Hemodialysis.com American Society Nephrology 2013 interviews

HEMODIALYSIS.COM
American Society of Nephrology Kidney Week 2013
Exclusive Interview with Nephrology Researchers
Editor: Marie Benz, MD
info@Hemodialysis.com
November 15 2013
For Informational Purposes Only: Not for Specific Medical Advice.

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Chronic Kidney Disease: Mindfulness Meditation and Blood Pressure
Hemodialysis.com Interview with:
Jeanie Park, MD, MS
Assistant Professor, Renal Division, Emory University

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Hemodialysis.com: What are the main findings of the study?
Dr. Park: The key results from our study are that mindfulness meditation acutely lowered muscle sympathetic nerve activity
and blood pressure in hypertensive patients with chronic kidney disease. Our conclusion is that mindfulness meditation may
have beneficial effects on blood pressure and autonomic function in patients with kidney disease.

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Hemodialysis.com:  Were any of the findings unexpected?
Dr. Park: We were unsure if a single session of mindfulness meditation would have beneficial effects on blood pressure and
sympathetic activity, and so were pleasantly surprised to find that there was an acute benefit on these parameters.
Hemodialysis.com: What should clinicians and patients take away from this study?
Dr. Park: There are not enough data to definitively conclude that mindfulness meditation lowers blood pressure and
sympathetic activity in kidney disease patients. Although our findings show that blood pressure and sympathetic activity are
significantly improved acutely during one session of mindfulness meditation, there are no studies investigating the long-term
effects or sustained effects on hemodynamics and autonomic function. However, this intervention is safe, and without side
effects, and may have beneficial physiologic and psychologic effects; thus, it may be a reasonable complementary therapy to
offer to interested patients. There are some data to support that mindfulness practice leads to modest but meaningful
reductions in blood pressure in hypertensive and nonhypertensive patient groups, and improves psychological resilience in
chronic diseases such as cancer.

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Citation:
[FR-PO501] Mindfulness Meditation Lowers Muscle Sympathetic Nerve Activity and Blood Pressure in Chronic Kidney
Disease Patients Authors/Faculty: Jeanie Park, MD, Robert H. Lyles, PhD, Susan Bauer-Wu Date/Time: Friday, November 8,
2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: Hypertension: Clinical

Read the rest of the interview on Hemodialysis.com

Hemodialysis Patients: Cognitive Function and All-Cause Mortality
Hemodialysis.com: Interview with:
David A Drew MD MS Renal Fellow, Tufts Medical Center and
Mark J. Sarnak, MD, MS Director of Research;
Associate Director, Research Training Program;
Professor, Tufts University School of Medicine

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Answer: We found an association between poor cognition function, as assessed by a battery of cognitive tests, and higher allcause mortality. Executive function, critical to planning and carrying out complex tasks, was most strongly associated with
mortality.

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Hemodialysis.com: Were any of the findings unexpected?
Answer: We found it interesting that executive function remained associated with mortality even after adjustment for
comorbid conditions, including a history of cardiovascular disease. This could imply two things. First, that poor executive
function may directly impact mortality. Second, diminished executive function may reflect the burden of sub-clinical vascular
disease and thereby be associated with mortality.
Answer: Cognitive function is often impaired in end-stage renal disease patients and may contribute to the extremely high
mortality rates seen in this population.
Hemodialysis.com: What recommendations do you have for future research as a result of your study?
Answer: The trajectory of cognitive function over time should be examined within dialysis patients. Treatments aimed at
modifying vascular disease and its risk factors may be useful in mitigating cognitive decline.
[FR-PO425] Cognitive Function and All-Cause Mortality in Hemodialysis Patients Authors/Faculty: Mark J. Sarnak, MD, FASN,
Hocine Tighiouart, David A. Drew, MD, Kristina Lou, Saeed Kamran Shaffi, MD, Tammy Scott, PhD, Li Fan, Daniel E. Weiner, MD,
FASN Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: Dialysis:
Epidemiology, Outcomes, and Clinical Trials: Non-Cardiovascular – I

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Stephen McMurray, MD FACP, vice president, Clinical Integrated Care Management
Diabetic ESRD: Effectivenss of StepAhead Program in Improving Care
Study: Effectiveness of the Diabetic StepAhead Program in Improving Patient Care Among Diabetic ESRD Patients

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Answer: Diabetes care can be improved by a physician-driven program in the dialysis facility.

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Answer: Many patients had no physician helping them managing their diabetes.
Answer: Just because patients have end stage renal disease, physicians should take the opportunity to ensure that their
patients have routine diabetes care, such as a doctor assisting in blood glucose management, regular eye exams to preserve
vision and regular foot checks to identify early foot abnormalities and prevent amputation.
Answer: We would like to investigate whether there is an opportunity to provide eye exams in the clinic, add a podiatrist to the
care team and find a method to capture blood glucose readings and provide a comprehensive diabetes report to the physician
managing the patient’s diabetes.
Hemodialysis.com: Anything else to add on this study?
Answer: Overall goal is to incorporate all the findings into the regular operation of the dialysis clinic.
Citation:
Abstract Presented at the 2013 American Society of Nephrology Meeting
[SA-PO376] Effectiveness of the Diabetic StepAhead Program in Improving Patient Care among Diabetic ESRD
Patients Authors/Faculty: Stephen D. McMurray, MD, Christine Ordway, Carey Colson, Pooja C. Oberai, Anne N.
Bubb Date/Time: Saturday, November 9, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: Diabetes
Mellitus and Obesity: Clinical – II

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Hemodialysis Patients: Cognitive Performance and FGF-23
MedicalResearch.com Interview with:
David A Drew MD MS, Renal Fellow, Tufts Medical Center and
Mark J. Sarnak, MD, MS, Director of Research;
Associate Director, Research Training Program;
Professor, Tufts University School of Medicine

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Answer: We found an association between high fibroblast growth factor 23 (FGF-23) and worse cognitive performance,
particularly in cognitive function assessing memory, in chronic hemodialysis patients. This finding was consistent even after
considering other factors that can influence both FGF-23 and memory such as age and comorbidity. Although no association
was seen between FGF-23 and a composite executive cognitive score, we did note an association with several individual tests of
executive function.

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Answer: FGF-23 has previously been associated with several adverse outcomes including an mortality, incident cardiovascular
events, and left ventricular hypertrophy. Although FGF-23 is also located in the brain, no previous studies have investigated its
association with cognitive function. Since cognitive impairment is common in hemodialysis patients, we thought it was
plausible that FGF-23 could be a contributing factor.
Answer: High FGF-23 may be one of many factors contributing to cognitive impairment in dialysis patients.
Answer: This finding should be replicated in larger, longitudinal studies aimed at identifying if a causal relationship exists
between FGF-23 and poor cognition. Studies should also be aimed at determining if FGF-23 can be lowered, and if such a
change results in improvement in clinical outcomes.
Citation:
[FR-PO659] Fibroblast Growth Factor 23 and Cognitive Performance in Hemodialysis Patients Authors/Faculty: David A. Drew,
MD, Hocine Tighiouart, Tammy Scott, PhD, Kristina Lou, Li Fan, Saeed Kamran Shaffi, MD, Daniel E. Weiner, MD, FASN, Mark J.
Sarnak, MD, FASN Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session
Info: Mineral Disease: Vitamin D, PTH, FGF-23 – I

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Hemodialysis and Obesity Paradox: Evaluation of Lean vs Fatty Tissue Indexes
Prof. Dr. Daniele Marcelli, MD, MBA, Nephrologist, Epidemiologist
MBA Int. Hospital and Healthcare Management
Vice President, EMEALA Medical Board
Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany

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Answer: In hemodialysis patients, low body mass index (BMI) is related to mortality whereas high BMI appears to have a protective effect, a phenomenon labelled “reverse
epidemiology”. However, it is unknown which components of body composition contribute to this outcome, i.e. fat or lean body mass. The routine implementation of wholebody multifrequency bioimpedance measurements using the Body Composition Monitor (BCM) in our European clinic network allowed us to now explore this. In total, lean
tissue mass and fat tissue mass measurements of 37,350 hemodialysis patients from 17 countries were evaluated. In essence, the results of this large multinational study
indicate that body composition, and not just BMI, is related to outcome, and that patients with the same BMI but different ratios of lean to fat mass may have different
outcomes. High lean tissue mass (expressed as Lean Tissue Index) was found to be associated with improved survival. While increases in lean tissue index (LTI) were found to
be associated with improved survival, increases in fat tissue index (FTI) appeared to be advantageous only in the presence of appropriate increases in lean tissue. In fact,
increasing fat tissue without an appropriate increase in lean tissue is associated with a higher mortality.
Answer: Almost half of the patients in our study had an LTI below the 10th percentile of an age and gender matched healthy population. A decreased lean body mass is a
component of the protein-energy-wasting syndrome and it is thought to be associated with a parallel decrease in BMI. However, our results show that the majority of patients
with low LTI had normal-to-high FTI and were overweight, classically defined as BMI between 25 and 29•9 kg/m2.
Answer: Based on the current findings, we believe that the presence of a normal BMI is insufficient to diagnose absence of malnutrition and that LTI must be taken into
account. LTI appears to be more specific and a better predictor of mortality. Knowing predictors of low LTI may help to develop preventive strategies. Our logistic regression
analysis indicated an association of low LTI with indicators of inflammation, nutrition and muscle mass (i.e. C-reactive protein, albumin and serum creatinine), so preventive
strategies should focus on measures to reduce sources of inflammation (e.g. catheter use, treatment of periodontitis), improve nutritional competence (dietary consultation,
supplemental oral nutrition), and physical exercise programs to increase muscle mass.

