Providing Ideal Dialysis Care Over the Next 5 Years William L. Henrich, MD University of Texas Health Science Center at San Antonio

Management Maintain euvolemia (increased use of extra sessions, nocturnal or quotidian dialysis) Excellent BP control (pre-dialysis SBP <130/80), using ACEI/ARB as first line agents where needed Monitor for LVH/LVMI with an echocardiogram or MRI (no contrast) Q months Manage Ca/P to a low pre-dialysis P, if possible, and a PTH of less than 500 pg/ml (or 1.5 to 2 times normal); replete Vitamin D where possible; controversy over Ca-containing vs. non-Ca-containing Phosphate binders at present. Hematocrit to guidelines Avoid catheters Improved nutrition LDL-C to <100 mg/dl, <70 in patients with documented CAD Cautious use of B-Blockers for low EF Systolic Failure Passive resistance exercise where feasible Stay tuned for evidence of benefit of aldosterone blocking agents on myocardial fibrosis/sudden death

Management Hematocrit to guidelines Avoid catheters Improved nutrition LDL-C to <100 mg/dl, <70 in patients with documented CAD Cautious use of B-Blockers for low EF Systolic Failure Passive resistance exercise where feasible Stay tuned for evidence of benefit of aldosterone blocking agents on myocardial fibrosis/sudden death Maintain euvolemia (increased use of extra sessions, nocturnal or quotidian dialysis Excellent BP control (pre-dialysis SBP <130/80), using ACEI/ARB as first line agents where needed Monitor for LVH/LVMI with an echocardiogram or MRI (no contrast) Q months Manage Ca/P to a low pre-dialysis P, if possible, and a PTH of less than 500 pg/ml (or 1.5 to 2 times normal); replete Vitamin D where possible; controversy over Ca-containing vs. non-Ca-containing Phosphate binders at present.

I asked 5 experts in ESRD to examine the list of recommendations I had made and to comment on where noticeable “gaps” were and to forecast key factors which will likely have an effect on care. The experts queried were: Ray Hakim, Jonathan Himmelfarb, Alan Kliger, Mike Lazarus and Jay Wish Here are their key points… What Does the Future Hold?

Hakim Malnutrition: With documentation by a low albumin concentration. Oral and parenteral supplements should be recommended (Evidence this helps? Cost?). Catheters: 82% of U.S. patients start dialysis with catheters. Recommends P4P focus in this with vascular surgeons/nephrologists (Identification of patients earlier; who will do this in an overloaded system?). Euvolemia: Already on list; but government should pay for volume monitoring devices (Cost for extra sessions?).

Himmelfarb Avoid catheters Nutritional support (p.o.) for malnourished patients

Kliger More frequent dialysis so that euvolemia, Ca/P can be better managed QOL: pay attention to this Differentiate between palliative dialysis care (in a hospice patient) vs. more aggressive care (for some someone trying to work).

Lazarus Euvolemia: Need a better tool to measure this (CRIT-Line, e.g., cost?) Improved safety: Need a better venous leak detector— key for greater home use IT: Improvement could revolutionize care with prompt adjustments made to the treatment (i.e., rapid exchange of information between home and central unit; cost?). Differentiate between palliative dialysis care and more standard care.

Wish Pay nephrologists for comprehensive care— costs more than the monthly capitation rate (↑ cost). P4P should reward good care, not just punish bad care (2% penalty proposed for violations in anemia, Kt/V, Ca/P). Make Euvolemia a goal, not just Kt/V. Medicare must pay for frequent dialysis— and consider home therapies, not just in-center therapies. Consolidation of industry— not a good thing; DaVita and Fresenius each have a 35% market share. Watch for COI— Phoslo owned by Fresenius. CMS seems to favor consolidation, e.g., Crown Web Electronic Data System for LDO’s vs smaller providers.

Wish, con’t Nutrition Vascular Access Hope that the NIH studies on frequent dialysis will be positive to compel some change in reimbursement.

Management Maintain euvolemia (increased use of extra sessions, nocturnal or quotidian dialysis Excellent BP control (pre-dialysis SBP <130/80), using ACEI/ARB as first line agents where needed Monitor for LVH/LVMI with an echocardiogram or MRI (no contrast) Q months Manage Ca/P to a low pre-dialysis P, if possible, and a PTH of less than 500 pg/ml (or 1.5 to 2 times normal); replete Vitamin D where possible; controversy over Ca-containing vs. non-Ca-containing Phosphate binders at present. Hematocrit to guidelines Avoid catheters Improved nutrition LDL-C to <100 mg/dl, <70 in patients with documented CAD Cautious use of B-Blockers for low EF Systolic Failure Passive resistance exercise where feasible Stay tuned for evidence of benefit of aldosterone blocking agents on myocardial fibrosis/sudden death ID CKD (>Stage 2) early and implement treatment

Summary/Conclusions 1.Current 3X/week dialysis is inadequate for CV health. 2.Need renewed education strategy for non nephrologists on the ravages of CKD/ESRD. 3.Need to prove that early CV interventions with an emphasis on better nutrition will pay dividends in reducing morbidity (e.g., hospital costs) and mortality. 4.Once identified, patients with later stage CKD need an AVF; physician extenders and best practice guidelines may help here.

Summary/Conclusions, Con’t 5.ESRD patients need longer treatment times to manage Ca/P, volume, LVH, BP. Better monitors and IT systems to create real time flow of information will help. 6.Funding for new trials (such as the one Dr. Cheung has proposed) is encouraged— we have to keep searching for an improved therapeutic combination. 7.Positive regular reward for P4P, not just negative. 8.View monopolies circumspectly.