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The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney HealthMIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney HealthMVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.

Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative?s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.

The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

Kidney transplantation is an excellent treatment option for many patients, providing a quality of life that is superior to that experienced by patients on dialysis. Despite its advantages, there are certain health implications that transplant recipients must face. In this article, Susie Lew et al review the nutritional factors that need to be considered to prevent health issues after kidney transplant

Until January 2019, Medicare beneficiaries requiring maintenance dialysis therapy were eligible for telehealth services only if the originating site was located in a rural area and the patient was situated in an authorized facility. Free-standing dialysis facilities and the patient’s home were clearly restricted sites. Beginning in 2019, new opportunities are available for home dialysis patients in the United States to engage in telehealth; these include existing waivers within End-Stage Renal Disease (ESRD) Seamless Care Organizations (ESCOs) participating in the Comprehensive ESRD Care demonstration project and, more broadly, for most prevalent home dialysis patients based on legislation within the 2018 Bipartisan Budget Act. Under this act, Medicare will pay for a monthly comprehensive telehealth encounter with the patient that originates from his or her home or a dialysis unit without geographic restrictions. The home dialysis patient has the sole power to choose the telehealth option, which may occur twice over a 3-month cycle and cannot occur during the first 3 months of home dialysis therapy. With studies suggesting that effective use of remote monitoring and telehealth encounters may improve patient satisfaction and outcomes while reducing the cost of care, increased use of telehealth has the potential to improve patient-centered care for home dialysis patients. In this perspective, we review the legislative changes, regulatory requirements, and technical and operational challenges for conducting telehealth encounters for home dialysis patients.

The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient’s home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), a well-established minimally invasive gastrointestinal procedure, has been used to diagnose and stage cancers of the pancreas. We describe the successful use of EUS-FNA in a peritoneal dialysis (PD) patient to evaluate a pancreatic cyst. The patient continued on PD immediately after the procedure without using hemodialysis. The patient did not experience any complication such as infection, bleeding, or peritoneal fluid leakage.

Starting 1 January 2019, home dialysis patients in the US may choose to receive their monthly end-stage kidney disease clinical assessments via telehealth. In preparation for these changes, certain operational factors need to be considered. Susie Q Lew and Neal Sikka describe the operational factors to be considered by patients and practitioners when implementing telehealth technologies.

As more end-stage renal disease patients require hemodialysis and live longer, many will fail to develop or maintain a functioning upper extremity vascular access. When a patient exhausts vascular access sites in the upper extremities, new fistulas and grafts can be constructed in the lower extremities, thorax, and abdomen as long as a pair of proximate artery and vein provide adequate blood inflow and outflow, respectively. When only a moderate size vein with adequate blood flow provides a conduit to either a patent superior or inferior vena cava, inserting a double-lumen venous hemodialysis catheter can provide temporary or permanent access. We review the literature and report the unusual sites for hemodialysis vascular access and catheter placement.

Purpose This article reviews the conventional vascular access types in the upper extremities for hemodialysis.Methods We performed a literature search for autogenous arteriovenous fistula in the upper extremities.Results The upper extremities have four potential sites: radio-cephalic or radio-basilic transposition in the forearm, and brachio-cephalic or brachio-basilic transposition in the upper arm. A pre-operative Duplex ultrasound provides valuable information regarding arterial inflow and venous outflow. The surgical approach to fistula formation and final product depends on vein diameter and length as well as proximal vein patency. The discussion focuses on access outcomes and management of common complications.Conclusions The upper extremity arteriovenous fistula is the preferred access for hemodialysis. A number of arteriovenous fistulas can be created in the upper extremities. The Duplex ultrasound identifies suitable arteries and veins for successful arteriovenous hemodialysis fistula creation. Arteriovenous hemodialysis fistula has the best long-term patency outcomes and the lowest associated morbidity and mortality. Early detection and intervention can save the fistula when complications occur.

We examined participant uptake and utilization of remote monitoring devices, and the relationship between remote biometric monitoring (RBM) of weight (Wt) and blood pressure (BP) with self-monitoring requirements. Participants on peritoneal dialysis (PD) (n= 269) participated in a Telehealth pilot study of which 253 used remote monitoring of BP and 255 for Wt. Blood pressure and Wt readings were transmitted in real time to a Telehealth call center, which were then forwarded to the PD nurses for real-time review. Uptake of RBM was substantial, with 89.7% accepting RBM, generating 74,266 BP and 52,880 Wt measurements over the study period. We found no significant correlates of RBM uptake with regard to gender, marital, educational, socio-economic or employment status, or baseline experience with computers; frequency of use of BP RBM by Black participants was less than non-Black participants, as was Wt RBM, and participants over 55 years old were more likely to use the Wt RBM than their younger counterparts. Having any review of the breach by a nurse was associated with reduced odds of a subsequent BP breach after adjusting for sex, age, and race. Remote biometric monitoring was associated with adherence to self-monitoring BP and Wt requirements associated with PD. Remote biometric monitoring was feasible, allowing for increased communication between patient and PD clinical staff with real-time patient data for providers to act on to potentially improve adherence and outcomes.

