Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)
Daniil Shimonov, Sri Lekha Tummalapalli, Stephanie Donahue, Vidya Narayana, Sylvia Wu, Lisa S Walters, Roberta Billman, Barbara Desiderio, Sandra Pressman, Oliver Fielding, Kariel Sweeney, Daniel Cukor, Daniel M Levine, Thomas S Parker, Vesh Srivatana, Jeffrey Silberzweig, Frank Liu, Andrew Bohmart...
INTRODUCTION: Multidisciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care; however, the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard.
METHODS: We conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 ml/min per 1.73 m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney Disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a preemptive kidney transplant. Secondary outcomes included home dialysis initiation, preemptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor, and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019.
RESULTS: Among 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 patients (62%) who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) on peritoneal dialysis, 16 (5%) on home hemodialysis, and 36 (12%) to preemptive transplant. Of the 195 patients (65%) starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% confidence interval [CI]: 1.05-1.71, P = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than the national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor.
CONCLUSION: Patients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.
Standardized Peritonitis Reporting: A Quality Improvement Initiative of the Optimizing Prevention of Peritoneal Dialysis-Associated Peritonitis in the United States (OPPUS) Study
Muthana Al Sahlawi, Brian Bieber, Shweta Bansal, Geoffrey Block, Tahsin Masud, Beth Piraino, Martin Schreiber, Vesh Srivatana, Isaac Teitelbaum, Sana Khan, Osama El Shamy, Suzanne Watnick, Leslie Garcia, Ronald L Pisoni, Jeffrey Perl...
Am J Kidney Dis. 2024 May;83(5):692-694. doi: 10.1053/j.ajkd.2023.09.004. Epub 2023 Oct 24.
A Distinct Nasal Microbiota Signature in Peritoneal Dialysis Patients
Iman Khan, Sylvia Wu, Anika Hudson, Clayton Hughes, Gabriel Stryjniak, Lars F Westblade, Michael J Satlin, Nicholas Tedrow, Anne-Catrin Uhlemann, Colleen Kraft, Darshana M Dadhania, Jeffrey Silberzweig, Iwijn De Vlaminck, Carol Li, Vesh Srivatana, John Richard Lee...
Kidney360. 2023 Oct 1;4(10):1419-1429. doi: 10.34067/KID.0000000000000249. Epub 2023 Aug 29.
ABSTRACT
KEY POINTS:
Staphylococcus, Corynebacterium, Streptococcus, and Anaerococcus are the most common genera in the anterior nares.
The nasal abundance of Staphylococcus is inversely correlated with the nasal abundance of Corynebacterium.
Peritoneal dialysis patients have a distinctly diverse representation of Staphylococcus and Streptococcus in their anterior nares.
BACKGROUND: The nasal passages harbor both commensal and pathogenic bacteria that can be associated with infectious complications. The nasal microbiome in peritoneal dialysis (PD) patients, however, has not been well characterized. In this study, we sought to characterize the anterior nasal microbiota in PD patients and assess its association with PD peritonitis.
METHODS: In this study, we recruited 32 PD patients, 37 kidney transplant (KTx) recipients, and 22 living donor/healthy control (HC) participants and collected their anterior nasal swabs at a single point in time. We followed the PD patients for future development of peritonitis. We performed 16S ribosomal RNA (rRNA) gene sequencing of the V4–V5 hypervariable region to determine the nasal microbiota. We compared nasal abundance of common genera among the three groups using Wilcoxon rank-sum test with Benjamini–Hochberg adjustment. DESeq2 was also used to compare the groups at the amplicon sequence variant levels.
RESULTS: In the entire cohort, the most abundant genera in the nasal microbiota included Staphylococcus, Corynebacterium, Streptococcus, and Anaerococcus. Correlational analyses revealed a significant inverse relationship between the nasal abundance of Staphylococcus and that of Corynebacterium. PD patients have a higher nasal abundance of Streptococcus than KTx recipients and HC participants. PD patients have a more diverse representation of Staphylococcus and Streptococcus than KTx recipients and HC participants. PD patients who concurrently have or who developed future Staphylococcus peritonitis had a numerically higher nasal abundance of Staphylococcus than PD patients who did not develop Staphylococcus peritonitis.
