Rationale: Social risk factors (SRFs) include potentially intervenable individual-level social and economic conditions that impact health. Limited data exist on the prevalence of SRFs and their impact on transplantation among individuals receiving dialysis. Study Design: A cross-sectional cohort study. Exposures: The SRF data (housing, food security, utilities, transportation & personal safety) were collected from maintenance dialysis patients at Dialysis Clinic, Inc. from May 2023 to March 2025 using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Outcome: Most recent transplant status, defined as neither being waitlisted nor having received a transplant through March 2025. Analytical Approach: A total SRF burden score was assigned to each patient, categorized as screening positive for none (0), one (1), or more than one (>1) SRF. We evaluated the association of SRF burden score and transplant status using logistic regression. Models were adjusted for age, sex, race/ethnicity, dialysis vintage, modality, clinic location, financial status, insurance coverage, and comorbid conditions. Supplementary analyses examined the association between each SRF domain and the outcome. Results: Among 12,994 patients with SRF data, 1,360 (10.5%) had a score of 1 and 445 (3.4%) had a score of >1. In an adjusted model, having one or more SRF was associated with increased odds of not being transplanted or waitlisted for transplant (odds ratio 1.19 [0.99-1.43] and 1.65 [1.14-2.38] for 1 and >1 SRF). Other associated SRFs included being financially uncomfortable (1.54 [1.33-1.78]) and dialyzing in a rural clinic (1.26 [1.11-1.44]). In supplementary analyses, transportation insecurity (2.59 [1.74, 3.87]) had the strongest association with the outcome. Limitations: Residual confounding and exposure misclassification. Conclusions: In a national cohort of maintenance dialysis patients, more than 10% had one or more SRF; this was associated with increased odds of not being transplanted or actively waitlisted. Addressing SRFs, including transportation barriers, may improve access to kidney transplants.

KEY POINTS:Patients on dialysis have high medication burden with average of 16 medications per day, 87% major polypharmacy rate and medication complexity index of 35. Medication burden has increased over the past 2 decades in patients receiving maintenance dialysis. Medication burden is primarily driven by cardiovascular, mineral and bone disorder, and diabetes medications. BACKGROUND:Medication burden is a significant clinical issue for patients receiving maintenance dialysis. Studies characterizing medication burden are often limited to a single time point. We investigated the change in medication burden for patients over a 22-year period at a large national not-for-profit dialysis organization. METHODS:Patients ≥18 years of age receiving maintenance hemodialysis or peritoneal dialysis as of October 1 of each year between 2003 and 2024 were included. Medication burden was characterized as number of active medications on profile, polypharmacy prevalence (≥10 medications), number of pills/capsules per day, and medication regimen complexity index. Medications were classified into therapeutic categories. Patients' demographic, clinical characteristics, and medication burden were summarized overall and each year during the study period and were stratified by modality. Trend analyses for longitudinal medication burden measures were performed using generalized linear models with generalized estimating equations for repeated measures. RESULTS:Among 82,549 distinct patients (hemodialysis, 72,412 [88%]; peritoneal dialysis, 10,137 [12%] at dialysis initiation), the mean age was 62±15 years, and 44% were female. For per patient-day, the number of medication increased from 13.4 to 15.9 (mean yearly rate of increase, 0.23; 95% confidence limit [CL], 0.22 to 0.24); pill burden increased from 18.1 to 18.6 (mean, 0.16; 95% CL, 0.15 to 0.17); and medication regimen complexity index increased from 29.3 to 35.0 (mean, 0.54; 95% CL, 0.53 to 0.56). Polypharmacy was initially present in 77% of patients and increased to 87% (yearly increase in odds of using ten or more medications per day, 5.1%; 95% CL, 4.9 to 5.4). Treatments for mineral and metabolic bone disease and cardiovascular disease contributed most to medication burden. CONCLUSIONS:Medication burden increased over the past 2 decades in patients receiving maintenance dialysis.