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Answer: This is an observational study and as such cannot offer proof but only hypotheses to be tested in appropriately designed interventional studies, e.g. a controlled
clinical trial to test the hypothesis that improving muscle mass in malnourished patients can improve survival. While such trials have proven difficult to perform, as attested by
the early termination of the trial to test the impact of growth hormone on nutritional status and survival, we strongly believe that they would be an important step towards
evidence-based improved care.
Citation:
[TH-OR114] Relationship between Body Composition Evaluated by Whole Body Bioimpedance and Survival in Hemodialysis Patients Authors/Faculty: Daniele Marcelli,
MD, Len A. Usvyat, PhD, Cristina Marelli, MD, Michael Etter, MD, PhD, Jeroen Kooman, MD, Aileen Grassmann, PhD, Laura Scatizzi, Inga Bayh, Peter Kotanko, MD, Bernard
Canaud Date/Time: Thursday, November 7, 2013 - 6:18 PM Course: Annual Meeting: Abstract Sessions Session Info: Nutrition and Metabolism: From Bench to Bedside


Pre-Hemodialysis: Relationship Between Serum Sodium and Blood Pressure
Jochen G. Raimann, MD
Research Scientist
Research Division, Renal Research Institute

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Dr. Raimann: The Monitoring Dialysis Outcomes (MONDO) initiative database encompasses data of hemodialysis (HD) patients initiating
treatment in more than 26 countries on all habitable continents. From this database we extracted data of 7675 incident patients and found,
employing linear mixed models using data over a period of 24 months after HD initiation, a relationship between pre HD systolic and
diastolic blood pressure (SBP, DBP) and pre HD serum sodium (SNa+). This relationship was consistent when data was analyzed for each
continent separately and in sensitivity analyses only analyzing data in Year 1 and 2, respectively.

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Dr. Raimann: Data reported by He et al. in the United Kingdom (J Hum Hypertens 27(2): 85-89) indicated a relationship between SNa+ and
blood pressure in chronic HD patients. The aim of the current analysis was to extend this analysis to an international level and to also
analyze data of patients considered incident and prevalent in stratified analyses in Year 1 and 2.
Dr. Raimann: Our study confirms previous analyses in chronic hemodialysis and supports the importance of pre HD SNa+ in hemodialysis. A
relationship between pre HD SBP and changes in SBP, respectively, as well as pre HD SNa+ and changes in SNa+, respectively, to mortality
need to be noted. To what extent these associations interrelate is speculative at this point and requires further research. However, at this
point it corroborates the importance of assessing both parameters prior to dialysis and to closely observe them longitudinally.
Dr. Raimann: Determinants of pre HD SNa+ and factors altering the association between SNa+ and BP may be potential areas of future
research. Therapeutic modification of pre HD SNa+ and clinical implications may be additional promising fields of future projects.
CITATION:

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Presented at the 2013 American Academy of Nephrology November 2013
[SA-PO452] Relationship between Pre HD Serum Sodium Concentration and Blood Pressure: Results from a Global Hemodialysis
Cohort Authors/Faculty: Jochen G. Raimann, MD, Michael Etter, MD, PhD, Jeroen Kooman, MD, Nathan W. Levin, MD, Daniele Marcelli,
MD, Cristina Marelli, MD, Frank van der Sande, MD, PhD, Stephan Thijssen, MD, Len A. Usvyat, PhD, Peter Kotanko, MD, Mondo
Consortium Date/Time: Saturday, November 9, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: Dialysis:
Epidemiology, Outcomes, and Clinical Trials: Cardiovascular – II


CKD: Activated Charcoal Reduces Intestinal Barrier Disruption, Systemic Inflammation
Nosratola D. Vaziri M.D., M.A.C.P.
Professor of Medicine, Physiology and Biophysics, School of Medicine
University of California, Irvine Orange, CA 92868

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Dr. Vaziri: Systemic inflammation is a constant feature of chronic kidney disease (CKD) and a major mediator of the associated complications e.g.
cardiovascular disease, cachexia, and anemia, among others. Systemic inflammation in patients with advanced CKD is associated with endotoxemia in the
absence of detectable infection. While the origin of endotoxemia in CKD patients has not been clearly defined gastrointestinal tract is the most likely
source. Until recently little attention had been paid to the role of the gastrointestinal tract as a potential source of the CKD-associated systemic
inflammation. Although located in the center of the body, the gastrointestinal tract is an extension of the external environment and as such it serves as a
barrier against entry of the microorganism, microbial toxins, digestive enzymes, degraded food products, antigens, and other harmful compounds in the
internal environment. In fact local and systemic inflammation in patients with inflammatory bowel disease is due to the disruption of the intestinal
epithelial barrier. The gastrointestinal barrier consists of the epithelial cells and the apical junctional complex which seals the gap between them. The most
important component of the junctional complex is the tight junction (TJ) which consists of the trans-membrane (occludin and claudin families), cytosolic
(zonula occludens family), and peri-junctional (actin and myosin) proteins. In an earlier autopsy study we found chronic inflammation throughout the
gastrointestinal tract in a large number of hemodialysis patients (Amer. J. Gastroenterology 77(8):562-565, 1982). In addition several studies have revealed
presence of endotoxemia in the absence of infection in uremic patients. Together these observations point to increased intestinal permeability and barrier
dysfunction in CKD.
In a series of recent studies we found extensive losses of the epithelial tight junction proteins in the colon, ileum, jejunum, and stomach in rats with CKD
(Nephrol Dial Transplant. 27(7):2686-93, 2012; Amer J Nephrol 38(2):99-103, 2013). These findings elucidated the underlying cause of endotoxemia which is
commonly present and is a major source of inflammation in CKD. Using cultured human colonic epithelial cells, in a separate study (Am J
Nephrology 37(1):1-6. 2012; Am J Nephrology 36(5):438-443, 2012) we showed that CKD-induced disruption of intestinal epithelial barrier is caused by the
heavy influx of urea into the gastrointestinal tract, its conversion by microbial urease to ammonia [CO(NH2)2 + H2O à CO2 + 2NH3] and formation of
ammonium hydroxide [NH3 + H2OàNH4OH] , which is a caustic compound capable of disrupting the tight junction complex (Am J Nephrology 37(1):1-6.
2012). These findings revealed a new mechanism for the previously documented beneficial effects of low protein diet and longer and more frequent
dialysis regimens which help to lower the burden of urea in CKD/ESRD patients.
In our latest study (Amer J Nephrol 37:518–525, 2013) we tested the hypothesis that by trapping the urea-derived ammonia, administration of the activated
charcoal preparation (AST-120) may attenuate the severity of uremia-induced intestinal barrier disruption and systemic inflammation in the CKD animals.
To this end rats with adenine-induced chronic interstitial nephropathy were randomized to receive a AST-120 (4 g/kg/day) or vehicle for 2 weeks. Normal
rats consuming regular diet served as controls. The untreated CKD rats exhibited depletions of the colonic epithelial TJ proteins, endotoxemia, oxidative
stress, and elevated plasma IL-6, TNFα, MCP-1, CINC-3, L-selectin, and ICAM-1. Administration of AST-120 resulted in partial restoration of the epithelial TJ
proteins and marked reduction of plasma levels of endotoxin and markers of oxidative stress and inflammation. In addition AST-120 administration
significantly lowered blood urea level which was due trapping and fecal elimination of ammonia and prevention of its absorption and conversion to urea in
the liver.