CONCLUSIONS: We find a distinct nasal microbiota signature in PD patients compared with KTx recipients and HC participants. Given the potential relationship between the nasal pathogenic bacteria and infectious complications, further studies are needed to define the nasal microbiota associated with these infectious complications and to conduct studies on the manipulation of the nasal microbiota to prevent such complications.
A Distinct Nasal Microbiota Signature in Peritoneal Dialysis Patients
Iman Khan, Sylvia Wu, Anika Hudson, Clayton Hughes, Gabriel Stryjniak, Lars F Westblade, Michael J Satlin, Nicholas Tedrow, Anne-Catrin Uhlemann, Colleen Kraft, Darshana M Dadhania, Jeffrey Silberzweig, Iwijn De Vlaminck, Carol Li, Vesh Srivatana, John Richard Lee...
medRxiv [Preprint]. 2023 Feb 24:2023.02.23.23286379. doi: 10.1101/2023.02.23.23286379.
ABSTRACT
RATIONALE & OBJECTIVE: The nasal passages harbor both commensal and pathogenic bacteria. In this study, we sought to characterize the anterior nasal microbiota in PD patients using 16S rRNA gene sequencing.
STUDY DESIGN: Cross-sectional.
SETTING & PARTICIPANTS: We recruited 32 PD patients, 37 kidney transplant (KTx) recipients, 22 living donor/healthy control (HC) participants and collected anterior nasal swabs at a single point in time.
PREDICTORS: We performed 16S rRNA gene sequencing of the V4-V5 hypervariable region to determine the nasal microbiota.
OUTCOMES: Nasal microbiota profiles were determined at the genus level as well as the amplicon sequencing variant level.
ANALYTICAL APPROACH: We compared nasal abundance of common genera among the 3 groups using Wilcoxon rank sum testing with Benjamini-Hochberg adjustment. DESeq2 was also utilized to compare the groups at the ASV levels.
RESULTS: In the entire cohort, the most abundant genera in the nasal microbiota included: Staphylococcus, Corynebacterium, Streptococcus , and Anaerococcus . Correlational analyses revealed a significant inverse relationship between the nasal abundance of Staphylococcus and that of Corynebacterium . PD patients have a higher nasal abundance of Streptococcus than KTx recipients and HC participants. PD patients have a more diverse representation of Staphylococcus and Streptococcus than KTx recipients and HC participants. PD patients who concurrently have or who developed future Staphylococcus peritonitis had a numerically higher nasal abundance of Staphylococcus than PD patients who did not develop Staphylococcus peritonitis.
LIMITATIONS: 16S RNA gene sequencing provides taxonomic information to the genus level.
CONCLUSIONS: We find a distinct nasal microbiota signature in PD patients compared to KTx recipients and HC participants. Given the potential relationship between the nasal pathogenic bacteria and infectious complications, further studies are needed to define the nasal microbiota associated with these infectious complications and to conduct studies on the manipulation of the nasal microbiota to prevent such complications.
BACKGROUND: The high incidence of acute kidney injury (AKI) requiring dialysis associated with COVID-19 led to the use of peritoneal dialysis (PD) for the treatment of AKI. This study aims to compare in-hospital all-cause mortality and kidney recovery between patients with AKI who received acute PD versus extracorporeal dialysis (intermittent haemodialysis and continuous kidney replacement therapy).
METHODS: In a retrospective observational study of 259 patients with AKI requiring dialysis during the COVID-19 surge during Spring 2020 in New York City, we compared 30-day all-cause mortality and kidney recovery between 93 patients who received acute PD at any time point and 166 patients who only received extracorporeal dialysis. Kaplan-Meier curves, log-rank test and Cox regression were used to compare survival and logistic regression was used to compare kidney recovery.
