allograft dysfunction. The aim of our pilot study was to identify serum biomarkers that could obviate the need for biopsy. Materials and Methods: We conducted a study to identify the biomarkers in the serum from different groups of chronic kidney disease (CKD) patients and kidney transplanted patients vs. healthy individuals. The four groups (n=25 in each group) were as follows: 1) Patients with unstable kidney allograft transplants requiring biopsy for cause, 2) Patients with stable kidney allograft transplants, 3) Patients with CKD not on immunosuppressive therapy and, 4) healthy subjects. We measured the activity and level of serum alkaline phosphatase (ALP) and other liver enzymes (alanine transaminase (ALT) and aspartate transaminase (AST)) as potential serum biomarkers in acute allograft dysfunction. Results: We found that ALP correlated with allograft biopsy findings, liver function, and clinical outcomes and possibly graft survival. Additionally, AST and ALT were higher in patients with graft rejection compared to non-rejected and stable kidney transplants. Moreover, the low Pearson correlations (r- values) between ALP level with age (r=0.179), gender, body mass index (r=0.236), creatinine (r=0.044) or estimated glomerular filtration rate (r=0.048) suggest that ALP may be an independent biomarker which is relatively unaffected by other individual-level variables. Conclusion: ALP may be a putative biomarker to predict kidney allograft function and rejection. Data also indicated that liver function plays an important role for the overall success of kidney transplantation.

Background Scleroderma Renal Crisis (SRC) is associated with significant morbidity and mortality. While prednisone is strongly associated with SRC, there are no previous large cohort studies that have evaluated ace inhibitor (ACEi) calcium channel blocker (CCB), angiotensin receptor blocker (ARB), endothelin receptor blocker (ERB), non-steroidal anti-inflammatory drug (NSAID), fluticasone, or mycophenolate mofetil (MMF) use in systemic sclerosis (SSc) and the risk of SRC. Methods In this retrospective cohort study of the entire military electronic medical record between 2005 and 2016, we compared the use of ACEi, ARB, CCB, NSAID, ERB, fluticasone, and MMF after SSc diagnosis for 31 cases who subsequently developed SRC to 322 SSc without SRC disease controls. Results ACEi was associated with an increased risk for SRC adjusted for age, race, and prednisone use [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.6–10.2, P = 0.003]. On stratified analyses, ACEi was only associated with SRC in the presence [OR 5.3, 95% CI 1.1–29.2, p = 0.03], and not the absence of proteinuria. In addition, a doubling of ACEi dose [61% vs. 12%, p

Introduction: The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival. Methods: We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome. Results: We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate 2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality. Conclusions: Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.

Background: Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period. Methods: In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables. Results: MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access. Conclusions: MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.

Background:Nephrologists are placing fewer non-tunneled temporary hemodialysis catheters. Requiring competence for nephrology fellow graduation is controversial.Methods:Anonymous, online survey of all graduates from a single, military nephrology training program (n = 81; 1985–2017) and all US Nephrology program directors (n = 150).Results:Graduate response and completion rates were 59% and 100%, respectively; 93% agreed they had been adequately trained; 58% (26/45) place non-tunneled temporary hemodialysis catheters, independent of academic practice or time in practice, but 12/26 did ⩽5/year and 23/26 referred some or all. The most common reason for continuing non-tunneled temporary hemodialysis catheter placement was that it is an essential emergency procedure (92%). The single most significant barrier was time to do the procedure (49%). Program director response and completion rates were 50% and 79%, respectively. The single most important barrier to fellow competence was busyness of the service (36%), followed by disinterest (21%); 55% believed that non-tunneled temporary hemodialysis catheter insertion competence should be required, with 81% indicating it was an essential emergency procedure. The majority of graduates and program directors agreed that simulation training was valuable; 76% of programs employ simulation. Graduates who had simulation training and program directors with ⩽20 years of practice were significantly more likely to agree that simulation training was necessary.Conclusion:Of the graduate respondents from a single training program, 58% continue to place non-tunneled temporary hemodialysis catheters; 55% of program directors believe non-tunneled temporary hemodialysis catheter procedural competence should be required. Graduates who had non-tunneled temporary hemodialysis catheter simulation training and younger program directors consider simulation training necessary. These findings should be considered in the discussion of non-tunneled temporary hemodialysis catheter curriculum requirements.