CKD: Activated Charcoal Reduces Intestinal Barrier Disruption, Systemic Inflammation
Nosratola D. Vaziri M.D., M.A.C.P.
Professor of Medicine, Physiology and Biophysics, School of Medicine
University of California, Irvine Orange, CA 92868

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Dr. Vaziri: Given the role of urea-derived ammonia in disruption of intestinal epithelial TJ shown in our earlier study and the
ability of the activated charcoal to avidly trap ammonia, the favorable effects of AST-120 observed in this study were not
surprising to the authors.
Hemodialysis.com: What should clinicians and patients take away from your report?
Dr. Vaziri: The findings of this study revealed the efficacy of AST-120 in attenuating the uremia-induced disruption of intestinal
epithelial TJ and the associated endotoxemia, oxidative stress and inflammation. It should be noted that long-term clinical trial
of AST-120 in patients with mild CKD did not significantly retard CKD progression. However the results of the present study
suggest that this product may be a useful adjunct in the treatment of uremia as opposed to being an effective tool to retard
progression of CKD.
Hemodialysis.com: What recommendations do you have for future research as a result of this study?
Dr. Vaziri: Clinical trials are needed to explore the efficacy of AST-120 or related products in reducing systemic inflammation
and the associated morbidities in the ESRD population.
Citation:
Source of the data:
Vaziri ND, Yuan J, Khazaeli M, Masuda Y, Ichii H, Liu S. Oral activated charcoal adsorbent (AST-120) ameliorates CKD-induced
intestinal epithelial barrier disruption and systemic inflammation. Amer J Nephrol 37:518–525, 2013
[PUB396] The Effects of AST-120 Treatment on Uremia-Induced Disruption of Colonic Epithelial Tight Junctions and the
Associated Systemic Inflammation Authors/Faculty: Hoang Anh Nguyen, MD, Jun Yuan, MD, Nosratola D. Vaziri,
MD Course: Annual Meeting: Abstract Sessions Session Info: Publication Only Abstracts


Hemodialysis Patients: FGF-23 and Cardiac Hospitalizations, Mortality
Kristen Jablonski, PhD Postdoctoral Fellow Division of Renal Diseases & Hypertension
University of Colorado Anschutz Medical

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Dr. Jablonski: Higher serum FGF-23 levels were independently associated with all-cause mortality and cardiac hospitalizations
and death in time-dependent Cox regression models.

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Dr. Jablonski: Modeling to include inflammatory markers did not significantly change the above associations.
Dr. Jablonski: These findings contribute to accumulating evidence that FGF-23 is independently associated with adverse
cardiovascular outcomes.
Dr. Jablonski: Future research is needed to determine whether intervening to lower FGF-23 reduces risk of cardiac events and
mortality as well as all–cause mortality.

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Citation: Abstract Presented at 2013 American Society of Nephrology
Fibroblast Growth Factor 23 and the Risk of All-Cause Mortality and Cardiac Hospitalizations and Death in Hemodialysis
Patients: Results from the HEMO Study
[SA-PO481] Fibroblast Growth Factor 23 and the Risk of All-Cause Mortality and Cardiac Hospitalizations and Death in
Hemodialysis Patients: Results from the HEMO Study Authors/Faculty: Kristen L. Jablonski, PhD, Jessica B. Kendrick, MD,
Alfred K. Cheung, MD, Tom Greene, PhD, Michel Chonchol, MD Date/Time: Saturday, November 9, 2013 - 10:00
AM Course: Annual Meeting: Abstract Sessions Session Info: Dialysis: Epidemiology, Outcomes, and Clinical Trials:
Cardiovascular – II


Hemodialysis Patients: PTH Affected by Body Size
Dr. Eiji Ishimura, MD, PhD, FASN
Second Department of Internal Medicine
Osaka City University Medical School Osaka, 545 Japan

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Answer: Serum levels of PTH are significantly affected by body size in hemodialysis patients.

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Answer: Above findings were all unexpected.
Answer: When clinicians see high levels of PTH high PTH should be considered by increased body size. In patients
with high PTH and large body size, cinacalcet is not necessarily prescribed. However, in patients with high PTH and
small body size, cinacalcet is surely necessarily prescribed.
Answer: A large study is necessary to confirm our data, and to make a formula of PTH corrected by body size.
Citation:
Abstract Presented at the 2013 American Society of Nephrology
[SA-PO399] Parathyroid Hormone (PTH) in Hemodialysis Patients Is Significantly, Positively Affected by Body Size:
Both by Fat Mass and Lean Mass, Independently Authors/Faculty: Eiji Ishimura, MD, PhD, FASN, Senji Okuno,
MD, PhD, Akihiro Tsuda, MD, Akinobu Ochi, MD, PhD, Shinya Nakatani, MD, PhD, Masaaki Inaba, MD,
PhD Date/Time: Saturday, November 9, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session
Info: Dialysis: Anemia, Inflammation, Malnutrition, and Metabolism -

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Hemodialysis: FGF-23 and Infection Related Hospitalizations
Kristen Jablonski, PhD  Postdoctoral Fellow Division of Renal Diseases & Hypertension, University of Colorado Anschutz Medical

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Dr.Jablonski: Higher serum FGF-23 levels were independently associated with infectious hospitalizations and death in timedependent Cox regression models.
Dr.Jablonski: Modeling to include inflammatory markers did not significantly change the above associations.
Dr.Jablonski: Although these results do not show causality, it is possible that increased FGF-23 may be contributing to the high
risk of adverse infectious outcomes in chronic hemodialysis patients.
Dr.Jablonski: Future research is needed to determine whether intervening to lower FGF-23 reduces risk of infectious
hospitalizations and death.
Citation:
Abstract Presented at 2013 American Society of Nephrology
[FR-PO442] Fibroblast Growth Factor 23 and the Risk of Infectious Hospitalizations and Deaths in Hemodialysis Patients:
Results from the HEMO Study Authors/Faculty: Kristen L. Jablonski, PhD, Jessica B. Kendrick, MD, Alfred K. Cheung, MD, Tom
Greene, PhD, Michel Chonchol, MD Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract
Sessions Session Info: Dialysis: Epidemiology, Outcomes, and Clinical Trials: Non-Cardiovascular – I


Acute Kidney Injury: Dipstick Test Associated with Severe AKI
Viviane Calice da Silva, MD
Renal Research Institute
New York, NY10065

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Answer: Based on data in a population of chronic kidney disease patients showing a good agreement between saliva
urea nitrogen (SUN) and blood urea nitrogen (BUN) reported by Raimann et al. [Clin Nephrol 76(1): 23-28] we
hypothesized that SUN may also have important predictive value in patient population suffering from acute kidney
injury (AKI) diagnosed as per the Acute Kidney Injury Network (AKIN) criteria. Studying such a population admitted to
Regiona lHans Dieter Schmidt Hospital in Joinville, Brazil, we also found good agreement at all stages of AKI and a
good diagnostic performance to discriminate between higher levels of BUN versus lower values. Furthermore we had
been able to diagnose AKI at AKIN III versus earlier stages (regardless of etiology of AKI). This implies the ability of
the dipstick to identify those in need of more intensive care (possibly also immediate dialysis) and closer observation
without any additional tools but a simple dipstick at very low cost.
Answer: Based on previous data we assumed a good agreement between both markers. Here we assessed the
diagnostic performance of SUN and BUN to diagnose AKI at stage AKIN III compared to those at less severe stages by
means of area under the curve of the ROC curve (AUC ROC). We did not expect that the diagnostic performance of
SUN (AUC ROC: 0.76 (95% CI 0.61-0.91) was better than that of BUN (AUC ROC: 0.69 (95% CI 0.51-0.87) in that
clinical situation.


