Lack of Dialysis Access for Undocumented Immigrants Stresses Patients and Providers

MedicalResearch.com Interview with:

Lilia Cervantes, M.D. Internal Medicine, Hospitalist Denver Health and Hospital Authority Assistant Professor, Division of General Internal Medicine Founder, Healthcare Interest Program and Health Equity Lecture Series at Denver Health University of Colorado Health Sciences Center

Dr. Cervantes

Lilia Cervantes, M.D.
Internal Medicine, Hospitalist
Denver Health and Hospital Authority
Assistant Professor, Division of General Internal Medicine
Founder, Healthcare Interest Program and Health Equity Lecture Series
at Denver Health
University of Colorado Health Sciences Center

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response:  For most undocumented immigrants with kidney failure in the U.S., access to hemodialysis is limited and they can only receive it when they are critically ill and near-death.  This type of “emergency-only” hemodialysis is already known to be nearly 4-fold more costly, has 14-fold higher mortality rate, and leads to debilitating physical and psychosocial distress for these patients compared to those receiving regular hemodialysis.

This study shows that clinicians who are forced to provide this substandard care are also harmed.  They experience moral distress, emotional exhaustion, and several other drives of professional burnout due to witnessing needless suffering and high mortality.  Continue reading

Majority of Dialysis Patients Unemployed

MedicalResearch.com Interview with:

Hemodialysis machine Wikipedia image

Hemodialysis machine
Wikipedia image

Dr. Kevin F. Erickson MD, MS
Section of Nephrology and Selzman Institute for Kidney Health
Baylor College of Medicine
Houston, TX

MedicalResearch.com: What is the background for this study?

Response: An amendment to the Social Security Act passed in 1972 made it so nearly every person who develops end-stage renal disease – or ESRD – in the U.S. becomes eligible for Medicare, regardless of their age. At the time the law was passed, the bill’s supporters argued that access to life-sustaining dialysis therapy would enable patients to continue being productive members of society through work and activities at home. While the law has succeeded in providing access to dialysis therapy for many patients who would have otherwise died from kidney failure, it has been less successful at helping patients to continue working. The rate of employment among patients with ESRD who are receiving dialysis in the U.S. is low and has continued to decrease over time, despite both financial benefits from employment and evidence suggesting that patients who are employed experience improved quality of life and sense of wellbeing.

We used a national ESRD registry to examine trends in employment between 1996 and 2013 among patients starting dialysis in the U.S. and in the six months before ESRD. Our goal was to determine whether difficulties that patients face when trying to work begin even before they develop ESRD.

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Kidney Failure From Diabetes Decreasing Across US

MedicalResearch.com Interview with:
Nilka Ríos Burrows, MPH, MT (ASCP)
Lead, Chronic Kidney Disease Initiative
CDC Division of Diabetes Translation. 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Kidney failure treated with dialysis or a kidney transplant is called end-stage renal disease (ESRD).  ESRD is a costly and disabling condition often resulting in premature death.

During 2000–2014, kidney failure from diabetes among U.S. adults with diabetes decreased by 33%, and it declined significantly in most states, the District of Columbia, and Puerto Rico. No state experienced an increase in kidney failure from diabetes. Continued awareness and interventions to reduce risk factors for kidney failure, improve diabetes care, and prevent type 2 diabetes might sustain these positive trends.

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Poor Functional Status Predicts Increased Mortality After Dialysis Initiation

MedicalResearch.com Interview with:

Silvi Shah, MD, FACP, FASN Assistant Professor, Division of Nephrology University of Cincinnati Cincinnati, OH

Dr. Shah

Silvi Shah, MD, FACP, FASN|
Assistant Professor
Division of Nephrology
University of Cincinnati
Cincinnati, OH

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Elderly represent the fastest growing segment of incident dialysis patients in Unites States. The annual mortality in end stage renal disease (ESRD) patients is very high ~ 20%.

