Scott E. Liebman

Introduction: Dialysis social workers (DSWs) educate and advocate for end‐stage kidney disease (ESKD) patients during the kidney transplantation (KT) process. However, little is known about the barriers DSWs face as they help patients get waitlisted and how to best support their efforts. We interviewed DSWs across New York (NY) State to examine their experiences, supports, and challenges in helping dialysis patients progress through KT education, referral, and evaluation.Methods: We conducted semi‐structured interviews with DSWs in NY State who had participated or expressed interest in a program designed to educate DSWs about KT and used rapid qualitative analysis to identify themes.Findings: We interviewed 17 DSWs. Seven themes emerged: (1) DSWs report involvement in KT interest assessment, education, referral, and evaluation support, (2) DSWs report varying nephrologist support in helping patients progress to KT, (3) DSWs perceive social support and adherence as key factors in KT centers’ eligibility determinations, (4) DSWs have knowledge gaps around living donation and appreciate learning about KT from transplant centers and non‐profit organizations, (5) Patients express KT concerns and DSWs counsel them about these concerns, (6) DSWs report solutions to help patients complete KT evaluation appointments, and (7) DSWs report communication deficiencies between dialysis centers and transplant centers, and patients.Conclusions: Education for DSWs, support from nephrologists, and resources to help patients complete KT evaluation steps facilitated DSW engagement throughout the pre‐transplant process, underscoring the need for multi‐level, cross‐disciplinary programs to support these efforts.

Background/Objectives: Whole-food plant-based diets (WFPBDs) are beneficial in managing hypertension in the general population but have not been well studied in chronic kidney disease (CKD), potentially due to concerns about hyperkalemia. We hypothesized that individuals with CKD 3 or 4 attending a 15-day WFPBD education program would achieve lower blood pressure compared to those who did not, without an increased risk of hyperkalemia. Methods: This was a pilot trial of 40 subjects with mild-to-moderate CKD and hypertension but without diabetes or proteinuria from a single academic center. The subjects were randomized to the 15-day education program or the control group. The changes in blood pressure, serum potassium, and other anthropometric and biochemical values were assessed. Results: Systolic blood pressure decreased from the baseline to day 15 in the intervention group by 8 mm Hg and increased in the control group by 2.7 mm Hg, although the difference in the blood pressure change did not reach statistical significance (p = 0.12). Diastolic blood pressure was not different between the two groups. Potassium changed by 0.01 mEq/L in the intervention group and −0.07 mEq/L in the control group (p = 0.52). The intervention subjects had significant decreases in body mass (−3.0 vs. −0.12 kg, p < 0.0001), total cholesterol (−39.4 vs. −5.0 mg/dL, p < 0.0001), low-density lipoprotein (−28.4 vs. −0.6 mg/dL, p < 0.0001), and high-density lipoprotein (−8.6 vs. −0.4 mg/dL, p = 0.006) compared to the controls. The changes in albumin and phosphorus were not different between the two groups. Conclusions: The subjects with mild-to-moderate CKD attending a 15-day WFPBD education program had a non-statistically significant reduction in systolic blood pressure without an increased risk of hyperkalemia compared to those who did not attend. The intervention subjects achieved significantly greater reductions in body mass and cholesterol without adverse effects on albumin or phosphorus. Larger and longer-duration trials using this approach in a diverse group of CKD patients are warranted.

Key Points: Historically underrepresented racial groups and those with high sociodemographic stress are less likely to initiate dialysis with a home modality. Differences in race are not significant in those who transition to a home dialysis modality after starting in-center hemodialysis. Measures of sociodemographic stress are not associated with home dialysis technique failure. Background: Despite offering several advantages to patients and health care systems, utilization of home dialysis modalities (HDMs) remains low, particularly among racial and ethnic minorities and those with increased sociodemographic stress. Providers' apprehension toward adverse outcomes and home dialysis failure remains a barrier to HDM referral. We investigated the relationship that sociodemographic factors have on HDM use and technique failure. Methods: We performed a retrospective cohort study of adult patients with incident ESKD over a 6-year period at the University of Rochester to evaluate the association between demographic factors, the Social Deprivation Index (SDI), and comorbidity burden on HDM utilization and technique failure. Person-time incidence rates were calculated to compare outcome variables, and rates were compared using a Poisson Rate Ratio Test. A univariate Cox regression was used to examine predictors affecting technique failure. Results: Of the 873 patients, 102 started dialysis with HDM, 79 patients converted to HDM, and 692 remained on in-center hemodialysis (ICHD). Age, race, and SDI scores were significantly different between patients starting on ICHD, peritoneal dialysis, and home hemodialysis with no significant difference in comorbidity burden. Black patients represented 32% of the overall cohort, but only 16% of the initial home dialysis population. Compared with those who remained on ICHD, individuals converting from ICHD to HDM were younger and had significantly different SDI scores. SDI was not associated with HDM technique failure. Conclusions: Historically underrepresented racial populations are less represented in those starting home dialysis; however, there was no racial difference in the group transitioning to HDM after initiating ICHD. Social deprivation scores were higher in those on ICHD compared with peritoneal dialysis. Neither social deprivation nor race predicted success on home therapy. These findings demonstrate a disparity in initial modality, and a disconnect between sociodemographic factors associated with home dialysis use and those predicting HDM technique failure.