Acute Kidney Injury: Dipstick Test Associated with Severe AKI
Viviane Calice da Silva, MD
Renal Research Institute
New York, NY10065

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Answer: The SUN dipstick can be an useful tool to semi-quantitatively assess kidney function, in particular in areas with limited
laboratory resources. In combination with clinical symptoms the SUN test could enable caregivers to diagnose AKI and help to
identify patients in need of immediate more aggressive therapeutic approaches. While not shown in this study, we believe that
the SUN test could also aid patient triage in mass disasters.
Answer: Additional research is needed to confirm the current findings in larger populations and other circumstances, e.g.mass
disasters. Furthermore we need to understand the diagnostic capabilities of a simple SUN dipstick measurement to follow the
progress of patients with AKI during therapy. We also need to identity factors affecting the agreement between SUN and BUN
and how we could further improve its diagnostic performance. The development of algorithms using SUN as addition to
currently employed diagnostic approaches using clinical symptoms is another promising area of research.
Citation:
Spit It out To Check Your Kidneys: Saliva Urea Nitrogen Dipstick as a New Bedside Diagnostic Tool of Acute Kidney Injury
[FR-PO001] Spit It Out to Check Your Kidneys: Saliva Urea Nitrogen Dipstick as a New Bedside Diagnostic Tool of Acute
Kidney Injury Authors/Faculty: Viviane Calice da Silva, MD, Marcos Alexandre Vieira, MD, Jochen G. Raimann, MD, Mary
Carter, PhD, John Callegari, Nathan W. Levin, MD, Peter Kotanko, MD, Roberto Pecoits-Filho, MD, PhD,
FASN Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: AKI: Clinical –
II


Hemodialysis Patients: Snoring Amplifies Heart Disease Risk
Claudia Torino, PhD
National Research Council
Institute of Biomedicine and Molecular Immunology U.O.S. Reggio Calabria – Italy

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Dr. Torino: We found that self-reported snoring (i.e. snoring information obtained by using a simple, two-questioned,
questionnaire administrated to patients at enrolment) exerted a strong effect modification on the risk of heart failure
(HF) for all-cause and CV death. In fact, even after adjustment for traditional and ESKD-related risk factors, the hazard
ratios (HR) associated to HF for both the study outcomes were highest in heavy snorers, intermediate in moderate
snorers and lowest and not significant in non-snorers.

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Dr. Torino: No. We know that SDB is associated to sympathetic over-activity, a well-known killer in dialysis
population. Sympathetic over activation raises blood pressure causing hypertension, and may worsen left ventricular
failure in patients with a pre-existing HF, leading to ventricular tachycardia and sudden death during the sleep. Selfreported snoring is a strong indicator of sleep disordered breathing (SDB), as we demonstrated in a validation ESKD
cohort. In this population we found that snoring habits collected by using a questionnaire had a high discriminatory
power [Area Under ROC Curve (AUC) = 75%] for SDB. All these consideration taken together let suppose that
sympathetic over-activity caused indirectly by snoring worsen heart failure, a well-established risk factor for all cause
and cardiovascular mortality, exacerbating its effect on these outcomes.


Hemodialysis Patients: Snoring Amplifies Heart Disease Risk
Claudia Torino, PhD
National Research Council
Institute of Biomedicine and Molecular Immunology U.O.S. Reggio Calabria – Italy

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Dr. Torino: The diagnosis of sleep apnea made by polysomnography is hard to obtain, mainly because this technique
is time-consuming and not well tolerate by patients. Even if the discrimination power of self-reported snoring is
about 40% (i.e. 40% of snorers really suffer from SDB), a negative predictive value equal to 100% (i.e. nobody who
does not snore is affected by SDB) makes the use of this simple questionnaire useful as a first screening for SDB, as it
is able to exclude people who surely do not suffer from this disease.
Dr. Torino: Our results come from an observational study, so we cannot say definitely that the treatment of snoring
will be able per se to reduce mortality in these patients. Obviously clinical trials should be planned to clarify whether
intensified surveillance and treatment (UF intensification) of HF snorers on dialysis may improve clinical outcomes in
this very high risk population.
Citation:
[FR-PO390] Snoring Is a Strong Amplifier of the Risk by Heart Failure for All Cause and Cardiovascular Mortality in
Chronic Kidney Disease in Patients on Dialysis (Stage 5D-CKD) Authors/Faculty: Claudia Torino, Graziella D’ arrigo,
Maurizio Postorino, Giovanni Tripepi, Francesca Mallamaci, Carmine Zoccali, MD, FASN, Progredire Work
group Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session
Info: Dialysis: Epidemiology, Outcomes, and Clinical Trials: Cardiovascular – I


APOL1 Gene Variants and Chronic Kidney Disease Progression in African Americans
Teresa K. Chen, MD, MHS
Assistant Professor of Medicine
The Johns Hopkins University School of Medicine Division of Nephrology

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Dr. Chen: Our study included 693 individuals who participated in the African-American Study of Kidney Disease and
Hypertension (AASK) and underwent Apolipoprotein L1 (APOL1) genotyping. Prior studies have demonstrated an increased risk
of chronic kidney disease (CKD) progression among individuals with two APOL1 high-risk alleles compared to those with one or
no high-risk alleles. We aimed to determine whether APOL1 risk allele status modifies the association between other
traditional risk factors and CKD progression (defined as a doubling of serum creatinine or end-stage renal disease).
None of the clinical, socio-demographic, or laboratory variables (including age, gender, body mass index, systolic blood
pressure, total cholesterol, high-density lipoprotein, smoking, vitamin D, intact parathyroid hormone, and fibroblast growth
factor-23) that we examined differed significantly between individuals with two APOL1 high-risk alleles and those with one or
no high-risk alleles.
Dr. Chen: Yes, we were surprised that none of the risk factors examined in our study differed by APOL1 risk allele status.
Dr. Chen: Among African-Americans, the presence of two APOL1 high-risk alleles is associated with increased risk for CKD
progression. However, the exact mechanism by which this occurs and how APOL1 relates to other risk factors for kidney
disease remain to be elucidated.
Hemodialysis.com: What recommendations do you have for further research as a result of your study?
Dr. Chen: Further investigations in larger studies are needed to determine whether other environmental or genetic risk factors
contribute to the progressive kidney disease observed in individuals with APOL1 high-risk alleles.
Citation: Presented at 2013 American Society of Nephrology
[TH-PO644] Factors Related to CKD Progression among African Americans with and without Apolipoprotein L1 (APOL1) Gene
Variants Authors/Faculty: Teresa K. Chen, MD, Wen Hong Linda Kao, PhD, Michael J. Choi, MD, Brad C. Astor, PhD, Julia J.
Scialla, MD, Lawrence J. Appel, MD, Deidra C. Crews, MD, FASN Date/Time: Thursday, November 7, 2013 - 10:00
AM Course: Annual Meeting: Abstract Sessions


Chronic Kidney Disease and Risk of ESRD: Low Income, Race and Dietary Acid Load
Hemodialysis.com Author Interview: Deidra C. Crews, MD, ScM, FASN
Assistant Professor of Medicine, Division of Nephrology
Core Faculty, Welch Center for Prevention, Epidemiology and Clinical Research Chair, Diversity Council, Department of Medicine
Gilbert S. Omenn Anniversary Fellow, Institute of Medicine
Johns Hopkins University School of Medicine Baltimore MD 21224

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Dr. Crews: Among low income Americans with chronic kidney disease, non-Hispanic blacks consume greater dietary acid load
(ie. diets high in meat and cheese, and low in fruits and vegetables), however, dietary acid load contributes little to explaining
racial disparities in CKD progression beyond ‘traditional’ risk factors. High dietary acid load is an independent predictor of
progression to ESRD only among low income non-Hispanic blacks.
Dr. Crews: Yes—we were surprised to find that high dietary acid load was an independent predictor of progression to ESRD only
among the low income non-Hispanic blacks in our study. We expected it to predict ESRD among low income blacks and whites.
Dr. Crews: While there is more work to be done to confirm our findings, patients with CKD may benefit from increasing their
fruit and vegetable intake.
Dr. Crews: Further studies of the role of diet in disparities in CKD are warranted, including large prospective studies and
culturally tailored interventional studies.
Citation:
Abstract Presented at the 2013 American Society of Nephrology:
Race, Dietary Acid Load and Risk of ESRD among Low Income Americans with CKD
[SA-OR050] Race, Dietary Acid Load and Risk of ESRD among Low Income Americans with CKD Authors/Faculty: Deidra C.
Crews, MD, FASN, Tanushree Banerjee, PhD, Donald E. Wesson, MD, FASN, Hal Morgenstern, PhD, Nilka Rios Burrows, Rajiv
Saran, MD, MBBS, Desmond Williams, Neil R. Powe, MD, FASN


Chronic Kidney Disease and Mortality: Association with Serum Alkaline Phosphatase
Dr. Csaba P. Kovesdy, MD, Professor of Medicine
University of Tennessee Health Science Center Chief of Nephrology
Memphis Veterans Affairs Medical Center

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Dr. Kovesdy: Elevated serum ALP is associated with worsening kidney function and with increased mortality in a cohort of
>650,000 US veterans with non-dialysis dependent chronic kidney disease (CKD). These results confirm the findings of several
smaller studies which have shown similar associations with higher mortality.