Oxalate nephropathy is an uncommon cause of acute kidney injury. Far rarer is its association with scleroderma, with only one other published case report in the literature. We report a case of a 75-year-old African-American female with a history of systemic scleroderma manifested by chronic pseudo-obstruction and small intestinal bacterial overgrowth (SIBO) treated with rifaximin, who presented with acute kidney injury with normal blood pressure. A renal biopsy demonstrated extensive acute tubular injury with numerous intratubular birefringent crystals, consistent with oxalate nephropathy. We hypothesize that her recent treatment with rifaximin for SIBO and decreased intestinal transit time in pseudo-obstruction may have significantly increased intestinal oxalate absorption, leading to acute kidney injury. Oxalate nephropathy should be considered in the differential diagnosis of acute kidney injury in scleroderma with normotension, and subsequent evaluation should be focused on bowel function to include alterations in gut flora due to antibiotic administration.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows' progress toward 23 subcompetency "context nonspecific" internal medicine subspecialty milestones. Fellows' advancement toward the "ready for unsupervised practice" target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific "curricular milestones," mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Objectives The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code–level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis. Design Retrospective cohort study. Participants/Setting Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014. Measurements We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences. Results Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13). Conclusions/Implications Black and Hispanic NH residents on dialysis had an apparent survival advantage. This “survival paradox” occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.Proportion of chart audit and quality indicator deficiencies.Longitudinal deficiency and ITE performance.Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue.Retrospective design and small trainee numbers.Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that contains both examination and training features and focuses on management and clinical knowledge of rare hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in managing the event. The OSCE tested and trained fellows in the recognition and management of rare hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty training; however, collaboration between training programs would be necessary to validate such exercises.

Purpose Hyperkalemia during renin-angiotensin-aldosterone system inhibition (RAAS-I) may prevent optimum dosing. Treatment options include sodium polystyrene sulfonate potassium binding resins, but safety and efficacy concerns exist, including associated colonic necrosis (CN). Alternative agents have been studied, but cost-utility has not been estimated. Methods We performed a cost-utility analysis of outpatients ≥ 18 years of age receiving chronic RAAS-I, with a history of hyperkalemia or chronic kidney disease, prescribed either sodium polystyrene sulfonate or a theoretical "drug X" binding resin for chronic hyperkalemia. Data were obtained from existing literature. We used a decision analytic model with Monte Carlo probabilistic sensitivity analyses, from a health care payer perspective and a 12-month time horizon. Costs were measured in US dollars. Effectiveness was measured in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Results Drug X could cost no more than $ 10.77 per daily dose to be cost-effective, at a willingness-to- pay (WTP) threshold of $ 50,000/QALY. At $ 40.00 per daily dose, drug X achieved an incremental cost effectiveness ratio of $26,088,369.00 per QALY gained. One-way sensitivity analysis showed sodium polystyrene sulfonate to be the cost-effective option for CN incidences ≤ 19.9%. Limitations include incomplete information on outpatient outcomes and lack of data directly comparing sodium polystyrene sulfonate to potential alternatives. Conclusions Alternatives may not be cost-effective unless priced similarly to sodium polystyrene sulfonate. This analysis may guide decisions regarding adoption of alternative agents for chronic hyperkalemia control, and suggests that sodium polystyrene sulfonate be employed as an active control in clinical trials of these agents.

Background An analysis of income and racial/ethnic disparities on renal transplant outcomes in recipients with lupus nephritis (LN) has not been reported. We analyzed the United States Renal Data System database to assess the impact of these disparities on graft loss and death in the LN and non-LN cohorts. Methods We identified 4214 patients with LN as the cause of end-stage renal disease in a retrospective cohort of 150,118 patients first transplanted from January 1, 1995 to July 1, 2006. We merged data on median household income from the United States Census based on the ZIP code. Results In multivariate Cox regression analyses, African-Americans (AF) recipients with LN (vs. non-AF) had an increased risk of graft loss (adjusted hazard ratio [AHR], 1.39; 95% confidence interval [CI], 1.21-1.60) and death (AHR, 1.33; 95% CI, 1.09-1.63). Furthermore, there were significant associations of lower-income quintiles with higher risk for graft loss and death among AF with LN. In comparison, among non-AF recipients with LN, income levels did not predict risk for transplant outcomes. The racial disparity for both graft loss and death outcomes among AF with LN was greater than among AF without LN (AHR, 1.32; 95% CI, 1.29-1.36 for graft loss and AHR, 1.02; 95% CI, 0.99-1.05 for death). Conclusions AF kidney transplant recipients with LN were at increased risk for graft loss and death compared with non-AF. Income levels were associated with the risk of graft loss and death in AF but not in non-AF recipients with LN.