Since most of the deaths occur in the first year of dialysis, it is possible that health conditions present prior to initiation of dialysis may impact long-term outcomes. In this study, we determined the impact of poor functional status at the time of dialysis initiation and pre-dialysis health status on type of dialysis modality, type of hemodialysis access and one-year mortality in elderly dialysis patients. We evaluated 49,645 adult incident dialysis patients (1/1/2008 to 12/31/2008) from the United Data Renal Data System (USRDS) with linked Medicare data for at least 2 years prior to dialysis initiation. Mean age of our study population was 72 years. At dialysis initiation, 18.7% reported poor functional status, 88.9% has pre-dialysis hospitalization, and 27.8% did not receive pre-dialysis nephrology care. Patients with poor functional status had higher odds of being initiated on hemodialysis than peritoneal dialysis, lower odds of using arteriovenous access as compared to central venous catheter for dialysis and higher risk of one-year mortality.

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Elderly Frail Patients At Higher Risk Of Mortality After Dialysis Initiation

MedicalResearch.com Interview with:

Silvi Shah, MD, FACP, FASN Assistant Professor, Division of Nephrology University of Cincinnati Cincinnati, OH

Dr. Shah

Silvi Shah, MD, FACP, FASN
Assistant Professor, Division of Nephrology
University of Cincinnati
Cincinnati, OH

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Elderly represent the fastest growing segment of incident dialysis patients in Unites States. The annual mortality in end stage renal disease (ESRD) patients is very high ~ 20%. Since most of the deaths occur in the first year of dialysis, it is possible that health conditions present prior to initiation of dialysis may impact long-term outcomes.

In this study, we determined the impact of poor functional status at the time of dialysis initiation and pre-dialysis health status on type of dialysis modality, type of hemodialysis access and one-year mortality in elderly dialysis patients. We evaluated 49,645 adult incident dialysis patients (1/1/2008 to 12/31/2008) from the United Data Renal Data System (USRDS) with linked Medicare data for at least 2 years prior to dialysis initiation. Mean age of our study population was 72 years. At dialysis initiation, 18.7% reported poor functional status, 88.9% has pre-dialysis hospitalization, and 27.8% did not receive pre-dialysis nephrology care. Patients with poor functional status had higher odds of being initiated on hemodialysis than peritoneal dialysis, lower odds of using arteriovenous access as compared to central venous catheter for dialysis and higher risk of one-year mortality.

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Acute Care Hospitalizations Prior To Initiation of Dialysis Signal Greater Mortality Risk

MedicalResearch.com Interview with:
Charuhas Thakar, MD Professor

Director of the Division of Nephrology Kidney CARE program
University of Cincinnati

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Based on the plausibility that pre-dialysis health status can impact outcomes after initiation of chronic dialysis, we examined large national USRDS dataset with linked Medicare claims prior to dialysis. We found that 88% of patients who initiate dialysis experience at least one acute care hospitalization in two years preceding their dialysis start.

If they do, that is associated with a significant increase in the risk of mortality at one year. We also examined effect of different types of hospitalizations in the pre-dialysis period – Cardiovascular, Infections, both, and neither of the two. There were statistical differences in the effect of type of hospitalization and post dialysis mortality.

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Dialysis Patients Use Emergency Rooms At Six Times Rate of General Population

MedicalResearch.com Interview with:

Rachel Patzer, PhD, MPH Director of Health Services Research, Emory Transplant Center Assistant Professor Emory University School of Medicine Department of Surgery Division of Transplantation

Dr. Rachel Patzer

Rachel Patzer, PhD, MPH
Director of Health Services Research,
Emory Transplant Center
Assistant Professor
Emory University School of Medicine
Department of Surgery
Division of Transplantation

MedicalResearch.com: What is the background for this study?