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Dr. Kovesdy: Serum ALP may serve as an additional marker of bone turnover, especially when more specific markers such as
bone-specific ALP are not readily available. Serum ALP may be a more robust predictor of adverse outcomes in this population
than serum PTH.
Dr. Kovesdy: Hemodialysis.com: Future research should examine if lowering serum ALP could have a beneficial effect on clinical
outcomes.
Citation:
Association of Serum Alkaline Phosphatase Levels with Kidney Function and with Mortality in a Nationally Representative
Cohort of U.S. Veterans with Non-Dialysis Dependent CKD
[SA-PO569] Association of Serum Alkaline Phosphatase Levels with Kidney Function and with Mortality in a Nationally
Representative Cohort of U.S. Veterans with Non-Dialysis Dependent CKD Authors/Faculty: Csaba P. Kovesdy, MD, Miklos
Zsolt Molnar, MD, PhD, Jennie Z. Ma, Leigh Darryl Quarles, MD, Kamyar Kalantar-Zadeh, MD, PhD,
FASN Date/Time: Saturday, November 9, 2013

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Declining Kidney Function and Progressive Lowering of Serum Albumin

Dr. Csaba P. Kovesdy, MD, Professor of Medicine
University of Tennessee Health Science Center Chief of Nephrology
Memphis Veterans Affairs Medical Center

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Dr. Kovesdy: Declining kidney function is associated with progressive lowering of serum albumin in over 650,000 US veterans with nondialysis dependent CKD. In addition, lower serum albumin is associated with significantly higher mortality, independent of the level of kidney
function.

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Dr. Kovesdy: There are currently no studies of similar size that link declining kidney function with worsening nutritional status.
Dr. Kovesdy: Serum albumin remains one of the most potent predictors of poor outcomes in this population. Worsening kidney function
leads to a decline in nutritional parameters, hence vigilance and proper interventions may be needed as an individual’s kidney function
deteriorates.
Dr. Kovesdy: Clinical trials should examine if correction of malnutrition (protein energy wasting) results in improved clinical outcomes.
Citation:
Abstract Presentation at the 2013 American Society of Nephrology
November 2013

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Changes in Serum Albumin Associated with Decreased Kidney Function, and Its Effects on Mortality in a Nationally Representative Cohort
of U.S. Veterans with Non-Dialysis Dependent CKD
1 [FR-PO801] Changes in Serum Albumin Associated with Decreased Kidney Function, and Its Effects on Mortality in a Nationally
Representative Cohort of U.S. Veterans with Non-Dialysis Dependent CKD Authors/Faculty: Csaba P. Kovesdy, MD, Jun Ling Lu, MD,
Miklos Zsolt Molnar, MD, PhD, Jennie Z. Ma, Joel D. Kopple, MD, Kamyar Kalantar-Zadeh, MD, PhD, FASN


Chronic Kidney Disease Progression and Body Mass
Lucy Lu, MD, CCRP Senior CRC
Division of Nephrology UTHSC
956 Court Ave., Memphis TN 38103

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Dr. Lu: In patients with NDD-CKD, obesity is not always associated with adverse renal outcomes. Overweight-to-mild
obesity seems to be the ideal BMI based on this CKD cohort in US veterans.

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Dr. Lu: We found a U-shaped association between BMI and progression of CKD, which is unexpected.

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Dr. Lu: Clinician and patients should not obsessively believe that reducing weight would result in a good prognosis for
patients with pre-existing chronic illnesses.

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Dr. Lu: Future clinical trials will need to determine what the ideal BMI is in CKD.
Citation:
Abstract Presented at the 2013 American Society of Nephrology
[TH-PO249] Association of Serum Calcium Concentration with Mortality in a Nationally Representative Cohort of U.S.
Veterans with Non-Dialysis Dependent Chronic Kidney Disease Author/Faculty: Barry M. Wall, MD, Kamyar KalantarZadeh, MD, PhD, FASN, Leigh Darryl Quarles, MD, Jun Ling Lu, MD, Csaba P. Kovesdy, MD


Metabolic Syndrome: Proteinuria and Elevated CRP in African Americans
Satyesh K Sinha, PhD Assistant Professor
Internal Medicine (College of Medicine)
Charles R Drew University of Medicine and Science
East 120th Street, Los Angeles, CA-90059

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Dr. Sinha: The study included participants of the National Health and Nutrition Survey Examination ( ≥20 years of age) with metabolic syndrome (MetS) and
excluded those with missing laboratory data. The total analytic sample was 7,309 adults. The findings of this study can be summarized as below:
Among racial/ethnic groups, significant differences were noted in all demographic and clinical parameters except low density lipoprotein. Mean value of Creactive protein (CRP) and urinary albumin excretion (UAE) was higher in African American (AA) compared to Whites and Hispanics.
Adjusted linear regression showed a significant association between UAE and CRP. The interaction term of CRP and race/ethnicity was statistically
significant, indicating that this relationship (between UAE and CRP) is being modified by race/ethnicity.
Among the patients with MetS, AA showed higher odds for CRP and UAE compared to Whites, while Hispanics showed higher odds only for UAE.
Dr. Sinha: I think findings are not entirely unexpected but are interesting and important showing race/ethnicity modifies the relationship between CRP and
UAE in patients with MetS.
Dr. Sinha: The results suggest that elevated level of subclinical inflammation in AA patients with MetS may increase the associated risk of developing
albuminuria, one of the important biomarker for CKD. However, this is a cross sectional study and need further investigation to establish these findings.
Dr. Sinha: Future studies need to consider the role of inflammatory molecules, including CRP, in development of CKD in patients with MetS in general and
in ethnic minorities in particular.
Citation: Abstract Presented at: American Society of Nephrology November 2013
Abstract: [FR-PO324] Elevated Level of C-Reactive Protein Identify African Americans with Metabolic Syndrome at High Risk of Developing Albuminuria
Satyesh K. Sinha, PhD, Magda Shaheen, MD, PhD, Deyu Pan, Susanne B. Nicholas, MD, PhD, FASN. Charles R Drew Univ of Medicine and Science, Los
Angeles, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA.
Elevated Level of C-Reactive Protein Identify African Americans with Metabolic Syndrome at High Risk of Developing Albuminuria


Starting Dialysis in the Elderly: Using Data to Guide Decision Making
Bjoerg Thorsteinsdottir, MD
Mayo Clinic

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Dr. Thorsteinsdottir: We studied 379 patients who started any form of Dialysis at Mayo Clinic Rochester and its satellite
community dialysis units. Our main findings were that the overwhelming majority (76%) of our patients started hemodialysis in
the hospital. Over half (60%) of those in the intensive care unit. In many of these patients their acute kidney injury was
precipitated by either surgery or a severe infection.
We also found that mortality was very high, with 40 percent of patients dying within six months. There was a big difference in
mortality by where the patients started dialysis. Our outpatient starters with End Stage Renal Disease did very well even at a
very advanced age with only 4% six month mortality. However patients who started dialysis in the intensive care unit had a
precipitous early mortality with only 27 percent alive after six months.
We also saw loss of independence. Patients who started dialysis in the hospital often were not able to return home. Of the
patients admitted to the hospital from home, 28 percent died while in the hospital or were discharged to hospice, 28 percent
were discharged to a nursing home, and only 37 percent were able to return home to independent living.
We also confirmed what others have shown before that age alone was not a good predictor of survival, comorbid burden and
context are more important.
Dr. Thorsteinsdottir: Yes, we were surprised by how many elderly face the difficult decision to start or not to start dialysis
under such acute and high stakes situations. This may explain why other investigators have found that patients do not feel that
they have been given any choice about whether or not to start and why so many patients start dialysis without proper
preparations i.e. AV fistulas.
We were also surprised at the high level of loss of independence, something many of our elderly patients value very highly.


Starting Dialysis in the Elderly: Using Data to Guide Decision Making
Bjoerg Thorsteinsdottir, MD
Mayo Clinic

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Dr. Thorsteinsdottir: They should question the current moral and technological imperative to dialyze everyone
irrespective of their health status and prognosis. Patients and families need to know what the chances of survival are
as well as other patient important outcomes such as independence, functional status and quality of life as defined by
the individual patient.
Dr. Thorsteinsdottir: We need to be able to predict better for the individual patient what their chances are of
surviving their acute medical event so that we can help them and their families make informed decisions based on
their goals and values.
Citation:
ASN 2103
Abstract: [FR-OR043] Starting Dialysis at Age 75 Years or Older – Outcomes Data to Help in Shared Decision
Making
Bjoerg Thorsteinsdottir, MD, Hanna L. W. Larson, LaTonya J. Hickson, MD, FASN, Molly A. Feely, MD, Amy W.
Williams, MD. Medicine, Mayo Clinic, Rochester, MN; Univ of San Diego, San Diego, CA.