Rationale & Objective:Peritoneal dialysis (PD) utilization remains lower in the United States compared with other countries. Data regarding the presence and association of patient-level social risk factors (SRFs) with PD use are lacking. Study Design:Multicenter cross-sectional study. Setting & Population:Maintenance dialysis patients receiving in-center hemodialysis or peritoneal dialysis with dialysis vintage <2 years who dialyzed between 2023 and 2025 at a medium-size, national dialysis provider. Exposures:Patient-level SRFs (housing, food, transportation, utility insecurity, and interpersonal safety) ascertained using the Accountable Health Communities Health-Related Social Needs Screening Tool. Outcome:Nonreceipt of PD at the time of social risk screening. Analytical Approach:Total SRF burden was tallied and categorized (0 (referent), 1, or >1). Adjusted logistic regression models accounted for demographics, comorbid conditions, dialysis vintage, and facility-level clustering. Sensitivity analysis were employed to explore the effect of an alternate definition of SRF burden. Results:Among 7,237 patients treated at 244 dialysis facilities, mean age was 64 ± 15 years, 43% were female, 26% were non-Hispanic Black, and 1,305 (18%) individuals received PD. One or more than 1 patient-level SRF was present in 9% and 3% of patients, respectively. Food insecurity (7%) and housing instability (4%) were most common. After adjustment, presence of 1 and more than 1 SRF was associated with higher odds of nonreceipt of PD as compared with no SRFs [adjusted odds ratio = 1.46 (95% confidence interval 1.10-1.92) and 2.27 (1.35-3.82), respectively]. Both housing instability and transportation insecurity were independently associated with nonreceipt of PD after adjustment. Limitations:Cross-sectional; residual confounding. Conclusions:Patient-level SRFs, including housing instability and transportation insecurity, are associated with nonreceipt of PD among maintenance dialysis patients. These findings should be explored in longitudinal analyses to identify potential patient- and policy-level interventions to improve PD utilization.

KEY POINTS:Identifying patients who cramp frequently over time is crucial for designing intervention studies to prevent cramping. One in five patients receiving hemodialysis reported muscle cramps every 4 weeks posing significant burden, although only one in eight patients cramped frequently In addition, population-based interventions are needed to address the high proportion of patients who are bothered by occasional cramps. BACKGROUND:Cramps are common in patients on dialysis, yet data on prevalence over time and patient burden are lacking. This quality improvement initiative evaluated the prevalence and natural history of muscle cramps to provide clinicians with baseline understanding of the magnitude and scope of cramping in patients on hemodialysis. METHODS:A recurring three-question cramps questionnaire with a 1-week recall period was embedded in routine care for patients on maintenance hemodialysis over five diverse, geographically distributed outpatient clinics to determine occurrence rate, pain severity, and burden from muscle cramps. This was repeated every 4 weeks during 2024. Prevalent patients completing ≥3 questionnaires were categorized as never-crampers, occasional crampers (<50% of responses with cramps), and frequent crampers (≥50% with cramps). The association between concurrent pain severity and bother scores (each ranging from 0 to 10) and changes in these scores were compared using linear regression. RESULTS:There were 420 patients who completed a median of nine (interquartile range, 7-11) questionnaires. Among this cohort, 159 (38%) never reported cramps, 208 (49%) reported occasional cramps, and 53 (13%) reported frequent cramps. Although 62% reported cramps at least once, on average, 19% reported cramps every 4-week period (range 11%-25%). Most patients (69%) reported at least one cramp episode as moderate to severely painful while 60% reported cramping as moderate to extremely bothersome. Pain and bother scores for the same week correlated (0.72, P < 0.001). Between consecutive questionnaires, each one-point increase in maximal pain score associated with a 0.74 increase in bother score ( P < 0.001). CONCLUSIONS:Surveys done every 4 weeks showed that one in five patients on hemodialysis report muscle cramps with significant burden, although only one in eight cramp frequently. Although patients who cramp frequently may be appropriate targets for initial intervention trials to prevent cramps, additional interventions could address the high proportion of patients who are bothered by occasional cramps.

Vitamin D sterols, phosphorus binders and calcimimetics are used to treat chronic kidney disease mineral and bone disorder (CKD-MBD) in hemodialysis. With few randomized trials, providers may titrate agents differently reflecting equipoise and opportunities for clinical trials. We studied patients initiating in-center hemodialysis at Dialysis Clinic, Inc facilities from 2006-2015 and who remained on hemodialysis for ≥90 days (n=23,549). Multinomial logit models assessed titration among users of each medication at the start of the month considering static and dynamic CKD-MBD laboratories. Similarly parameterized logistic models assessed treatment initiation. Differences across facilities were quantified as random effects and corresponding median odds ratios. We observed patterns of titration associated with CKD-MBD laboratories including albumin-corrected serum calcium (Ca), serum phosphorus and parathyroid hormone (PTH) and minimal impact of patient characteristics. Best fit models incorporated 3 months of lagged Ca and phosphorus values and linear splines for current Ca, phosphorus and PTH values. Absolute titration probabilities for vitamin D sterols and calcimimetics were influenced by all three CKD-MBD parameters, such that Ca and phosphorus values altered the threshold PTH at which escalation and de-escalation probabilities crossed. Median odds ratios indicated the greatest facility variation for vitamin D sterol titration. Providers titrate CKD-MBD medications based largely on the full CKD-MBD laboratory phenotype, including the recent serum Ca, phosphorus and PTH history. Facility variation suggests equipoise in titration of vitamin D sterols with opportunities for clinical trials.

