JUST BECAUSE WE CAN…

LIFE WITHOUT DIALYSIS

Robert Quigley D.O.NOMA Winter Conference

Outline of discussion

◦ Where it all began

◦ Scary slides about Dialysis

◦ Advancing American Kidney Health Initiative July 2019

◦ Diet as a way to prevent advanced CKD

◦ Educating patients about options surrounding dialysis

Infancy-unintended consequences

◦ The Medicare program for the elderly was enacted in 1965.

◦ Seven years later, in 1972, Medicare eligibility was extended both to disabled persons aged

18 to 64 and to persons with irreversible kidney failure who required dialysis or

transplantation.

◦ 20% uncovered

◦ When Medicare eligibility was first extended to beneficiaries with ESRD, only about 10,000

individuals were receiving dialysis

◦ By 2016, this patient group grew to 511,270.

◦ Even though the ESRD population remains at less than 1% of the total Medicare population,

it has accounted for about 7% of Medicare fee-for-service spending in recent years

Accompanying chronic diseases such as diabetes

and heart failure compound the cost of caring for

these individuals, and kidney disease has been

deemed a “cost multiplier” for this reason.

Substantial cost savings may result if these

conditions are detected and treated early,

therefore preventing further complications.

UNITED STATES RENAL DATA SYSTEM 2018 SUMMARY327,000,000

folks are in the

US

Only positive from

opoid epidemic

726,000

folks

Kidney disease ranks as the ninth leading

cause of death in America.

Ultimate Killer

Friends at the coffee Clutch

37 million patients suffer from chronic kidney disease

726,000 have end-stage renal disease (ESRD).

“Decades of paying for sickness and

procedures in kidney care, rather

than paying for health and outcomes,

has produced less-than-satisfactory

outcomes at tremendous cost”

unnamed politician

Advancing American Kidney Health Initiative(July 2019)

◦ Reducing the number of Americans developing end-stage renal disease by 25 percent by

2030

◦ Having 80 percent of new ESRD patients in 2025 either receiving dialysis at home or

receiving a transplant

◦ Needs to address payment model for medications

◦ Doubling the number of kidneys available for transplant by 2030

There are nearly 100,000

Americans waiting on the list to

receive a kidney transplant

Goals of KCF◦ Later and “Better” dialysis starts

◦ Reduced cost of care

◦ Increased transplant rates

Creating a “team” of providers

◦ Kidney Disease Education (KDE) payments will be made for up to six 1-hour session

for stage 4, 5, and ESRD within the first 6 months.

◦ Telemedicine Services

◦ Post-Discharge Home Visits performed by “auxiliary personnel” under supervision.

◦ Home Health services can be provided as needed.

Health Care Hotspotting — A Randomized,

Controlled Trial

NEJM 1/2020

There is widespread interest in programs aiming to

reduce spending and improve health care quality

among “superutilizers,” patients with very high use of

health care services. The “hotspotting” program was

created by the Camden Coalition of Healthcare

Providers . The study evaluated 800 patient

discharges from an inner city hospital

CONCLUSIONS

In this randomized, controlled trial involving patients

with very high use of health care services,

readmission rates were not lower among patients

randomly assigned to the Coalition’s program than

among those who received usual care

Strategies to achieve goal number 1Reducing the number of Americans developing end-stage renal disease by 25 percent by

2030

CHANGE MY DIET?

Not you Daddy’s acid trip.. Metabolic acidosis◦ Affect the kidney by tubular toxicity of elevated ammonium concentrations

◦ Activation of the renin-angiotensin system

◦ Activation of alternative complement pathway

◦ Metabolic acidosis increases the risks:

◦ Hypertension

◦ Heart failure

◦ Muscle wasting

◦ Bone loss

◦ Chronic inflammation

◦ Progression of renal failure

High Dietary Acid Load Predicts ESRD among Adults with CKD JASN 7/2105◦ We examined the association between Dietary Acid Load and progression to ESRD in a

nationally representative sample of adults in the United States. Among 1486 adults with

CKD age≥20 years enrolled in the National Health and Nutrition Examination Survey III

◦ In total, 311 (20.9%) participants developed ESRD.