Hydrothorax in a patient treated with peritoneal dialysis (PD) poses a diagnostic dilemma. Hydrothorax due to migration of dialysis fluid across the diaphragm and into the pleural space creates a serious complication of PD but generally does not threaten life. Shortness of breath causes the patient to seek medical attention. A sudden diminution in dialysis adequacy or poor ultrafiltration rate constitutes a unique marker for patients treated with PD compared to the general population. This article reviews the etiology for hydrothorax specifically in the PD population. Thoracentesis with chemical analysis of the fluid, imaging studies with and without contrast or markers, and video-assisted thoracoscopic surgery play important roles in the evaluation of hydrothorax. A conservative PD regimen, surgical intervention, and pleurodesis provide treatment options to those receiving PD.

There are differences in the way men and women experience end-stage renal disease (ESRD). Women are more likely to shoulder much of the burden of adapting family environments to accommodate life with ESRD. Issues such as fertility and conception are different from women in the general population. In the ESRD population, women express more depressive affect, anxiety, and personality disorder than men. Several psychosocial parameters have been found to be linked with differential survival between men and women such as social support and marital satisfaction. Women are more likely to serve as living donors for kidney transplantation yet less likely to be recipients of a cadaveric or living kidney transplant. We review the available literature on gender differences in ESRD with a focus on chronic hemodialysis.

Hemoperitoneum is seen in patients receiving peritoneal dialysis (PD) because the PD catheter provides a window to the peritoneum. Gynecological associated phenomena account for the majority of cases. Intra-abdominal pathology of solid organs such as the kidney, liver, and spleen as well as the gastrointestinal tract is recognized. Unique to PD patients, hemoperitoneum may be associated with the catheter itself, uremic bleeding, or peritonitis. A successful PD program requires nephrologists, PD nurses, and patients assess and manage hemoperitoneum in a systematic fashion. This paper reviews hemoperitoneum in adult PD patients.

Background:Dialyzers reprocessed with chlorine-based solutions have been associated with increases in ultrafiltration coefficient and middle-molecule removal. Increased pore size has been hypothesized as the mechanism for the latter phenomenon. Dialyzers exposed to Amukin-D (Amuchina Int Inc, Gaithersburg, MD), a chlorine-based reprocessing agent, were evaluated for changes in molecular weight (MW) cutoff and ultrafiltration properties. Methods:In vitro MW cutoff studies were performed on Fresenius F-80A (Fresenius, Lexington, MA) and Gambro Polyflux 17 (Gambro, Lakewood, CO) hemodialyzers that were reprocessed 20 times using Amukin-D. Permeability (Uf-A), defined as the area from the ultrafiltered compartment (Uf) compared with the area from the equivalent arterial compartment (A), for dextran across the hemodialyzer membrane was determined after the initial use and after reuses 1, 5, 10, 15, and 20 by using size-exclusion chromatography. Results:Uf-A for dextran increased approximately 10-fold between hemodialyzer reuses 1 and 5. Thereafter, additional reprocessing did not increase the Uf-A ratio further. MW cutoff increased during these 5 washes and did not change thereafter. Conclusion:Reprocessing with Amukin-D increased the MW cutoff and permeability of both hemodialyzers between reuses 1 and 5, resulting in a greater ultrafiltration rate and greater middle-molecule removal. After reuse 5, there were no further increases in MW cutoff with additional reprocessing in either hemodialyzer. This suggests that reprocessing and storage of each hemodialyzer with Amukin-D affects the permeability of dextran in a nonlinear fashion and to a finite level, such that subsequent reprocessing has no further effect on the MW cutoff of the membrane.