The Saving Kidneys, Hearts, and Lives workshop in March 2025, hosted by the American Society of Nephrology, brought together diverse stakeholders in the care of patients with cardiovascular-kidney-metabolic (CKM) syndrome, including multispecialty health care professionals, patients, and researchers from academic and community-based backgrounds. The CKM syndrome encompasses multidirectional interactions among kidney diseases, cardiovascular diseases, diabetes, and obesity. Highly efficacious therapies are presently available to reduce risks of adverse kidney and cardiovascular events as well as all-cause mortality. The goal of the Saving Kidneys, Hearts, and Lives workshop was to gain insights into and make recommendations for the role of nephrology in CKM care. Following a series of plenary talks about the current state, interactive discussions among participants focused on developing tangible strategies and opportunities for nephrology in addressing CKM syndrome. Participants noted that nephrology spans internal medicine, with special expertise in managing kidney diseases, BP, and CKM risk factors along with training that emphasizes interactions among complex chronic conditions. Participants highlighted the importance of screening and implementation of CKM syndrome diagnostic and therapeutic strategies earlier than when patients have been typically referred to nephrology specialty care. In addition, participants explored the contributions of nephrologists to upstream care, beyond their conventional focus on high-risk, rare, or advanced kidney diseases. Participants recognized barriers, including payment structures that provide relatively modest resources for complex chronic care before KRT and gaps in nephrology training to manage CKM syndrome. Ongoing strategies by the American Society of Nephrology will focus on collaborations and crossing traditional specialty boundaries of nephrology, cardiology, and metabolic diseases to promote overall CKM health.

The Saving Kidneys, Hearts, and Lives workshop in March 2025, hosted by the American Society of Nephrology, brought together diverse stakeholders in the care of patients with cardiovascular–kidney–metabolic (CKM) syndrome, including multispecialty health care professionals, patients, and researchers from academic and community-based backgrounds. The CKM syndrome encompasses multidirectional interactions among kidney diseases, cardiovascular diseases, diabetes, and obesity. Highly efficacious therapies are presently available to reduce risks of adverse kidney and cardiovascular events as well as all-cause mortality. The goal of the Saving Kidneys, Hearts, and Lives workshop was to gain insights into and make recommendations for the role of nephrology in CKM care. Following a series of plenary talks about the current state, interactive discussions among participants focused on developing tangible strategies and opportunities for nephrology in addressing CKM syndrome. Participants noted that nephrology spans internal medicine, with special expertise in managing kidney diseases, BP, and CKM risk factors along with training that emphasizes interactions among complex chronic conditions. Participants highlighted the importance of screening and implementation of CKM syndrome diagnostic and therapeutic strategies earlier than when patients have been typically referred to nephrology specialty care. In addition, participants explored the contributions of nephrologists to upstream care, beyond their conventional focus on high-risk, rare, or advanced kidney diseases. Participants recognized barriers, including payment structures that provide relatively modest resources for complex chronic care before KRT and gaps in nephrology training to manage CKM syndrome. Ongoing strategies by the American Society of Nephrology will focus on collaborations and crossing traditional specialty boundaries of nephrology, cardiology, and metabolic diseases to promote overall CKM health.

The global incidence of acute kidney injury (AKI) is increasing. AKI is associated with both short- and long-term risks, including increased risk of chronic kidney disease and kidney failure, cardiovascular events, and all-cause death. This review summarizes existing posthospitalization AKI care guidelines, interprets the current state of evidence for AKI survivor care models including nephrology-specific and multidisciplinary team interventions, and details the health policy landscape for AKI survivors receiving outpatient dialysis in the United States. The main finding of this review is that evidence supporting specific posthospitalization AKI care interventions is very limited, resulting in imprecise consensus-based practice recommendations by national and international kidney societies for AKI survivors. The main implication of this work is to highlight the urgent need for additional research evaluating the efficacy of different care models among AKI survivors at high risk of maintenance dialysis, progression of kidney disease, rehospitalization, and death to devise value-based care models and clinical interventions that improve patient outcomes.