Kidney Function: Mediterranean Style Diet Impact
Minesh Khatri, MD
Nephrology, Columbia Univ, New York, NY

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Dr. Khatri: In this observational, longitudinal study of 900 mostly older participants in New York, we found that
dietary patterns with increased similarity to a Mediterranean diet were associated with reduced risk of CKD and rapid
kidney function decline. Subjects within this multi-ethnic cohort who were consuming a Mediterranean diet above
the median for this cohort had a 50% reduced risk for incident CKD over the course of the seven-year follow-up
period. There was no interactions between the Mediterranean diet and age, race-ethnicity, BMI, or hypertension. In
secondary analyses, there did seem to be an increased benefit with this dietary pattern in non-diabetics compared to
diabetics. Increased vegetable intake may also have been driving the benefit as that individually was one component
of the Mediterranean diet that was significantly associated with reduced risk of incident CKD.

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Dr. Khatri: I don’t think these results were entirely unexpected. There is biological plausibility that the Mediterranean
diet may have benefits on kidney function, based on studies in other populations suggesting that it can improve
inflammation, cholesterol, blood pressure, and other potential causal pathways in the pathophysiology of kidney
disease progression. We were impressed with the findings that this diet was associated with reduced incidence of
CKD, which will need to be confirmed in other studies. Many dietary studies have focused on subjects with preexisting CKD, which is unlike our study of subjects with relatively well-preserved kidney function.


Kidney Function: Mediterranean Style Diet Impact
Minesh Khatri, MD
Nephrology, Columbia Univ, New York, NY

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Dr. Khatri: Clinicians and patients should understand that this is an observational study, and we cannot draw firm conclusions
that the Mediterranean diet is beneficial for either kidney disease prevention or progression. We need further research before
we can universally recommend this approach for kidney disease patients. However, there is substantial data that the
Mediterranean diet may be beneficial (e.g. the PREDIMED study earlier this year in the New England Journal of Medicine) for
prevention of heart disease. Additionally, there is accumulating data that poor dietary patterns, such as the western diet (high
in red meats and processed foods), has adverse effects on kidney function. I think the balance of the data is beginning to
suggest that unhealthy eating may contribute to kidney disease, and we should be mindful of trying to improve our dietary
habits for the betterment of kidney and overall health.
Dr. Khatri: In the future, observational studies should focus on the effect of a Mediterranean diet in subjects with advanced
chronic kidney disease. This study was in a cohort of people with relatively well-preserved kidney function. Larger, longitudinal
studies in other populations would also add useful information Ultimately, however, randomized control trials are needed to
definitively prove whether a Mediterranean diet significantly impacts kidney function.
Citation:
American Society of Nephrology 2013
[SA-OR052] The Impact of a Mediterranean Style Diet on Kidney Function Authors/Faculty: Minesh Khatri, MD, Yeseon
Park moon, Nikolaos Scarmeas, Yian Gu, Consuelo Mora-mclaughlin, Hannah Gardener, PhD, Clinton Wright, MD, Ralph L.
Sacco, MD, Tom Nickolas, MD, Mitchell S. V. Elkind, MD


Proteinuric Diabetic Nephropathy: ACEI and ARB Combo Not Safe
Linda Fried, MD, MPH, Professor of Medicine
Associate Professor of Epidemiology
Chief, Peritoneal Dialysis, VA Pittsburgh Healthcare System
Staff Physician, VA Pittsburgh Healthcare System

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Dr. Fried: We evaluated combination losartan and lisinopril vs losartan alone on progression of kidney disease in individuals with type 2
diabetes
and urine albuminuria greater than 300 mg/g.
The study was stopped early by the DSMB for safety.
Combination therapy reduced albuminuria but did not decrease the risk of the primary endpoint of change in eGFR, ESRD or death. There
was a trend toward slowing decline in eGFR or ESRD but it was overwhelmed by the increased risk of the intervention. Combination therapy
led to a higher hospitalization rate (17 per 100 patient year higher) mainly due to a higher risk of AKI. There was also a higher risk of
hyperkalemia.
Dr. Fried: The survival curves for the secondary endpoint of eGFR decline or ESRD started to diverge and then narrow again so overall there
was not a significant benefit. We also found that AKI predicted the subsequent development of the primary endpoint suggesting that the AKI
episodes had long term consequences. One possible explanation for the curve narrowing is the cumulative effect of the higher AKI rate.
Dr. Fried: That combination ACEI and ARB therapy is not safe in individuals with proteinuric diabetic nephropathy and should not be used.
Dr. Fried: I think future studies of CKD progression should consider AKI as an important outcome
Citation:
Combined Angiotensin Inhibition for Treatment of Diabetic Nephropathy: VA Nephron D (Abstract 5780)
Disclosures: Linda F. Fried receives research funding from Reata (site investigator) and Merck (drug donation to Veterans Affairs for study).
Nicholas Emanuele receives honoraria from Merck. Paul M. Palevsky is a consultant for Sanofi-Aventis, Cytopherx, Complexa; and receives
research funding from Spectral Diagnostics, Inc. Stephen L. Seliger receives research funding from Roche Diagnostics Corporation, and
Amgen, Inc. Peter Peduzzi receives honoraria from St. Jude Medical. The authors report receiving support from Veterans Affairs and Merck
(study drug donation).


Dialysis: Targeted Medication Therapy Management Improves Outcomes for Patients and Health Care System
Study: Targeted Medication Therapy Management (MTM) Improves Outcomes for Dialysis Patients and the Health Care
System
Author: Josh Howland, Pharm.D., MBA, DaVita Rx manager – Targeted Medication Review

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Answer: The data collected in this study suggests that a pharmacist driven targeted medication review program
focused on a vulnerable patient population not only lowers overall healthcare costs, but improves patient outcomes
by preventing hospitalizations and emergency department visits, which ultimately relate to an improved quality of
life.

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Answer: We were really conservative in our estimated costs avoided model and we were still able to show that this
program could have a significant effect on healthcare costs even with a small number of interventions. The
implications of this study could have even more exciting results in a large scale study population.


System

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Answer: The biggest take away from this study for patients is that having a pharmacist with a background in medication therapy management and a renal
focus can have a huge impact on ensuring that appropriate medications are given to meet the specific needs of end stage renal disease (ESRD) patients; it’s
vitally important that programs like this exist so patients can discuss their medications thoroughly and thoughtfully with their pharmacist. From a clinician
standpoint, it’s apparent from this study that the future of medicine involves an interdisciplinary team to improve outcomes and control healthcare costs.
Answer: Future research in this area should definitely include a matched control population so the study can track actual hospitalizations, outcomes and
healthcare expenditures longitudinally to avoid limitations with estimated costs avoided (ECA) model. That’s something we’re looking into to complete and
validate the findings of this study. Otherwise, it’s really important to not only have a well-defined population and focused interventions, but it would also
be immensely helpful to have pharmacy and medical claims available to account for confounding variables.
Answer: We built the targeted medication review capability because of DaVita’s commitment to find ways to improve patient outcomes and reduce
healthcare costs. This capability is being used in integrated healthcare models where we take risk on improving patients’ outcomes and healthcare cost. We
are expanding the patients we serve as we engage in partnership with accountable care organizations (ACOs), ESRD Seamless Care Organizations (ESCOs)
and forward-thinking commercial payors.
This study is meant to provide a starting point and give insight into what this model could become in an integrated healthcare model such as an ACO.
Because of that it’s too early to draw final conclusions, but the data so far is exciting and shows that pharmacists, with the support of highly-skilled and
well-trained technicians, can have a sizable positive impact on the overall care of dialysis patients. The more we are able to validate this model, the more
likely it will be that it can be scaled appropriately to affect the most positive change in the healthcare system and further advance the case for an integrated
multidisciplinary healthcare team.
Citation:
[SA-OR045] Targeted Medication Therapy Management (MTM) Improves Outcomes for Dialysis Patients and the Healthcare
System Authors/Faculty: Joshua K. Howland, PharmD, May Hoang, PharmD, Maricela Lara Nevarez, PharmD, Kelly K. Chillingworth, RPh, Tracy Furgiuele,
RPh Date/Time: Saturday, November 9, 2013 - 5:54 PM Course: Annual Meeting: Abstract Sessions Session Info: CKD Health Services Research