Background:The National Kidney Foundation-Dialysis Outcome Quality Initiative (NKF-DOQI) recommends a weekly creatinine clearance (CrCl) of 60 L/wk/1.73 m2or greater and a Kt/V of 2.0 or greater as peritoneal dialysis (PD) adequacy standards. It has been described that approximately one quarter of patients may have discrepancies between these goals. The purpose of this study is to identify associated factors in patients reaching both criteria, none, or only weekly Kt/V, where K is clearance, t is time, and V is volume. Methods:We studied 64 patients and their adequacy results in a cross-sectional analysis. Patients were divided in three groups. Group 1 reached both weekly Kt/V and CrCl criteria. Group 2 did not reach either criteria. Group 3 reached only the weekly Kt/V criterion. A new weekly Kt/V also was calculated, assigning to all patients a male V. One patient who met only the CrCl criterion was excluded. Results:Groups 2 and 3 had significantly less residual renal function (RRF) than group 1 (residual CrCl, 5.50 and 1.33 versus 37.3 L/wk/1.73 m2, respectively; P< 0.001). Other differences, such as age, weight, peritoneal membrane transport, nutritional parameters, or number of patients with diabetes, were not significantly different. Group 3 made up 19% of patients and was predominantly females. Conversely, group 2 was predominantly males. Using a male V, we obtained a weekly Kt/V below the NKF-DOQI recommendations for group 3 (1.9 versus 2.2; P< 0.05). Conclusion:Conservation of RRF was the main factor in reaching both PD adequacy criteria. Discrepancies were frequent, accounting for 19% of our population. Female gender explained why patients reached weekly Kt/V only. This difference disappeared when we calculated Kt/V using a male V. Am J Kidney Dis40:1301-1305. © 2002 by the National Kidney Foundation, Inc.

Emphysematous pyelitis is air in the renal collecting system in patients with urinary tract infections. This entity is uncommon and seen primarily in patients with diabetes mellitus. We report a case of a patient with end-stage renal disease treated with peritoneal dialysis who developed emphysematous pyelitis who presented with signs and symptoms that were more consistent with appendicitis. The spectrum of infections causing air in the urinary tract and the method by which end-stage renal disease patients are treated are discussed. Patients receiving dextrose peritoneal dialysis are at risk for emphysematous pyelonephritis, pyelitis, and cystitis. © 2002 by the National Kidney Foundation, Inc.

Hemodialysis (HD) membrane biocompatibility is defined as absence of complement activation. We have recently shown that circulating levels of interleukin (IL) 1 and IL-2 predict death and survival, respectively, of HD patients. Studies have assessed IL-1 in treatments with biocompatible and less biocompatible dialysis membranes, but no study has correlated circulating levels of all these immunoreactants. We assessed these immunoreactants, and temperature as an outcome, during HD in patients treated with different membranes. Twelve stable patients, receiving thrice-weekly chronic bicarbonate HD, were randomly dialyzed with three different types of membranes, composed of: Cuprophan, cuprammonium rayon modified cellulose, and Hemophan. Blood was drawn from the arterial line port before (Pre) and 15, 30, and 60 min during and after (Post) HD. Patients’ temperatures were measured before and after each treatment. The plasma concentrations of IL-1 and IL-2 and factors C3a and C5a were assessed by ELISA. There were no differences between baseline levels of any of the immunoreactants in patients treated with different dialyzers. C3a, C5a, and IL-1 levels increased significantly during HD treatments with all three different membranes. C3a, C5a, and IL-1 levels during Cuprophan and Hemophan treatments were significantly higher than the levels during modified cellulose treatment at 30 and 60 min and Post (p < 0.01). For all the immunoreactants, however, the Post levels were higher than the Pre levels. In contrast to IL-1, there were no differences in mean IL-2 levels during treatments when different membranes were compared. There were few correlations of plasma C3a and C5a levels with plasma IL-1 levels, but there was only one treatment time in one dialyzer group during which IL-2 and any of the other factors were correlated. Pre and Post temperature values and percent change in temperature were not correlated with any of the immunoreactants measured. These data show that C3a, C5a, and IL-1 responses are similar, but not identical, during treatments with different membranes. The response of circulating IL-2 levels to treatments is quite different from that of plasma C3a, C5a and IL-1 levels and suggests that these changes are not solely due to treatment factors. Treatment with modified cellulose membranes is associated with a different immunoreactive profile as compared with patients dialyzed using other cellulose membranes. We suggest that circulating IL-1 levels are good biocompatibility markers.