RATIONALE & OBJECTIVE:Latino adults aged 65 years and older comprise the fastest growing minoritized group in the United States and experience a disproportionate burden of kidney failure. Decision aids improve decisional quality and goal-concordant care among older patients with chronic kidney disease (CKD). However, decision aids for kidney replacement therapy have yet to be adapted for the older Latino adult population with advanced CKD. This study assessed the acceptability, accessibility and adaptions needed to facilitate use of a Spanish version of the Decision-Aid for Renal Therapy (DART-S) for older Latino adults with advanced CKD. STUDY DESIGN:Qualitative study applying the Cultural Targeting and Tailoring of Shared Decision-Making Technology Framework in focus groups and structured interviews. Suggested adaptations were grouped into recommendations and analyzed qualitatively. SETTING & PARTICIPANTS:Five focus groups (N = 17) and interviews (N = 15) with Spanish-speaking patients and care partners were conducted. ANALYTICAL APPROACH:Thematic analysis. RESULTS:Among patient participants, 55% were male, and the mean age was 68 ± 9 years. Overall, the participants found DART-S to be acceptable and accessible. Thematic analysis revealed the importance of incorporating lived experiences, including patient and family testimonials, to illustrate the mental health impact of CKD, self-care strategies, and home dialysis adaptations. Some found the delivery of prognostic information distressing, highlighting the need for more sensitive communication. The tailoring recommendations included information about financial barriers, nutrition, and lifestyle. Participants preferred that DART-S be disseminated via kidney clinicians upon CKD diagnosis and recommended leveraging social media for broader reach. LIMITATIONS:Findings are not generalizable beyond the Latino subgroups in this study. Legal status was not ascertained. CONCLUSIONS:Targeting and tailoring decision aids is a necessary step in providing goal-concordant and person-centered care for older Latino adults with advanced CKD. Future research should examine the comparative efficacy of DART-S in increasing knowledge and decisional quality among Latino patients.

BACKGROUND:Falls are thought to be common in patients undergoing maintenance hemodialysis, but little is known about their frequency or outcomes. In this prospective study, we sought to increase our knowledge regarding the incidence, timing, circumstances, and outcomes of falls in this population. METHODS:Between January 2021 and April 2023, adults undergoing maintenance hemodialysis from 103 U.S. dialysis facilities were enrolled in the HOPE Consortium trial, which randomized participants with moderate or severe chronic pain to a pain coping skills cognitive behavioral therapy intervention or usual care. Occurrence of falls was a pre-specified trial outcome. The research team inquired about falls at each four-week follow-up visit during the 36-week study. Multivariable regression was used to explore associations of demographic and clinical characteristics, including patient-reported symptoms, with fall risk. RESULTS:Of 643 trial participants, 178 (28%) experienced 293 falls over a cumulative follow-up period of 429 participant-years for an overall rate of 0.68 falls per participant-year (95% CI: 0.61, 0.76). Accidents were the most frequent cause of falls (38%). It was rare for falls to be related to the hemodialysis treatment or to occur in the hemodialysis unit. Of the 293 falls, 36 (12%) were evaluated in the emergency department without subsequent hospitalization, 41 (14%) resulted in a hospital admission, and 19 (7%) led to a fracture. In multivariable analyses, neither demographic characteristics severity of pain symptoms or medication use such as opioids at enrollment was associated with the fall risk. CONCLUSIONS:Falls were common in this cohort of maintenance hemodialysis patients with chronic pain, occurring in 28% of individuals during a planned follow-up of 36 weeks. Falls rarely occurred in the dialysis unit, with the vast majority occurring at participants' homes and due to accidental causes. There was no significant association between patient-reported symptoms or medication use and the risk of subsequent falls. TRIAL REGISTRATION:NCT04571619.

Older Latino adults (aged 65+ years) comprise the fastest growing minoritized group among the older population in the United States and experience a disproportionate burden of kidney failure as well as disparities in kidney care compared with non-Hispanic White individuals. Despite significant need and barriers uniquely faced by this population, few educational resources or decision aids are available to meet the language and cultural needs of Latino patients. Decision aids are designed to improve knowledge and empower individuals to engage in shared decision making and have been shown to improve decisional quality and goal-concordant care among older patients with chronic kidney disease (CKD). In this commentary, we examine the barriers faced by older Latino people with CKD who must make dialysis initiation decisions. We conclude that there is a need for culturally concordant decision aids tailored for older Latino patients with CKD to overcome barriers in access to care and improve patient-centered care for older Latino CKD patients.

