Innovations in Hemodialysis Access

The established types of vascular access for hemodialysis are central venous catheters (CVCs), arteriovenous fistulas (AVFs), and arteriovenous grafts (AVGs). Innovations in CVC tip and coating design may improve patency and blood flow rates. AVFs are preferred over CVCs as they are less prone to clotting and infection, while providing reliable and adequate blood flow rates. However, AVF creation requires a surgical procedure with associated risks. Because of a paucity of surgeons available to create high-quality dialysis access, newer access creation techniques have been developed, including a percutaneous endovascular method that has the potential to revolutionize dialysis access. Innovations in AVGs include drug-eluting devices that may reduce neointimal hyperplasia and bioengineered blood vessels. To bypass vessel stenoses, a hybrid AVG/CVC device has been developed. Although many of these innovations have yet to become mainstream, they promise to improve dialysis access in the future

Unstable Housing and Kidney Disease: A Primer.

Stable housing is essential for health. Over 580,000 Americans experienced homelessness during one night in 2020, and over 37 million households spend over 30% of their income on housing. Unstable housing has been associated with mortality, acute care utilization, communicable and non-communicable diseases, a higher risk of kidney disease, and kidney disease progression. In this review, we define various forms of unstable housing, provide an overview of the interaction between unstable housing and health, and discuss existing evidence associating housing and kidney disease. We provide historical context for unstable housing in the United States, and detail policy, community, and individual-level factors that contribute to the risk of unstable housing. Unstable housing likely affects kidney health via a complex interplay of individual and structural factors. Various screening tools are available for use by providers. Special considerations should be made when working with individuals experiencing unstable housing to meet their unique needs, facilitate health care engagement, and optimize outcomes. Housing interventions have been shown to improve outcomes and should be examined for their role in kidney disease

Patients\u27 Perspectives on Health-Related Social Needs and Recommendations for Interventions: A Qualitative Study

RATIONALE & OBJECTIVE: People with low socioeconomic status are disproportionately affected by kidney failure, and their adverse outcomes may stem from unmet health-related social needs. This study explored hemodialysis patient perspectives on health-related social needs and recommendations for intervention. STUDY DESIGN: Qualitative study using semi-structured interviews. SETTINGS & PARTICIPANTS: Thirty-two people with low socioeconomic status receiving hemodialysis at three hemodialysis facilities in Austin, Texas. ANALYTICAL APPROACH: Interviews were analyzed for themes and subthemes using the constant comparative method. RESULTS: Seven themes and 21 subthemes (in parentheses) were identified: 1) kidney failure was unexpected (never thought it would happen to me, do not understand dialysis); 2) providers fail patients (doctors did not act, doctors do not care); 3) dialysis is detrimental (life is not the same, dialysis is all you do, dialysis causes emotional distress, dialysis makes you feel sick); 4) powerlessness (dependent on others, cannot do anything about my situation); 5) financial resource strain (dialysis makes you poor and keeps you poor, disability checks are not enough, food programs exist but are inconsistent, eat whatever food is available, not enough affordable housing, unstable housing affects health and wellbeing); 6) motivation to keep going (faith, support system, will to live); and 7) interventions should promote self-efficacy (navigation of community resources, support groups). LIMITATIONS: Limited quantitative data such as on dialysis vintage. Limited geographic representation. CONCLUSIONS: Dialysis exacerbates financial resource strain, and health-related social needs exacerbate dialysis-related stress. Participants made recommendations to address social needs with an emphasis on increasing support and community resources for this population