Response: Patients with End Stage Renal Disease (ESRD) make up less than 1% of all Medicare patients, but account for more than 7% of all Medicare expenses. Patients with ESRD have the highest risk of hospitalization of any patient with a chronic disease, and while hospital admissions have decreased over the last several years, emergency department utilization for this patient population has increased by 3% in the last 3 years. The purpose of the study we conducted was to describe the clinical and demographic characteristics associated with emergency department utilization.

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IV Iron in Hospitalized Hemodialysis Patients Not Linked With Worsening Infections

Dr. Julie H. Ishida MD San Francisco Veterans Affairs Medical Center Nephrology Section San Francisco, CAMedicalResearch.com Interview with:
Dr. Julie H. Ishida MD
San Francisco Veterans Affairs Medical Center
Nephrology Section
San Francisco, CA

Medical Research: What is the background for this study? What are the main findings?

Dr. Ishida: Intravenous iron is important in the treatment of anemia of end-stage renal disease, but it is biologically plausible that iron may increase infection risk. While results from epidemiologic studies evaluating the association between intravenous iron and infection in hemodialysis patients have been conflicting, guidelines for the treatment of anemia of chronic kidney disease have recommended caution in prescribing, avoidance and withholding of intravenous iron in the setting of active infection. However, no data specifically support the recommendation to withhold intravenous iron during active infection.

Our study observed that among hemodialysis patients hospitalized for bacterial infection who had been receiving intravenous iron as an outpatient, continued receipt of intravenous iron was not associated with higher all-cause mortality, readmission for infection, or longer hospital stay.

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Association Between Poverty and Chronic Kidney Disease May Be Getting Stronger Over Time

Holly Kramer, MD, MPH Department of Public Health Sciences Loyola University Chicago Health Sciences Campus Maywood, ILMedicalResearch.com Interview with:
Holly Kramer, MD, MPH

Department of Public Health Sciences
Loyola University Chicago
Health Sciences Campus
Maywood, IL

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Kramer: The U.S. dialysis dependent population continues to grow with  636,905 prevalent cases of end-stage renal disease (ESRD) in the U.S. as of December 31, 2012, , an increase of 3.7% since 2011.  Poverty is a well described risk factor for ESRD because poverty impacts access to care and nutritious foods.  The definitions for poverty in the U.S. have not changed over the past several decades despite marked changes in social structure.  For example, social integration in the U.S. society currently requires a cell phone, computer and internet access and access to transportation.  Healthy foods also cost more now relative to unhealthy foods compared to past decades.  Thus, the link between poverty and any chronic disease or health outcome is likely dynamic due to the evolving financial burden for living in a rapidly changing industrialized society.  Our study defined poverty as living in a zip code defined area with > 20% of the residents living below the federal poverty line.  We show that the prevalence of adults receiving dialysis who are living in poverty has increased over time.  We also show that the association between poverty and ESRD may be getting stronger over time.  

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More Dialysis Patients Becoming Pregnant

Dr. Mala Sachdeva MD North Shore University Hospital, Long Island Jewish Medical Center Assistant Professor, Nephrology, Internal Medicine Hofstra North Shore-LIJ School of MedicineMedicalResearch.com Interview with:
Dr. Mala Sachdeva MD
North Shore University Hospital, Long Island Jewish Medical Center
Assistant Professor, Nephrology, Internal Medicine
Hofstra North Shore-LIJ School of Medicine

Medical Research: What is the background for this study?

Dr. Sachdeva: The last study examining pregnancy and dialysis outcomes in the United States was performed more than 15 years ago. Our study was conducted to evaluate practice patterns and to trend maternal and fetal outcomes in the pregnant dialysis female over the past five years. We did a surveymonkey-based survey of American nephrologists on their knowledge of managing pregnancy patients on dialysis.

Medical Research: What are the main findings?

Dr. Sachdeva: Over the past five years, more than 59 pregnancies have been reported. During this time period, almost half of the American nephrologist respondents (43%) have cared for pregnant females on hemodialysis. Hence, we can see that more nephrologists are now faced with taking care of the pregnant dialysis patient. Although a good number of patients initiated dialysis during pregnancy (32%), the majority (58%) of pregnancies occurred within the first five years of being on maintenance dialysis.