Whole food plant-based diets are gaining popularity as a preventative and therapeutic modality for numerous chronic health conditions, including chronic kidney disease, but their role and safety in end-stage kidney disease patients on peritoneal dialysis (PD) is unclear. Given the general public’s increased interest in this dietary pattern, it is likely that clinicians will encounter individuals on PD who are either consuming, considering, or interested in learning more about a diet with more plants. This review explores how increasing plant consumption might affect those on PD, encompassing potential benefits, including some specific to the PD population, and potential concerns.

The mainstay of therapy for chronic kidney disease is control of blood pressure and proteinuria through the use of angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) that were introduced more than 20 years ago. Yet, many chronic kidney disease (CKD) patients still progress to end-stage kidney disease—the ultimate in failed prevention. While increased oxidative stress is a major molecular underpinning of CKD progression, no treatment modality specifically targeting oxidative stress has been established clinically. Here, we review the influence of oxidative stress in CKD, and discuss regarding the role of the Nrf2 pathway in kidney disease from studies using genetic and pharmacologic approaches in animal models and clinical trials. We will then focus on the promising therapeutic potential of sulforaphane, an isothiocyanate derived from cruciferous vegetables that has garnered significant attention over the past decade for its potent Nrf2-activating effect, and implications for precision medicine.

Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship’s educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and educational practice patterns and identify areas for improvement. Our survey explored fellowship program demographics, fellows’ workload, call structure, and education. Program directors were asked to estimate the average and maximum number of patients on each of their inpatient services, the number of patients seen by fellows in clinic, and to provide details regarding their overnight and weekend call. In addition, we asked about number of and composition of didactic conferences. Sixty-eight out of 148 program directors responded to the survey (46%). The average number of fellows per program was approximately seven. The busiest inpatient services had a mean of 21.5±5.9 patients on average and 33.8±10.7 at their maximum. The second busiest services had an average and maximum of 15.6±6.0 and 24.5±10.8 patients, respectively. Transplant-only services had fewer patients than other service compositions. A minority of services (14.5%) employed physician extenders. Fellows most commonly see patients during a single weekly continuity clinic, with a typical fellow-to-faculty ratio of 2:1. The majority of programs do not alter outpatient responsibilities during inpatient service time. Most programs (approximately 75%) divided overnight and weekend call responsibilities equally between first year and more senior fellows. Educational practices varied widely between programs. Our survey underscores the large variety in workload, practice patterns, and didactics at different institutions and provides a framework to help improve the service/education balance in nephrology fellowships.

At our institution, we have noted that end-stage renal disease patients choosing a home dialysis modality after education often initiate renal replacement therapy with in-center hemodialysis (HD) instead. We interviewed 24 such patients (23 choosing peritoneal dialysis [PD], one choosing home HD) to determine reasons for this mismatch. The most common reasons cited for not starting home dialysis were: lack of confidence/concerns about complications, lack of space or home-related issues, a feeling of insufficient education, and perceived medical or social contraindications. We propose several potential strategies to help patients start with their preferred modality.

Background Quality of life (QOL) is an important metric of high-quality dialysis care. QOL is commonly measured by the Short Form 36 Questionnaire (SF-36), which provides two summary scores: a mental component score (MCS) and a physical component score (PCS). Poor QOL is associated with mortality in dialysis patients. Small studies show that changes in QOL also predicts mortality. We investigated whether changes in QOL over time are associated with mortality in a large cohort of maintenance hemodialysis patients. Methods This retrospective study was conducted in 1017 outpatient dialysis facilities. Over 10,000 hemodialysis patients completed two SF-36 surveys. We compared 1-year morality rates in those whose MCS or PCS increased or decreased ±5 vs. those whose did not. Results For those who completed two surveys, mean score for PCS was unchanged, whereas MCS increased slightly (48.6 vs. 48.9, p = 0.05). Individual patients, however, showed marked variation. On the second survey, more than half of patients demonstrated a ± 5 point change in the PCS and/or MCS. After multivariate adjustment, a ≥ 5 decrease in MCS was associated with an increase in mortality (HR = 1.33, 95 % CI 1.18, 1.50). Conclusions Clinicians should be aware that many patients experience a significant change in both the MCS and PCS on dialysis. A MCS decrease of ≥5 was associated with increased mortality. More study is needed to determine whether this is a causal relationship. Physicians should evaluate root causes and seek to mitigate declines in QOL whenever possible.

Introduction: Kidney transplantation (KTX) is considered the treatment of choice for most individuals with end-stage kidney disease. The purpose of this study was to assess the employment status and social participation after successful KTX. Methods: This was a retrospective cross-sectional study. Eligible participants were patients who received a transplant ≥1 year ago and who were previously on hemodialysis (HD) for ≥1 year. Two hundred individuals participated in this study. Results: A significant number (93.5%) of patients reported they were working prior to HD versus 35% while on HD. Only 14% reported receiving disability benefits prior to HD versus 75% receiving disability while on HD. Comparing transplant recipients with pre-HD patients, 35.5% versus 93.5% reported working, and 74.5% versus 14% reported receiving disability benefits, respectively. After transplant, patients were more likely to join recreational clubs, travel frequently, and participate in recreational/religious activities and social events than when they were on HD. Conclusion: Posttransplant, these individuals are more likely to participate in social and leisure activities, but the majority did not resume employment and continued to receive disability payments. Future studies could explore barriers to employment in patients who underwent successful transplantation and the causes and factors as to why these individuals continue to receive disability benefits.