Interview with Dr.Terry Ketchersid, Fresenius VP Clinical Health Information Management
Dr.Terry Ketchersid, MD, MBA, VP
Clinical Health Information Management
Fresenius Medical Care North America

In an interview during 2013 Kidney Week, Dr. Ketchersid discussed several topics important to nephrologists including:
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Stage 2 Meaningful Use implications
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Acumen EHR update
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ICD-10 implementation
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Regarding Stage 2 implementation of the CMS EHR Incentive Program, Dr. Ketchersid notes there is good news and
bad news.
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The good news is that 4900 providers, over half of those eligible, have enrolled and been paid for Stage 1
implementation. This includes 2/3 of eligible nephrologists.
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The bad news is that the hurdles are much higher for Stage 2 compliance. In addition to more requirements, the
“50% rule” requires more than half of face-to-face patients encounters occur in a venue equipped with a certified
EHR. The only exceptions will be hospital encounters using place-of-service codes 21 or 23 (Inpatient Hospital and
Emergency Room-Hospital). If more than 50% of a nephrologist’s encounters occur in a dialysis setting, either the
dialysis EHR note has to duplicate or contain all of the Stage 2 objectives that an office EHR note contains, or the
nephrologist is not in compliance with the Stage 2 mandates.



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he silver lining for nephrologists is that if more than half of encounters occur in a dialysis facility unable to capture
the Stage 2 requirements, the nephrologist may qualify for a hardship exception. The nephrologist will not receive a
meaningful use incentive, but will also not be hit with the 1% penalty. It is worth remembering that the incentives
for compliance are much lower for Stage 2 than Stage 1 as the incentive program was essentially front-loaded.

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Dr. Ketchersid also notes that some of the mandatory quality measures in Stage 2 may not be pertinent, and may
even be contraindicated, in chronic kidney disease patients. For example, weight loss counseling may be
counterproductive in ESRD patients, as moderate obesity confers a survival advantage. In effect, the nephrologist
may be ‘dinged’ for doing the right thing for the patient.

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Editor’s note: Dr. Ketchersid explains the potential options for nephrologists in greater detail in his blog, linked here.



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Regarding Acumen and ICD-10 implementation.
Acumen EHR will be certified for Stage 2 compliance. While preserving historic data with ICD-9 codes, the search
function will be improved in order to search by text or number for the ICD-10 code and to generate the correct
SNOMED CT.
Other Acumen improvements included a Help Language embedded search tool and Review of Systems and Past
Medical History wizards.
Dr. Ketchersid notes that the vast majority of ICD-10 codes used by nephrologists will be replicated from ICD-9.
However, Dr. Ketchersid predicts that non-Medicare providers, particularly state Medicaid agencies, will not be
prepared for ICD-10 claims, resulting in potential payment delays and cash flow interruptions for nephrology
providers. His advice: stock up on cash and pay attention to how and when claims are paid.
Dr. Ketchersid concluded by stating he hopes CMS will back away from a rigid interpretation of Meaningful Use
mandates, allowing providers to devote more time to the real meaningful use objectives of providing improved
patient care.


World Dialysis Population Doubles Over Past 20 Years
Bernadette Thomas MD
Senior Clinical Research Nephrology Fellow
University of Washington Visiting Researcher
Institute for Health Metrics and Evaluation Seattle, WA

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Dr. Thomas: The global prevalence of maintenance dialysis has almost doubled within the past 2 decades. This growth is far beyond what
was anticipated secondary to population growth and aging, and is noted for both countries with and without ability to provide universal
dialysis access.

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Dr. Thomas: Though more men than women were in receipt of maintenance dialysis in both 1990 and 2010, the rate of increase within the
past two decades was higher in women than men. Also, when assessing the degree of increase in maintenance dialysis when grouping
countries into those that do and do not provide universal dialysis provision, both groups experienced an increase greater than 100%.
Dr. Thomas: The rate of growth of maintenance dialysis is notable. It is becoming increasingly important to effectively prevent chronic
kidney disease, and detect it at earliest stages to prevent or retard progression.
Dr. Thomas: We need to support research efforts aimed at understanding chronic kidney disease progression, detecting chronic kidney
disease at its earliest stages, and methods for developing and providing maintenance dialysis in the most affordable ways possible.
Citation
The Rapidly Growing Global Burden of End-Stage Renal Disease – An Analysis of the Change in Maintenance Dialysis Prevalence between
1990 and 2010
[TH-OR135] The Rapidly Growing Global Burden of End-Stage Renal Disease – An Analysis of the Change in Maintenance Dialysis
Prevalence between 1990 and 2010 Authors/Faculty: Bernadette A. Thomas, MD, Sarah Wulf, Rajnish Mehrotra, MD, FASN, Jonathan
Himmelfarb, MD, FASN, Mohsen Naghavi, MD, PhD, Christopher Jl Murray, MD Date/Time: Thursday, November 7, 2013 - 4:30
PM Course: Annual Meeting: Abstract Sessions Session Info: Update in Patient-Centered Research in Hemodialysis

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Chronic Hemodialysis: Alignment of Dialysate and Serum Sodium
Research Scientist

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emodialysis.com: What are the main findings of the study?
Dr. Raimann: The current study results are, to the best of our knowledge, from the largest prospective project of
DNa+ to SNa+ alignment to date. The projects used an algorithm previously published [Raimann, J. G., et al. (2011).
Semin Dial 24(5): 587-592] and encompassed 4 dialysis clinics. Several smaller studies in the past have shown
favorable results of reducing DNa+ and our results confirm these positive effects. Comparing to a matched cohort
from non-participating dialysis clinic (matched according to time of SNa+, observation period, age (above and below
60 years), hemodialysis vintage (<1, 1-3.9, >4 years) and catheter presence]) on interdialytic weight gain (IDWG),
systolic and diastolic blood pressure (SBP, DBP) and other parameters, remarkably without causing a higher need of
saline administration.

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Dr. Raimann: The aforementioned earlier studies have suggested similar effects and we have also published some
preliminary data suggesting similar effects of the first dialysis clinic included in this quality improvement initiative
[Raimann, J. G., et al. (2011). Semin Dial 24(5): 587-592.]. The lack of differences in terms of hospitalization were
somewhat surprising in regard of data suggesting that a large scale reduction of DNa+ resulted in a reduction of fluid
overload-related hospitalizations [Lacson, E.K., et al. (2011). J Am Soc Nephrol 22(Abstract Supplement): 93A.].
However, it is important to note that the current analysis may not be adequately powered for an analysis of such
outcomes.


Chronic Hemodialysis: Alignment of Dialysate and Serum Sodium
Research Scientist

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Dr. Raimann: The main message of the current data should be that DNa+ requires increased attention by the
community. Data on dietary sodium intake showed increased mortality with increase Na intake. The same
relationship has not yet been proven for a positive dialysate to serum sodium gradient (GNa+) however the currently
available prospective data shows that reduction of the GNa+ by simple means of DNa+ to SNa+ alignment improves
soft outcomes.
Dr. Raimann: Additional research from prospective studies {e.g. the SoLID trial in New Zealand [Dunlop, J. L., et al.
(2013). BMC Nephrol 14: 149.]} are of great importance to find definite answers.
Citation:
FR-PO448] Alignment of Dialysate (DNa) and Serum Sodium (SNa) in Chronic Hemodialysis (HD) Patients (pts):
Results of a Quality Improvement Initiative Authors/Faculty: Jochen G. Raimann, MD, Linda H. Ficociello, PhD, Len
A. Usvyat, PhD, Qingqing Xiao, Yuedong Wang, PhD, Claudy Mullon, PhD, Jose A. Diaz-Buxo, MD, Paul M. Zabetakis,
MD, Peter Kotanko, MD Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract
Sessions Session Info: Dialysis: Epidemiology, Outcomes, and Clinical Trials: Non-Cardiovascular – I


Chronic Kidney Disease and Food Insecurity
Tanushree Banerjee, M.S., M.Phil., Ph.D. Research Specialist,
Department of General Internal Medicine,
San Francisco General Hospital,
University of California, San Francisco

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Answer: We observed that food insecurity (a participant is food insecure if ≥3 items in the 18-item household
questionnaire in NHANES were answered affirmatively) is strongly and independently associated with the
development of ESRD. Net acid excretion which we hypothesized to be a mediator in the association between food
insecurity and progression to ESRD did not act as a mediator.
Hemodialysis.com:  Were any of the findings unexpected?
Answer: Our earlier cross sectional study on dietary acid load and CKD has revealed that in low-income individuals
limited access to nutritious food and relatively easier access to less nutritious food may be linked to poor diets and,
ultimately, to diet-related diseases. We had therefore hypothesized dietary acid load, quantified by net acid
excretion, which is high in the less nutritious food may act as a mediator in the association between food insecurity
and kidney damage. But our findings showed that the relation of food insecurity and ESRD is likely due to factors not
captured by the measurement of net acid excretion.