Pregnancy outcomes can improve. Of the reported pregnancies 23% did not result in live births. 50% of the pregnancies were complicated by preeclampsia. There were no maternal deaths.

Most nephrologists prescribe 4 to 4.5 hours of hemodialysis. 64% of respondents provide dialysis for six days per week. Only 21% aimed for a target predialysis BUN of less than 20 mg/dL while 66% of nephrologists targeted a BUN less than 50mg/dL.  75% of respondents do not have access to fetal monitoring during dialysis for their pregnant patient.

There are approximately 32% of American nephrologists who are somewhat to very uncomfortable caring for a pregnant woman on hemodialysis. 51% of American nephrologists or a member of their staff counsel their female dialysis patients about contraception.

So in summary, while majority of the US based nephrologists are trying to dialyze pregnant ESRD patients with more intense prescriptions, there are still some gaps with comfort and knowledge.

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Heart Attack Carries Worse Prognosis In Dialysis Patients

Hemodialysis

Hemodialysis

MedicalResearch.com Interview with:
Tanush Gupta, MD

Department of Medicine, Division of Cardiology
New York Medical College, NY

Medical Research: What is the background for this study? What are the main findings?

Dr. Gupta: There are approximately 600,000 prevalent cases of end stage renal disease (ESRD) in the United States. Cardiovascular disease is the leading cause of death in ESRD patients. Moreover, approximately 20% of these deaths due to cardiovascular disease are attributable to acute myocardial infarction (AMI). Multiple studies have shown that ESRD patients have poor short- and long-term survival after AMI relative to the general population. We analyzed the publicly available Nationwide Inpatient Sample (NIS) databases from 2003 to 2011 to examine the temporal trends in ST-elevation myocardial infarction (STEMI), use of mechanical revascularization for STEMI, and in-hospital outcomes in adult ESRD patients in the United States.

We found that from 2003 to 2011, whereas the number of acute myocardial infarction hospitalizations in ESRD patients increased from 13,322 to 20,552, there was a decline in the number of STEMI hospitalizations from 3,169 to 2,558. The use of percutaneous coronary intervention (PCI) for STEMI increased from 18.6% to 37.8%, whereas there was no significant change in the use of coronary artery bypass grafting. During the study period, in-hospital mortality in ESRD patients with STEMI increased from 22.3% to 25.3%. We also observed an increase in average hospital charges and a decrease in mean length of stay during the study period.

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Tool Helps Chronic Kidney Disease Patients Make Dialysis Decisions

MedicalResearch.com Interview with:
Suma Prakash MD, MSc, FRCPC

Department of Medicine, Division of Nephrology
Case Western Reserve University
MetroHealth Medical Center Cleveland, Ohio

Medical Research: What is the background for this study? What are the main findings?

Dr. Prakash: Patients with advanced chronic kidney disease are often faced with difficult decisions of having to choose between options to replace their kidney function. Many patients may not be ready to make treatment decisions since most people don’t want to need a chronic medical treatment.

The behavioural stage of change model originally used to help people with smoking cessation has been used to help patients make decisions about self-care with diabetes and undergo cancer screening. It has not been studied in patients with chronic kidney disease. As patients progress through the stages, they are more ready to make decisions. Focusing on better understanding the decision making process from patients’ perspectives allows us as medical professionals to help patients make timely decision about their options.

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Ferric Citrate – Auryxia™ – Demonstrates Safety and Cost Savings in Dialysis Patients

Dr. Julia Lewis, MD, Lead Investigator Nephrologist and Professor of Medicine Vanderbilt University Medical CenterMedicalResearch.com Interview with:
Dr. Julia Lewis, MD, Lead Investigator

Nephrologist and Professor of Medicine
Vanderbilt University Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Lewis: The 48-week Open Label Extension (OLE) study for Auryxia™ (ferric citrate) was conducted to determine long term safety following the Phase 3 52-week active-control period. The study also evaluated changes in serum phosphorus, transferrin saturation (TSAT), serum ferritin, hemoglobin, hematocrit and additional parameters, as well as intravenous (IV) iron and erythropoiesis-stimulating agent (ESA) usage.