Rationale & Objective:Commercial health insurance typically reimburses at a higher rate for dialysis than Medicare. A recent ruling by the US Supreme Court could result in many commercially insured patients who receive dialysis forgoing their private health insurance and shifting to Medicare as the primary payer. Our objective was to determine whether differences in commercial payers as a proportion of payer mix affect the quality of care at dialysis facilities. Study Design:Cross-sectional study. Setting & Population:We examined US patients receiving dialysis from US Dialysis Facility Reports and the Dialysis Facility Compare websites in 2019. Exposures:Percentage of prevalent dialysis patients with commercial health insurance. Outcomes:Seven key dialysis facility quality metrics included in Dialysis Facility Compare star ratings. Analytical Approach:Multivariable linear regression models adjusted for observed confounders. Results:Among 7,194 US dialysis facilities, an average of 4.4% of prevalent dialysis patients had commercial insurance. Each 10% absolute increase in the percentage of dialysis patients in a facility with commercial insurance was associated with an adjusted 8.3% (3.0%-13.6%) lower standardized mortality ratio. Commercial health insurance was not significantly associated with the remaining quality metrics examined, including standardized fistula rate, long-term catheter rate, standardized hospitalization ratio, standardized transfusion ratio, dialysis adequacy, and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems patient experience score. Limitations:The potential for unobserved confounders including social risk factors limits the ability to make causal inferences. Conclusions and Relevance:Dialysis facilities with a higher percentage of patients with commercial health insurance had better performance in standardized mortality ratio. If this association reflects a causal connection, then increased shifting of coverage from commercial health insurance to Medicare could adversely affect the quality of care at dialysis facilities.

Key PointsOf the 643 patients undergoing long-term hemodialysis enrolled in a clinical trial for chronic pain, 28% experienced at least one fall, an incidence of 0.68 per participant year.Accidents were the most frequent cause of falls, and it was rare for them to be related to the hemodialysis procedure or occur at the hemodialysis unit.In multivariable analyses, demographic characteristics, severity of pain symptoms, or medication use such as opioids were associated with the fall risk.BackgroundFalls are believed to be common in patients undergoing maintenance hemodialysis, but little is known about their frequency or outcomes. In this prospective study, we sought to increase our knowledge regarding the incidence, timing, circumstances, and outcomes of falls in this population.MethodsBetween January 2021 and April 2023, adults undergoing maintenance hemodialysis from 103 US dialysis facilities were enrolled in the Heart Outcomes Prevention Evaluation Consortium trial, which randomized participants with moderate or severe chronic pain to a pain coping skills, cognitive behavioral therapy intervention, or usual care. Occurrence of falls was a prespecified trial outcome. The research team inquired about falls at each 4-week follow-up visit during the 36-week study. Multivariable regression was used to explore associations of demographic and clinical characteristics, including patient-reported symptoms, with fall risk.ResultsOf 643 trial participants, 178 (28%) experienced 293 falls over a cumulative follow-up period of 429 participant-years for an overall rate of 0.68 falls per participant-year (95% confidence interval, 0.61 to 0.76). Accidents were the most frequent cause of falls (38%). It was rare for falls to be related to the hemodialysis treatment or to occur in the hemodialysis unit. Of the 293 falls, 36 (12%) were evaluated in the emergency department without subsequent hospitalization, 41 (14%) resulted in a hospital admission, and 19 (7%) led to a fracture. In multivariable analyses, demographic characteristics, severity of pain symptoms, or medication use such as opioids at enrollment were not associated with the fall risk.ConclusionsFalls were common in this cohort of maintenance hemodialysis patients with chronic pain, occurring in 28% of individuals during a planned follow-up of 36 weeks. Falls rarely occurred in the dialysis unit, with the vast majority occurring at participants' homes and due to accidental causes. There was no significant association between patient-reported symptoms or medication use and the risk of subsequent falls.Clinical Trial registry name and registration number:ClinicalTrials.gov, NCT04571619.

1Division of Nephrology, University of Washington School of Medicine, Seattle, WA, USA 2Section of Nephrology, Seattle VA Medical Center, Seattle, WA, USA 3American Society of Nephrology, Washington, D.C., USA 4Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA aCorrespondence: Dr. Suzanne Watnick, University of Washington, 1959 NE Pacific Street, Box 356521, Health Sciences Building, BB-1271, Seattle, WA 98195, [email protected], (tel) 503-329-9820