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Friday, April 12, 2013

NKF: Kidney Disease Staging Gets Spotlight

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ORLANDO -- A new way of staging kidney disease is likely to garner much discussion at this year's spring clinical meeting of the National Kidney Foundation.
There's an entire session devoted to the updated version of the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline, which was released in January.
"This new staging system will have implications for how we talk about chronic kidney disease," Charmaine Lok, MD, of the University of Toronto, chair of this year's scientific program, told MedPage Today. "Not only are we looking at the level of kidney function, but also at albuminuria as a measure of how quickly patients may progress to end-stage renal disease (ESRD)."
The updated guideline offers more accurate risk prediction and management by subdividing estimated glomerular filtration rate (eGFR) stages based on the level of albuminuria. Though there are still five disease stages, the third stage is divided into 3a and 3b.
It also guides clinicians on the appropriate frequency of monitoring based on eGFR and albuminuria categories.
Lok explained that the driving force behind the update was a desire to make it more precise. "For instance, if someone has albuminuria, that may be an indicator of progression and poorer outcomes. Are the implications the same if you're in stage 4 and you show signs of progressing or not progressing?" she said.
"It's a much more informative and clinically relevant staging system," she added.
Trends in Dialysis
Clinicians will also hear from experts on peritoneal dialysis which is "having a rebirth in the U.S.," given new rules for reimbursement for intravenous dialysis medication, better known as "bundling," according to Beth Piraino, MD, of the University of Pittsburgh and president of the NKF.
Bundling went into effect in January 2011. It establishes a single payment rate for dialysis and all medications given intravenously during dialysis, such as erythropoiesis-stimulating agents (ESAs), iron, and vitamin D.
In January 2014, oral medications for ESRD-related complications, including phosphate binders, oral iron, and oral vitamin D, will end up in the bundle as well.
Nephrologists had expressed concerns that such changes could impact care, and at last year's NKF meeting, analyses from two databases (DOPPS & USRDS) found that dialysis patients' hemoglobin levels have fallen in concert with the bundling changes -- but also because of label changes on ESAs that said the drugs are no longer necessary once patients reach hemoglobin levels of 11 g/dL.
"The uptick of patients going on peritoneal dialysis has been pretty striking because bundling favors peritoneal dialysis," Piraino told MedPage Today. "It bundles in the cost of the injectable like epoetin and you need a lot less of those for peritoneal dialysis patients."
Debates and Updates
Lok also highlighted another controversial area in kidney disease management: Anticoagulation for patients with chronic kidney disease or ESRD. Cardiologist Charles Herzog, MD, of the Hennepin County Medical Center in Minneapolis, and nephrologist Catherine Clase, MD, of McMaster University in Canada will debate the issue.
As new anticoagulants gain market share and momentum, one particular area of controversy has been the use of anticoagulation drugs in kidney patients with atrial fibrillation (Afib). "There are data now that demonstrate that [anticoagulation for Afib] may or may not be applicable in patients with chronic kidney disease," Lok said.
Piraino singled out an update session on BK virus, a benign virus in most patients that could become a serious complication for immunosuppressed transplant recipients.
"It's something that we don't know very well how to treat," Piraino told MedPage Today, especially because transplant patients are on such heavy immunosuppression for the first 6 months. During that time, BK colonization in the urine can enter the bloodstream and lead to BK nephropathy, destroying the kidney, she added.
There are no good therapies for BK virus, beyond experimentation with other treatments such as antiviral infusions, antibiotics (ciprofloxacin), and even immunoglobulin.
"But there aren't any properly done studies to show which of these would be the best approach, or if any of them are better than just reducing the immunosuppression," Piraino said. "Yet you're on a fine line there because if you reduce the immunosuppression too much, then you're going to get rejection. So it's a bit of a tricky affair."
Kristina Fiore
Staff Writer
Kristina Fiore joined MedPage Today after earning a degree in science, health, and environmental reporting from NYU. She's had bylines in newspapers and trade and consumer magazines includingNewsdayABC NewsNew Jersey Monthly, and Earth Magazine. At MedPage Today, she reports with a focus on diabetes, nutrition, and addiction medicine.

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