Unstable Housing and Mortality Among US Veterans Receiving Dialysis

IMPORTANCE: Housing status is an important health determinant, yet little is known about unstable housing among individuals receiving dialysis. OBJECTIVE: To determine factors associated with unstable housing among US veterans receiving dialysis and to estimate the association of unstable housing with risk of death. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from the US Veterans Health Administration (VHA) and the US Renal Data System for patients who initiated dialysis between October 1, 2012, and December 31, 2018. Veterans were included if they used VHA outpatient services and completed 1 or more unstable housing screenings within a 3-year period before starting dialysis. Data analysis was conducted from January 24 to June 16, 2023. EXPOSURES: Unstable housing was defined as self-report of not having stable housing within the past 2 months or having concerns about stable housing in the next 2 months. MAIN OUTCOMES AND MEASURES: The main outcome was all-cause mortality. Characteristics associated with unstable housing at the time of dialysis initiation were examined. The multivariate Fine and Gray cumulative incidence model was used, treating transplant as a competing risk and age as an effect modifier, to examine the risk of death associated with unstable housing. RESULTS: This study included 25 689 veterans, with a median age of 68 (IQR, 62-74) years. Most participants were men (98%), and more than half (52%) were White. There were 771 veterans (3%) with a positive screen for unstable housing within a 3-year period before starting dialysis. Compared with veterans with stable housing, those with unstable housing were younger (mean [SD] age, 61 [8] vs 68 [10] years), were more likely to be Black (45% vs 32%) or Hispanic (9% vs 7%), and were more likely to start dialysis with a central venous catheter (77% vs 66%), receive in-center hemodialysis (96% vs 91%), and have non-Medicare insurance (53% vs 28%). Factors associated with unstable housing included Hispanic ethnicity, non-arteriovenous fistula vascular access, lack of predialysis nephrology care, and non-Medicare insurance. Veterans with unstable housing had higher all-cause mortality (adjusted hazard ratio [AHR], 1.20 [95% CI, 1.04 to 1.37] for a median age of 68 years), and risks increased with age (P = .01 for interaction). In age-stratified analyses, unstable housing was associated with higher mortality among veterans aged 75 to 85 years (AHR, 1.64 [95% CI, 1.18 to 2.28]), but associations were not observed for other age groups. CONCLUSIONS AND RELEVANCE: In this cohort study of veterans receiving dialysis, unstable housing experienced before starting dialysis was associated with increased risk of all-cause mortality, and risks increased with age. Further efforts are needed to understand the experiences of older adults with unstable housing and to estimate the scope of unstable housing among all individuals receiving dialysis

Patient Outcomes in Renal-Limited Antineutrophil Cytoplasmic Antibody Vasculitis With Inactive Histology

Introduction: Little is known about the anticipated disease course for individuals who present with renal-limited antineutrophil cytoplasmic antibody (ANCA)−associated vasculitis but who lack inflammation on a kidney biopsy. The impact of immunosuppression on renal and overall survival is unknown. Methods: Patients were recruited from 2005 to 2016 from 8 centers worldwide (N = 16) for this descriptive study. All had positive ANCA, elevated serum creatinine with active urine sediment, histologic evidence of pauci-immune glomerulonephritis without active lesions, and had no evidence of extrarenal vasculitis. We describe the characteristics of this cohort and the differences in the clinical, histologic, and therapeutic parameters of those who developed primary outcomes of end-stage renal disease (ESRD) and vasculitis relapse. Results: The cohort was 63% Caucasian, and 75% were men, with a median age of 62 years. At entry, the mean ± SD estimated glomerular filtration rate (eGFR) was 24 ± 20 ml/min per 1.73 m2, and 5 patients required dialysis. Twelve patients received immunosuppressive therapy, 25% experienced disease relapse, and 38% developed ESRD. Patients who developed ESRD had lower baseline eGFRs (8 ± 5 ml/min per 1.73 m2 vs. 35 ± 18 ml/min per 1.73 m2; P = 0.001) and more often required dialysis at presentation (83% vs. 0%; P = 0.001). Patients who relapsed were less likely to receive immunosuppression (25% for the relapsed group vs. 92% for the nonrelapsed group; relative risk: 0.27, risk difference: 67%; P = 0.03). Conclusion: Among these patients, lower initial eGFR and dialysis dependence at presentation might increase the risk for ESRD. Immunosuppression did not affect renal outcomes in this sample of patients but was associated with a reduced risk for vasculitis relapse. More information is needed on factors that predict treatment response in this high-risk group. Keywords: ANCA-associated vasculitis, glomerulonephritis, renal limited vasculiti

Proceedings of a Workshop to Promote Community Health Worker Interventions in Nephrology

AbstractLatinx populations face a higher burden of kidney failure and associated negative outcomes compared with non-Latinx White populations, despite sharing a similar prevalence of CKD. Community health worker (CHW) interventions have been shown to improve outcomes for Latinx individuals, but they are largely underutilized in kidney disease. We convened a workshop of four ongoing kidney disease CHW programs to identify successes, challenges, potential solutions, and needed research to promote CHW programs for Latinx individuals with kidney disease. Key points from the workshop and recommendations for intervention and research are highlighted. Facilitators of program success included prioritizing trust-building with participants, enabling participants to determine what aspects of the intervention were needed, providing participants with tools to help themselves and others after the intervention, and taking a trauma-informed approach to relationships. Challenges included persistent systemic barriers despite successful care navigation and low recruitment and retention. Research is needed to capture the effect of CHW interventions on outcomes and to determine how to implement CHW interventions for people with kidney disease nationwide