Summary Disparities in the incidence, risk factors, and treatment of chronic kidney disease (CKD) and end-stage renal disease are well documented, disproportionately affecting racial/ethnic minorities and persons with low socioeconomic status. The black–white disparities in the prevalence of CKD in the United States have primarily been observed in those with advanced CKD, which may be due to faster rate of progression of kidney dysfunction and an apparent survival advantage among blacks with late-stage CKD. A similar phenomenon has been observed among Hispanic patients, resulting in higher incidence and prevalence of end-stage renal disease than non-Hispanic whites. Assessment of racial disparities in CKD among other smaller minority groups is limited by the lack of adequate longitudinal data and heterogeneity of the individual population, thus further epidemiologic research is warranted. The underlying mechanisms of racial/ethnic disparities in CKD outcomes are complex and include genetic, biologic, socioeconomic, environmental, psychosocial, and cultural factors, as well as patient, provider, and health care system factors that affect access and quality of care.

Despite the near-universal access to treatment for end-stage renal disease (ESRD) under the federally funded Medicare program, ESRD constitutes a major health disparity among racial and ethnic minority groups in the United States, particularly among blacks. Racial and ethnic minority patients have an excess risk of ESRD attributed to diabetes or hypertension, in part due to increased susceptibility to accelerated progression of chronic kidney disease in addition to other environmental, sociocultural, and behavioral factors. Furthermore, racial and ethnic disparities with respect to the treatment of ESRD, to include kidney transplantation, are well documented. Despite having poor intermediate health outcomes, however, minority groups with ESRD on dialysis survive longer than non-Hispanic whites, the so-called survival paradox. Health inequities among minority groups with ESRD warrant a research imperative to better understand many of the genetic, biological, environmental, sociocultural, and health care system-level factors that could ultimately lead to improved outcomes for all patients with ESRD.

Background: End-stage renal disease (ESRD) incidence due to Type 2 diabetic nephropathy (DN) is 35–50%, according to the United States Renal Data System. Methods: A single-center, retrospective cohort study to determine incidence and diagnostic accuracy for Type 2 DN as the primary cause of ESRD (Code 250.40) on the Center for Medicare & Medicaid (CMS) Medical Evidence Report form (CMS2728) submitted at renal replacement therapy initiation. All patients ≥18 years of age with a CMS2728 submitted between 1 March 2006 and 31 March 2015 at a single academic military medical center (ESRD Network 5) were included. Medical records of those with a Code 250.40 diagnosis were reviewed to determine whether they met the Kidney Disease Outcomes Quality Initiative (KDOQI) 2007 criteria for DN. Results: ESRD incidence secondary to Type 2 DN was 18.7% (56/299 individual CMS2728 submissions over 9.09 years). In all, 12/56 (21.4%) did not meet KDOQI criteria for Type 2 DN. Although all had diabetes, those not meeting criteria had shorter disease duration (P = 0.007), were more likely to have active urine sediment (P = 0.006), and were less likely to have macroalbuminuria (P = 0.037) or retinopathy (P = 0.002) prior to ESRD. On exact logistic regression, retinopathy was significantly associated with KDOQI-predicted DN [odds ratio = 19.16 (confidence interval 2.76–223.7), P = 0.0009]. Conclusions: In this single-center cohort, 21.4% identified as having Type 2 DN as the primary cause of ESRD were incorrectly assigned per KDOQI 2007 clinical criteria. If replicated in larger populations, this could have substantial implications regarding the epidemiology of ESRD in the USA.

From 2010 to 2011, more than 70% of the clinical rotation competency evaluations for nephrology fellows in our program were rated “superior” using a 9-point Likert scale, suggesting some degree of “grade inflation.”Background We sought to assess the efficacy of a 5-point centered rotation evaluation in reducing grade inflation.Objective This retrospective cohort study of the impact of faculty education and a 5-point rotation evaluation on grade inflation was measured by superior item rating frequency and proportion of evaluations without superior ratings. The 5-point evaluation centered performance at the level expected for stage of training. Faculty education began in 2011–2012. The 5-point centered evaluation was introduced in 2012–2013 and used exclusively thereafter. A total of 68 evaluations, using the 9-point Likert scale, and 63 evaluations, using the 5-point centered scale, were performed after first-year fellow clinical rotations. Nine to 12 faculty members participated yearly.Methods Faculty education alone was associated with fewer superior ratings from 2010–2011 to 2011–2012 (70.5% versus 48.3%, P = .001), declining further with 5-point centered scale introduction (2012–2013; 48.3% versus 35.6%; P = .012). Superior ratings declined with 5-point centered versus 9-point Likert scales (37.3% versus 59.3%, P = .001), specifically for medical knowledge, patient care, practice-based learning and improvement, and professionalism. On logistic regression, evaluations without superior scores were more likely for 5-point centered versus 9-point Likert scales (adjusted odds ratio [aOR] = 8.26; 95% CI 1.53–44.64; P = .014) and associated with faculty identifier (aOR= 1.18; 95% CI 1.03–1.35; P = .013), but not fellow identifier or training year quarter.Results Conclusions Grade inflation was reduced with faculty education and the 5-point centered evaluation scale.