RESULTS: The mean age was 61 ± 11 years; 31% were women; 96% had confirmed COVID-19 with median follow-up of 21 days. After adjusting for demographics, comorbidities, oxygenation and laboratory values prior to starting dialysis, the use of PD was associated with a lower mortality rate compared to extracorporeal dialysis with a hazard ratio of 0.48 (95% confidence interval: 0.27-0.82, p = 0.008). At discharge or on day 30 of hospitalisation, there was no association between dialysis modality and kidney recovery (p = 0.48).
CONCLUSIONS: The use of PD for the treatment of AKI was not associated with worse clinical outcomes when compared to extracorporeal dialysis during the height of the COVID-19 pandemic in New York City. Given the inherent selection biases and residual confounding in our observational study, research with a larger cohort of patients in a more controlled setting is needed to confirm our findings.
Peritoneal Effluent Cell-Free DNA Sequencing in Peritoneal Dialysis Patients With and Without Peritonitis
Philip Burnham, Fanny Chen, Alexandre P Cheng, Vesh Srivatana, Lisa T Zhang, Emmanuel Edusei, Shady Albakry, Brittany Botticelli, Xunxi Guo, Amanda Renaghan, Jeffrey Silberzweig, Darshana M Dadhania, Joan S Lenz, Michael Heyang, Iliyan D Iliev, Joshua A Hayden, Lars F Westblade, Iwijn De Vlaminck, John R Lee...
Kidney Med. 2021 Oct 28;4(1):100383. doi: 10.1016/j.xkme.2021.08.017. eCollection 2022 Jan.
ABSTRACT
RATIONALE & OBJECTIVE: Conventional culture can be insensitive for the detection of rare infections and for the detection of common infections in the setting of recent antibiotic usage. Patients receiving peritoneal dialysis (PD) with suspected peritonitis have a significant proportion of negative conventional cultures. This study examines the utility of metagenomic sequencing of peritoneal effluent cell-free DNA (cfDNA) for evaluating the peritoneal effluent in PD patients with and without peritonitis.
STUDY DESIGN: Prospective cohort study.
SETTING & PARTICIPANTS: We prospectively characterized cfDNA in 68 peritoneal effluent samples obtained from 33 patients receiving PD at a single center from September 2016 to July 2018.
OUTCOMES: Peritoneal effluent, microbial, and human cfDNA characteristics were evaluated in culture-confirmed peritonitis and culture-negative peritonitis.
ANALYTICAL APPROACH: Descriptive statistics were analyzed and microbial cfDNA was detected in culture-confirmed peritonitis and culture-negative peritonitis.
RESULTS: Metagenomic sequencing of cfDNA was able to detect and identify bacterial, viral, and eukaryotic pathogens in the peritoneal effluent from PD patients with culture-confirmed peritonitis, as well as patients with recent antibiotic usage and in cases of culture-negative peritonitis.
LIMITATIONS: Parallel cultures were not obtained in all the peritoneal effluent specimens.
CONCLUSIONS: Metagenomic cfDNA sequencing of the peritoneal effluent can identify pathogens in PD patients with peritonitis, including culture-negative peritonitis.
A Mobile Health-Based Survey to Assess COVID-19 Vaccine Intent and Uptake Among Patients on Dialysis
Sri Lekha Tummalapalli, Daniel Cukor, Andrew Bohmart, Daniel M Levine, Thomas S Parker, Frank Liu, Alan Perlman, Vesh Srivatana, Meghan Reading Turchioe, Said A Ibrahim, Jeffrey Silberzweig...
Kidney Int Rep. 2022 Mar;7(3):633-637. doi: 10.1016/j.ekir.2021.12.006. Epub 2021 Dec 13.
Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion
Bruce M Robinson, Murilo Guedes, Mohammed Alghonaim, Aleix Cases, Indranil Dasgupta, Liangying Gan, Stefan H Jacobson, Talerngsak Kanjanabuch, Yong-Lim Kim, Werner Kleophas, Laura Labriola, Rachel L Perlman, Gianpaolo Reboldi, Vesh Srivatana, Rita S Suri, Kazuhiko Tsuruya, Pablo Urena Torres, Ronald L Pisoni, Roberto Pecoits-Filho...
