American Society of Nephrology

Integrating patient preferences into the design of randomized clinical trials (RCTs) may help accelerate innovation for alternative kidney replacement therapy by appropriately selecting a trial's significance level and sample size, and have a meaningful impact on people suffering from kidney failure. While a conventional one-sided significance level threshold of 2.5% is often used to assess the safety of a proposed device, we show in this study that it is not necessarily consistent with the risk-preferences of patients with dialysis-dependent kidney disease. We apply a Bayesian decision analysis (BDA) framework to results from a patient preference survey and estimate the optimal significance level and sample size required in an RCT to assess the safety of a hypothetical dialysis device. Based on survey responses from 599 patients with dialysis-dependent kidney failure, we found that the optimal significance level threshold differs significantly from the classical 2.5% threshold used in two-sided hypothesis tests across various patient subgroups. On average, patients tended to require a significance level of 1.2% for the risk of bleeding and a significance level <0.1% for the risk of serious infection, suggesting that the survey respondents were not willing to bear either type of additional risk presented by the hypothetical device in exchange for the possible benefits described in the survey. However, there was heterogeneity among the patient subgroups of dialysis modality, age, gender, ethnicity, and time on dialysis. Overall, our study shows that the BDA framework is a robust, systematic, transparent, and reproducible method for incorporating patient preference information into the design and regulatory review process of clinical trials for novel therapeutics.

A s a discipline, nephrology is burdened by commonly held but incorrect perceptions.Unfortunately, these myths can make nephrology less appealing as a career option for medical students, residents, and future researchers and scientists; decrease how health systems value the specialty; and make it more difficult for ASN to advocate on behalf of the more than 850 million people worldwide living with kidney diseases.Identifying the most insidious myths, presenting evidence to prove these misconceptions false, and providing a more realistic explanation will help change how nephrology and nephrologists are viewed.In Meditations, Roman emperor Marcus Aurelius expressed the Stoic perspective, "All things fade and quickly turn to myth: quickly too utter oblivion drowns them" (1).Rather than accept misperceptions that threaten the field, ASN and the rest of the kidney community must continue to strive to present facts and truth.Myth: Nephrologists earn among the lowest compensation of all internal medicine specialties.No one contends that nephrologists are compensated fairly.In most cases, nephrologists work harder-and longer hours, especially when considering the "windshield time" required to drive between dialysis units or transplant outreach clinics-to generate a reasonable wage.Additionally, payors fail to differentiate among the different types of nephrologists."Nephrology is cognitive and procedural, has a primary care component focused on identifying patients and slowing progression of kidney diseases, and includes the need to manage comorbidities," ASN Past President Anupam Agarwal, MD, FASN, and I observed in 2020 (2)."Nephrologists also provide 24-hour coverage-often for dialysis services for [patients who are critically ill]-an important service to health systems."Among the 13 internal medicine specialties, nephrology ranks sixth for average compensation (3).Physician work relative value units (wRVUs), accounting for the time, effort and technical skill, judgment and mental energy, and stress to provide a service (2), are misvalued and unfairly favor procedure-based specialties (4).Unfortunately, wRVUs do not reflect changes in technology, which have vastly increased the efficiency of many procedures, thus allowing some physicians to generate more RVUs per hour than specialties requiring actual face time with complex patients, such as in nephrology (4).

This study seeks to provide insights into the current state of vascular access education in adult nephrology fellowship programs in the United States and to identify areas for improvement. A total of 63 adult nephrology programs and 71 second-year adult nephrology fellows were randomly selected for participation in a roundtable. Virtual roundtable discussions preceded by a survey were conducted to gather information on the delivery of vascular access education. Descriptive statistics were employed for analysis. Among the respondents invited to the roundtable discussions, 42 individuals (30 faculty, 12 fellows) completed the survey, while 21 individuals (13 faculty, 8 fellows) also participated in the roundtable discussion. Of these respondents, a majority (67%) of didactic lectures on vascular access in fellowship programs were delivered by general nephrologists, with 57% provided by interventional nephrologists, 36% by surgeons and 17% by interventional radiologists (respondents were able to select multiple disciplines). The respondents reported limited exposure to proceduralists, including interventional nephrologists and vascular access surgeons during fellowship training. Faculty and fellows were less comfortable with physical examination skills related to vascular access, particularly in using point-of-care ultrasound and interpreting vascular imaging as compared to naming and identification of vascular access. Both groups emphasized the importance of hands-on modalities in vascular access education. Roundtable discussions highlighted the need for enhanced hands-on training, multidisciplinary collaboration, and standardized curricula in vascular access education. Recommendations were formulated in alignment with the three levels of competency outlined by the American Society of Nephrology (ASN) Task Force on the Future of Nephrology, aiming to address gaps and improve the quality of vascular access education in nephrology fellowship programs. This study underscores the importance and need for a comprehensive vascular access education in nephrology fellowship training. By implementing the identified recommendations, programs can better prepare fellows to manage vascular access-related challenges in clinical practice.

Metabolic responses to glucagon beyond the promotion of endogenous glucose production in type 1 diabetes remains poorly explored. Therefore, we aimed to investigate the metabolic responses to glucagon stimulation in type 1 diabetes and explore whether recent exposure to hypoglycemia would impact glucagon sensitivity. Twenty-nine participants, 19 with type 1 diabetes and 10 healthy controls, underwent a hyperinsulinemic-euglycemic clamp with 5-stepwise ascending glucagon injections. Metabolic responses were assessed before and during each glucagon injection. During the glucagon injections, the series of the incremental area under the curve of plasma glucose concentration did not differ between the groups. However, during the first injection of 10 μg of glucagon, participants with type 1 diabetes produced a higher incremental area under the plasma glucose concentration curve than healthy controls. Plasma concentration of nonesterified fatty acids, glycerol, and metabolites from metabolomic analyses did not differ between the groups. In participants with type 1 diabetes, exposure to hypoglycemia did not impact the metabolic responses induced by glucagon. Generally, metabolic responses to glucagon stimulation in type 1 diabetes are similar to healthy controls. However, elevated glucose production was observed following the lowest glucagon dose in participants with type 1 diabetes compared with healthy controls, indicating enhanced glucagon sensitivity to low-dose glucagon stimulations.

1American Society of Nephrology, Washington, DC 2University of North Carolina Kidney Center, Chapel Hill, North Carolina and the WG (Bill) Hefner VA Medical Center, Salisbury, NC 3Department of Internal Medicine, Division of Nephrology, UT Southwestern, Dallas, Texas

Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD. To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient. Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities. The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.