In the OLE study, Auryxia demonstrated long-term safety in dialysis-dependent chronic kidney disease (CKD) patients. The results were consistent with those seen in the published pivotal Phase 3 trial.

The study demonstrated that the adverse events (AE’s) profile of Auryxia was similar to that seen in the Phase 3 52-week active-control period. AEs occurred in 142 patients treated with Auryxia. They were primarily non-serious gastrointestinal (GI) – related AE’s, including diarrhea, nausea, vomiting and constipation. Serious adverse events occurred in 75 patients, though none were related to Auryxia. In addition, there were no clinically or statistically significant differences in liver enzymes or aluminum levels observed from baseline to the end of the 48 weeks.

Similar to the original trial, we witnessed excellent phosphorus control with the drug, along with an increase and then a plateau in serum ferritin and TSAT levels with Auryxia. The plateauing of serum ferritin and TSAT further supports iron absorption is highly regulated by the gastrointestinal track as seen in the 52-week active control period. This suggests that the body absorbs iron as needed for effective erythropoiesis.

Additionally, iron store increases from ferric citrate resulted in, by the end of the extension study, 85% of subjects not using any IV iron.

We presented this data at the 2014 American Society of Nephrology Meeting. The abstract can be found online at www.asn-online.org.

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Test Helps Determine Which Patients May Not Benefit From Elevated HDL

Thomas Weichhart, PhD Associate Professor, Medical University of Vienna Institute of Medical Genetics Vienna AustriaMedicalResearch.com Interview with:
Thomas Weichhart, PhD

Associate Professor, Medical University of Vienna
Institute of Medical Genetics Vienna Austria

Medical Research: What is the background for this study?

Dr.  Weichhart: Impairment of high-density lipoprotein (HDL) function has been associated with cardiovascular events in patients with kidney failure on hemodialysis. The protein composition of HDLs is altered in these patients presumably compromising the cardioprotective effects of HDLs. In an earlier study we found that two proteins in particular, namely Serum Amyloid A (SAA) and Surfactant Protein B (SP-B), are significantly raised in the HDL of dialysis patients, and these also contribute towards HDL losing its protective effect. In the current study we have now developed an novel test that can quickly and directly measure the SAA and SP-B bound to HDL.

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Exercise Improves Outcomes in Dialysis Patients

Prof. Francesca Mallamaci Professor of Nephrology Head of the Hypertension Unit at the Department of Nephro-Urology, CNR-IBIM Research on Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, ItalyMedicalResearch.com Interview with:
Prof. Francesca Mallamaci
Professor of Nephrology
Head of the Hypertension Unit at the Department of Nephro-Urology, CNR-IBIM Research on Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy

Medical Research: What is the background for this study? What are the main findings?

Dr. Mallamaci: It is well known that physical activity is beneficial both in normal individuals and in patients with heart failure which represent a high risk category of patients. We have scanty information about physical activity in dialysis patients. So the aim of our study was to test the effectiveness of a low-intensity, easy to implement, home exercise program on physical performance in about 300 dialysis patients in a multicenter, randomized, controlled clinical trial (EXCITE, ClinicalTrials.gov NCT01255969). What we found in our study was that dialysis patients who performed exercise improved their physical performance and this was documented by 2 well known and validated performance tests such as the Six Minute Walking Test and the Sit-to-stand-to sit test. We found also that after 2 year follow-up dialysis patients who were in the active exercise arm had a lower rate of hospitalization and a trend to a better survival, compared to dialysis patients in the control arm of the study. Continue reading