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