Kidney Med. 2021 Jul-Aug;3(4):619-634. doi: 10.1016/j.xkme.2021.03.006. Epub 2021 May 14.
ABSTRACT
As the worst global pandemic of the past century, coronavirus disease 2019 (COVID-19) has had a disproportionate effect on maintenance dialysis patients and their health care providers. At a virtual roundtable on June 12, 2020, Dialysis Outcomes and Practice Patterns Study (DOPPS) investigators from 15 countries in Asia, Europe, and the Americas described and compared the effects of COVID-19 on dialysis care, with recent updates added. Most striking is the huge difference in risk to dialysis patients and staff across the world. Per-population cases and deaths among dialysis patients vary more than 100-fold across participating countries, mirroring burden in the general population. International data indicate that the case-fatality ratio remains at 10% to 30% among dialysis patients, confirming the gravity of infection, and that cases are much more common among in-center than home dialysis patients. This latter finding merits urgent study because in-center patients often have greater community exposure, and in-center transmission may be uncommon under optimal protocols. Greater telemedicine use is a welcome change here to stay, and our community needs to improve emergency planning and protect dialysis staff from the next pandemic. Finally, the pandemic's challenges have prompted widespread partnering and innovation in kidney care and research that must be sustained after this global health crisis.
To demonstrate feasibility of acute peritoneal dialysis (PD) for acute kidney injury during the coronavirus disease 2019 (COVID-19) pandemic, we performed a multicenter, retrospective, observational study of 94 patients who received acute PD in New York City in the spring of 2020. Patient comorbidities, severity of disease, laboratory values, kidney replacement therapy, and patient outcomes were recorded. The mean age was 61 ± 11 years; 34% were women; 94% had confirmed COVID-19; 32% required mechanical ventilation on admission. Compared to the levels prior to initiation of kidney replacement therapy, the mean serum potassium level decreased from 5.1 ± 0.9 to 4.5 ± 0.7 mEq/L on PD day 3 and 4.2 ± 0.6 mEq/L on day 7 (P < 0.001 for both); mean serum bicarbonate increased from 20 ± 4 to 21 ± 4 mEq/L on PD day 3 (P = 0.002) and 24 ± 4 mEq/L on day 7 (P < 0.001). After a median follow-up of 30 days, 46% of patients died and 22% had renal recovery. Male sex and mechanical ventilation on admission were significant predictors of mortality. The rapid implementation of an acute PD program was feasible despite resource constraints and can be lifesaving during crises such as the COVID-19 pandemic.
Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee
Susie Q Lew, Eric L Wallace, Vesh Srivatana, Bradley A Warady, Suzanne Watnick, Jayson Hood, David L White, Vikram Aggarwal, Caroline Wilkie, Mihran V Naljayan, Mary Gellens, Jeffrey Perl, Martin J Schreiber...
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.
Characteristics of Acute Kidney Injury in Hospitalized COVID-19 Patients in an Urban Academic Medical Center
John R Lee, Jeffrey Silberzweig, Oleh Akchurin, Mary E Choi, Vesh Srivatana, Jonathan Lin, Frank Liu, Line Malha, Michelle Lubetzky, Darshana M Dadhania, Divya Shankaranarayanan, Daniil Shimonov, Sanjay Neupane, Thalia Salinas, Aarti Bhasin, Elly Varma, Lorenz Leuprecht, Supriya Gerardine, Perola Lamba, Parag Goyal, Eric Caliendo, Victoria Tiase, Rahul Sharma, Joel C Park, Peter A D Steel, Manikkam Suthanthiran, Yiye Zhang...
Clin J Am Soc Nephrol. 2021 Feb 8;16(2):284-286. doi: 10.2215/CJN.07440520. Epub 2020 Sep 18.
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