We screened the laboratory data of 50 chronic hemodialysis patients selected randomly over a 21-month period to generate 158 data points which identified two groups: (1) those with a predialysis total CO2 concentration less than or equal to 19 mEq/l (data A; n = 57) and (2) those with a predialysis total CO2 concentration greater than 19 mEq/l (data B; n = 101). Then, both groups were compared for the following parameters: predialysis blood urea nitrogen (BUN), serum phosphorus, uric acid, creatinine, and albumin concentrations, Kt/V, urea reduction ratio, normalized protein catabolic rate, dry weight, ultrafiltration, blood flow and dialysis flow rates, duration of dialysis treatment, and blood pressure. Group data A had significantly higher predialysis BUN, phosphorus, and uric acid concentrations than group data B. There were significant inverse correlations between predialysis serum bicarbonate and predialysis BUN, phosphorus, and uric acid concentrations. Although it is not clear what the long term side effects of moderate metabolic acidosis are, we recommend its correction.

The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renalreplacement is increasing. Better medical care is helping patients live longer but, at the same time, is raising ethical questions. Treatment decisions for ESRD patients present a forum for the consideration of ethical questions surrounding the issues of scarce health care resource allocation and the withholding or withdrawal of life-sustaining treatment. As background for the consideration of ethical issues in ESRD patients, the quality of life they experience and what they may expect as death approaches also are discussed.

The prevalence of human immuodeficiency virus (HIV)-infected patients with end stage renal disease (ESRD) is likely to increase and many of them will be on peritoneal dialysis as renal replacement therapy. Infectious complications are a major problem associated with peritoneal dialysis (PD). It has been speculated that the HIV-positive peritoneal dialysis population may develop peritonitis more frequently than other peritoneal dialysis patients. We present the complications and unexpected good response to medical management of PD-associated peritonitis in a young HIV-infected black male. He had two unusual and serious infections; the first was a polymicrobial peritonitis which predisposed the patient to an unusual infection caused by Corynebacteria JKfor which he was successfully treated without catheter removal.

We present two cases of non-resolving peritonitis treated with a standard peritonitis protocol. The organism identified from the peritoneal effluent was Mycobacterium fortuitum, a group IV (Runyon’s classification) rapidly growing, nontuberculous mycobacterium. M. fortuitumis ubiquitous and can be isolated from a number of natural sources. Risk factors these two patients had for developing M. fortuitumperitonitis included underdialysis, the immunocompromised state associated with end stage renal disease, prior or prolonged broad spectrum antibiotic treatment, and possible exposure to environmental factors, since both were hospitalized at about the same time. The isolates were resistant to the conventional antibiotics recommended for the treatment of this mycobacterium. Both patients, however, responded to catheter removal and antibiotics administered according to the sensitivities of the mycobacterium isolated.

There are an increasing number of reports about unusual causes of peritonitis in peritoneal dialysis (PD) patients. The Propionibacteria species is a microorgasnism that is a normal skin flora. Under the presence of certain risk factors, it may produce serious infections. Patients at risk of having Propionibacteria sp infections have malignancy, diabetes mellitus, foreign bodies, or immunodeficiency. We describe a PD-associated peritonitis in a 51-year-old woman that was caused by Propionibacteria sp. This patient's risk factors for developing Propionibacteria sp peritonitis include a history of CREST syndrome, malignancy of the breast, and recent catheter surgery. To our knowledge, this is the first case of a PD-associated peritonitis caused by Propionibacteria sp reported in the literature.

This report describes the first case of uninterrupted peritoneal dialysis (PD) after robotic-assisted laparoscopic hysterectomy. Frequent low-volume PD exchanges in a supine position to minimize intra-abdominal pressure starting on post-operative day 3 successfully provided adequate clearance and ultrafiltration. The patient did not encounter any metabolic or wound complications. Pre-admission PD prescription was resumed on post-operative day 14. Interim hemodialysis was not needed.

Due to the paucity of long-term observational data, it is still unclear whether the decreased glomerular filtration rate (GFR) noted in older humans is a result of true changes in renal function over time. The fact that a carefully characterized subpopulation of subjects showed no decrease in GFR over time suggests that the ‘physiological decrease’ in GFR noted in the elderly is not inevitable. In studies in our patient population, there was a significant correlation between creatinine clearance and nutritional protein intake in elderly patients without renal disease. In our studies, elderly subjects without renal disease who ingested > 1 g/kg day of protein had creatinine clearances in the range of 90–100 ml/min/1.73 m2, while those with lower protein intakes had lower creatinine clearances. Our studies suggest that GFR is not a fixed function, and that its value may change both over short periods and over decades in humans, with these changes being associated with changes in nutritional protein intake. Low levels of GFR are not necessarily equivalent to a diagnosis of renal disease. Diet must be considered in the assessment of renal function in elderly patients before a diagnosis of renal insufficiency can be made. Decreased GFR is not an inevitable consequence of ageing in humans.