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Highlights and Takeaways from the 2016 Annual Dialysis Conference in Seattle, WA

Highlights and Takeaways from the 2016 Annual Dialysis Conference in Seattle, WA

By Kimberlee Langford, RN BSN CCM CPC

Written for Renalogic - like them on Facebook! 

Preserving Residual Renal Function, improving quality of life for people with CKD and ESRD, and promoting the use of Evidenced-Based Practice Measures and Patient-Centered quality measures to dictate policies to improve renal and dialysis care instead of relying on often antiquated and inadequate guidelines – were the themes I found to be most prevalent at the recent ADC, Annual Dialysis Conference in Seattle Washington this past week.

Renalogic is a pioneering company in the field of renal and dialysis care and cost containment in the United States.  As one of their nurse case managers, I was privileged to attend this conference along with our Executive Vice President of Operations and Technology and 2 other nurses.  School is never out for the professional, and it seems the more one learns, the more there is to learn!   Our nurses are always looking to stay abreast of new innovations in kidney care, better ways to educate ourselves and our members and maintain our expertise in the area of kidney care.

Kidney care is indeed changing, with a consolidation of Providers becoming payers and payers becoming providers.  Approximately 1.5% of Medicare patients are with ESRD/late-stage CKD and this group accounts for 10% off all costs – at about $30 billion/year.  The rising rates of CKD and a changing medical services milleau  - along with a sharp decline in nephrologist fellowships and a diminishing role of the nephrologist in CKD care certainly does create an atmosphere of concern. 

While all this does cause concern, we still have cause to maintain hope.  In the Opening Session of the ADC, we celebrated the fact that last year the death rate in dialysis patients fell from 22.5 to 17.1% - and while hospitalization rates has decreased for those with CKD, so has other Medicare populations – though these rates are still greater for those in dialysis. 

‘Policy pushes Mode’ was a phrase I often heard at the conference, and it was pointed out that reimbursement guidelines certainly drive policies - ergo these guidelines are likely to implement fast and wide.  Because of this trend, at the conference physicians counselled each other to be careful to remember that quality and evidenced – based practice really should be the drivers in developing policies not just reimbursement aims.   The nurse’s role here as patient advocate was celebrated and reinforced by nurse leaders in the field of CKD and ESRD care. 

Practitioners from around the world shared study findings and differences in practice measures – and the discussion often ended with a polite debate around how to best yield greater survival rates, preserve residual renal function, and provide quality care while balancing stewardship needs with scarce resources.  In the US – it was estimated that only 10% of ESRD patients are on PD. Thailand and Hong Kong show excellent survival rates of 79% and 64% (respectively and follow a PD 1^st policy, with HD available only if there are medical complications/contraindications with PD).

  Other countries follow a PD-Favored policy – like Guatemala, Canada, China, Mexico and India (though it was noted that only 10% of India’s population has access to Renal Replacement Therapy at all). 

Globally we are seeing the impact of patient outcomes of PD-1st and PD favored programs.  Most studies cited observational measures and as such it was hard to find good studies to demonstrate a quantifiable difference; but the underlying tone throughout the sessions was such that there was certainly found a more rapid decline in renal function with hemodialysis than in peritoneal – for multiple factors, and this was widely accepted by most of the physician speakers in the sessions I attended. 

The general aim seemed to favor starting patients on peritoneal dialysis, wherever possible, in order to preserve residual renal function as long as possible, improve patient survival rates, reduce risk of CVC-related infection, lower cost, decrease travel and increase ability to work.  Of course while these were the reasons cited in many sessions, the speakers also pointed out that some of the studies cited were susceptible to bias as many were observational studies – and as always…more studies are needed.  That being said there was definitely a prevalent preference by most nephrologists to start on PD, wherever possible and preserve the integrity of the peritoneal membrane to support PD for as long as possible.  The more rapid decline in residual renal function with HD was thought to be mainly related to inflammation and greater hemodynamic instability and dehydration.  Studies consistently pointed to the fact that with increased urine volume we see decreased death rate.   That being said, PD is tough on the peritoneum.  Peritonitis, constipation, Colitis and diverticulitis, high glucose exposures and inflammation, Ultrafiltration Failure, and other conditions like Encapsulating Peritoneal Sclerosis often lead to a deterioration of the peritoneal membrane such that PD often cannot be continued for more than about 3 - 8 years, at which point HD or transplant is necessary.

 

There is a growing trend supporting the initiative to avoid CVC’s involving urgent start PD, where the PD catheter is placed and can be used within 2 weeks of insertion, and many practitioners opt to start with intermittent – or incremental dialysis.  There seems to be some differing opinions here – with many countries outside the US starting dialysis much later seeming to favor the intermittent PD, and in one session, there was a polite, yet somewhat heated debate over this practice.  We even heard very creative solutions when needed to rest the peritoneal membrane, patients used a combination of HD two days per week and PD one day per week, as a way to try to protect the peritoneal membrane, and preserve residual renal function by trying to delay the time to full HD as long as possible.

The fact remains that dialysis is a huge burden for patients, and in order to reach them, we do need to be able to have and show some empathy for the huge burden that ESRD and dialysis is for our patients.  One particularly motivating session for me was on having empathy for these folks and understanding WHY they miss dialysis:  “How can something that makes me feel so bad not be hurting me.” – Indeed, in one survey, 90% of people surveyed said they would take a pill to make them feel better – even if it shortened their lives.    It is important for us, as patient advocates and educators to recognize where our patients are, what are the beliefs driving their actions, and to recognize some factors that make OUR teaching agenda difficult – including myocardial and brain shunting, depression, fatigue, pain, difficulty with pill burdens, financial concerns, grief and loss.  Recognizing these barriers can help us really see where they are, and find meaningful ways to connect to increase cooperation and empower them to make decisions that truly – only they can make.

 

I thrilled at the challenge to practitioners to think outside the box and to work to develop new innovations in kidney care.  We were shown the WAK – wearable artificial kidney – which has been used by 21 people already around the globe with very exciting benefits and widely enjoyed by the wearers.  As one presenter put it: ‘We don’t pee three times a week;  why would we expect people to feel good on dialysis three times a week.”  Innovations like the WAK and the implantable artificial kidney (chip) seek to mimic the kidney’s natural functions, providing greater freedom for the patient in terms of diet and lifestyle, along with improved clearance and outcomes

 

Dialysis and CKD are one of our biggest healthcare burdens in the U.S. today and I am proud to be a part of a team dedicated to improving not just the quality of care and reducing the cost of care – but to truly empowering individual patients to step up and take on the demand of increasing personal ownership of their own care and by so doing, claim a better quality of life for themselves, and in the process – lighting the way for those who follow.