Chronic Kidney Disease and Food Insecurity
Tanushree Banerjee, M.S., M.Phil., Ph.D. Research Specialist,
Department of General Internal Medicine,
San Francisco General Hospital,
University of California, San Francisco

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Answer: Screening patients with CKD for food insecurity may be appropriate. As clinicians aim to better inform
patients of their CKD risk profile and individually tailor their management plan, it may be important to assess any
potential barriers to following lifestyle recommendations. The translation of interventions for CKD into low-income
communities must specifically address the financial difficulty participants may have in implementing recommended
dietary changes.
Answer: Approaches to address old and new food security challenges through innovative, locally owned and
sustainable solutions, which can be scaled up and mainstreamed should be tested for their impact on health
outcomes. Priority should be given to prevention and preparedness strategies to avert food crises or mitigate their
effects through improved food security information systems and coordination.
Citation
Abstract Presented at 2013 American Society of Nephrology:
[SA-PO159] Association of Food Insecurity and End Stage Renal Disease (ESRD) among a National Cohort of LowIncome Adults with Chronic Kidney Disease (CKD) Authors/Faculty: Tanushree Banerjee, PhD, Deidra C. Crews, MD,
FASN, Donald E. Wesson, MD, FASN, Sai Hurrish Dharmarajan, Rajiv Saran, MD, MBBS, Sharon Saydah, Nilka Rios
Burrows, Neil R. Powe, MD, FASN Date/Time: Saturday, November 9, 2013 - 10:00 AM Course: Annual Meeting:
Abstract Sessions Session Info: CKD: Epidemiology, Outcomes – III


Hemodialysis Patients: Increased Tryptophan Metabolism
Hemodialyisis.com Interview with:
Dr. Rakesh Malhotra
UMDNJ-New Jersey Medical School

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Hemodialyisis.com: What are the main findings of the study?
Answer: We found that hemodialysis (HD) patients have low levels of tryptophan (Trp) and high levels of kynurenine
(Kyn) metabolites as compared to healthy controls. We also observed positive correlation between Kyn/Trp ratio and
C-reactive protein (CRP).

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Hemodialyisis.com: Were any of the findings unexpected?
Answer: Rat models have shown significant decrease of Trp plasma level and augmented concentrations of its
metabolites in renal insufficiency. Our preliminary findings are consistent with the reported literature.


Outpatient Hemodialysis: Minimizing Catheter-Related Bloodstream Infections Pilot Program
Hemodialysis.com Interview with
David Van Wyck, MD
Vice President DaVita Clinical Support Services

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Dr. Van Wyck: Tools and interventional approaches that reduce catheter-related bloodstream infections (BSI) in
hospitals can be successfully applied to reduce catheter-related bloodstream infections in chronic dialysis centers.
Dr. Van Wyck: The fact that we were able to show a positive effect in a relatively small, multi-interventional quality
improvement effort was somewhat surprising, and certainly gratifying.
Dr. Van Wyck: Bloodstream infection in hemodialysis patients represents another opportunity to improve patient
lives through quality improvement.
Dr. Van Wyck: More information is needed to distinguish bloodstream infection that is vascular-access-related from
BSI that is unrelated to vascular access.
Citation:
[TH-PO327] A Pilot Quality Improvement Program to Minimize Catheter-Related Bloodstream Infection in an
Outpatient Hemodialysis Setting Authors/Faculty: David B. Van Wyck, MD, Nancy Culkin, RN, Peter J. Pronovost,
MD, Christine A. Goeschel, Mahesh Krishnan, MD, FASN, Allen R. Nissenson, MD, FASN Date/Time: Thursday,
November 7, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session Info: CKD: Health Services
Research


Hemodialysis: Shorter Sessions and Higher Mortality, Hospitalizations
Study: Shorter Hemodialysis Session Length Is Strongly Associated With Higher Rates of Mortality and Hospitalization
Steven Brunelli, MD, MSCE, senior director, DaVita Clinical Research

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Answer: In total, the records of 39,864 individuals receiving thrice weekly hemodialysis were analyzed. Outcomes were compared between
7,185 patients who had mean dialysis session length of ≥240 minutes and patients receiving dialysis for shorter time periods. Analyses
found a dose response association between incrementally shorter session length and greater risk of heart failure/fluid overload
hospitalization, myocardial infarction, post-dialysis fluid related hospitalization, cardiovascular mortality, and all-cause mortality.

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Answer: It was unanticipated that the occurrence of atrial fibrillation would have an incrementally lower incidence with patients receiving
shorter dialysis sessions, an opposite finding of all other outcomes studied.

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Answer: Maintaining session length of 240 minutes or more in thrice weekly in-center hemodialysis patients may minimize the risk of
hospitalization or death due to heart failure and myocardial infarction.
Answer: There is cardiovascular stress and tissue hypoxia associated with excessive fluid accumulation between hemodialysis sessions;
however, studies are greatly needed to further delineate the physical and molecular mechanisms of cardiovascular events in patients with
end-stage renal disease undergoing dialysis. Also, because this was an observational study, clinical trials are needed to confirm causality.
Answer: Additional staff education and patient interventions that communicate the importance of maintaining hemodialysis session length
may help to improve patient outcomes.
Shorter Hemodialysis Session Length Is Strongly Associated with Higher Rates of Mortality and Hospitalization Authors/Faculty: Steven
M. Brunelli, MD, Emmanuel A. Anum, PhD, Karthik Ramakrishnan, Donna E. Jensen, PhD, Gilbert Marlowe, Mahesh Krishnan, MD, FASN,
Allen R. Nissenson, MD, FASN Date/Time: Friday, November 8, 2013 - 10:00 AM Course: Annual Meeting: Abstract Sessions Session
Info: Dialysis: Epidemiology, Outcomes, and Clinical Trials: Cardiovascular –

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System

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Answer: The biggest take away from this study for patients is that having a pharmacist with a background in medication therapy
management and a renal focus can have a huge impact on ensuring that appropriate medications are given to meet the specific needs of
end stage renal disease (ESRD) patients; it’s vitally important that programs like this exist so patients can discuss their medications
thoroughly and thoughtfully with their pharmacist. From a clinician standpoint, it’s apparent from this study that the future of medicine
involves an interdisciplinary team to improve outcomes and control healthcare costs.
Answer: Future research in this area should definitely include a matched control population so the study can track actual hospitalizations,
outcomes and healthcare expenditures longitudinally to avoid limitations with estimated costs avoided (ECA) model. That’s something we’re
looking into to complete and validate the findings of this study. Otherwise, it’s really important to not only have a well-defined population
and focused interventions, but it would also be immensely helpful to have pharmacy and medical claims available to account for
confounding variables.
Answer: We built the targeted medication review capability because of DaVita’s commitment to find ways to improve patient outcomes
and reduce healthcare costs. This capability is being used in integrated healthcare models where we take risk on improving patients’
outcomes and healthcare cost. We are expanding the patients we serve as we engage in partnership with accountable care organizations
(ACOs), ESRD Seamless Care Organizations (ESCOs) and forward-thinking commercial payors.
This study is meant to provide a starting point and give insight into what this model could become in an integrated healthcare model such as
an ACO. Because of that it’s too early to draw final conclusions, but the data so far is exciting and shows that pharmacists, with the support
of highly-skilled and well-trained technicians, can have a sizable positive impact on the overall care of dialysis patients. The more we are able
to validate this model, the more likely it will be that it can be scaled appropriately to affect the most positive change in the healthcare
system and further advance the case for an integrated multidisciplinary healthcare team.
Citation:
[SA-OR045] Targeted Medication Therapy Management (MTM) Improves Outcomes for Dialysis Patients and the Healthcare
System Authors/Faculty: Joshua K. Howland, PharmD, May Hoang, PharmD, Maricela Lara Nevarez, PharmD, Kelly K. Chillingworth, RPh,
Tracy Furgiuele, RPh Date/Time: Saturday, November 9, 2013 - 5:54 PM Course: Annual Meeting: Abstract Sessions Session Info: CKD
Health Services Research


Hemodialysis.com American Society Nephrology 2013 interviews

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