Foods that maybe more acidifying

◦ Grains

◦ Sugar

◦ Fish

◦ Processed foods

◦ Fresh meats and processed meats

◦ Sodas and other sweetened beverages.

◦ High-protein foods and supplements.

Food that are Alkalanizing

◦ Fruit (apples, peaches, and raisins)

◦ Legumes

◦ Vegetables (spinach and cauliflower)

◦ Potatoes

American Journal of Kidney

Disease

Allowed cheating twice a

week

Results

Phosphorous significant cardiovascular mortality in CKD/ESRD◦ As CKD progresses phosphorous excretion decreases

◦ Increased Levels of PTH/ Fibroblast Growth Factor 23 to compensate

◦ Vascular calcification is an active, cell–regulated process in which ectopic deposition

of calcium-phosphate salts occurs in blood vessels mainly in the arteries or cardiac

valves.

◦ Intimal calcification (calcification of the innermost layer of the vasculature) is

associated with atherosclerotic plaque, and medial calcification is associated with

stiffening of the blood vessels.

Battle to lower phosphorous

◦ Binders

Give People Options

Hyperuricemia has increased the risk of progression of chronic kidney disease: propensity score matching analysis from the KNOW-CKD studyNature. Scientific Reports 4/2019

◦ A total 2042 patients with CKD were analyzed in the KoreaN cohort Study for Outcomes

in patients With Chronic Kidney Disease (KNOW-CKD), a prospective cohort study.

◦ Patients were classified into quartiles on the basis of their serum uric acid level and the

prevalence of advanced CKD was higher in patients with a high uric acid level.

◦ A composite renal outcome was defined as one or more of the following:

◦ initiation of dialysis or transplantation

◦ Two-fold increase in baseline serum creatinine levels

Uric acid lowering medication did not modify results: Feboxostat, Allopurinol

Results

Uric Acid food to avoid

◦ Organ and glandular meats. Avoid meats such as liver, kidney and sweetbreads, which

have high purine levels and contribute to high blood levels of uric acid.

◦ Red meat. Limit serving sizes of beef, lamb and pork.

◦ Seafood. Some types of seafood — such as anchovies, shellfish, sardines and tuna —

are higher in purines than are other types.

◦ Alcohol. Beer and distilled liquors are associated with an increased risk of gout and

recurring attacks. Moderate consumption of wine doesn't appear to increase the risk of

gout attacks. Avoid alcohol during gout attacks, and limit alcohol, especially beer,

between attacks.

◦ Sugary foods and beverages. Limit or avoid sugar-sweetened foods such as sweetened

cereals, bakery goods and candies. Limit consumption of naturally sweet fruit juices.

Reducing the number of Americans developing end-stage renal disease by 25

percent by 2030, by education patients about choices

To find health should be the object of the doctor. Any one can find disease.

AT Still

Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis

Treatmentand Receipt of Hospice Services

JAMA 2/2015

Results

Functional Status of Elderly Adults before and

after Initiation of Dialysis NEJM 5/2009

Clinical Question

Is functional status before dialysis is maintained

after the initiation of this therapy in elderly

patients with end-stage renal disease ?

Data were missing for 549 nursing home residents at 3

months, 696 residents at 6 months, 823 residents at 9

months, and 787 residents at 12 months from the full

analytic cohort of 3702 residents

Results

Transition of health status HD or no?◦ 20 % of ESRD patient are referred for hospice palliative care

◦ Dialysis is no longer covered on hospice

◦ 53% of HD patients who withdraw from dialysis are palliative care/ hospice

◦ Average length of life once patients withdraw from dialysis 7-10 days.

◦ Depending on length of time on HD and residual function

Long-Term Consequences of Kidney DonationNEJM 1/2009◦ The long-term renal consequences of kidney donation by a living donor are

attracting increased appropriate interest. The overall evidence suggests that living

kidney donors have survival similar to that of nondonors and that their risk of end-

stage renal disease (ESRD) is not increased. Previous studies have included

relatively small numbers of donors and a brief follow-up period.

Conclusions

◦ ESRD population is growing

◦ People are living longer with chronic problems

◦ Need more emphasis on diet as a way to postpone dialysis

◦ Palliative care discussions prior to start of dialysis

◦ Quality of life goals as opposed to quantity of life