Ninety days is not enough - Re-inventing the wheel in declaring kidney failure: A call to KDIGO and UNOS.

The current practice in the United States is to classify a dialysis-dependent patient as having end-stage kidney disease (ESKD) after more than 90 days on maintenance dialysis. According to KDIGO guidelines, an arbitrary duration of >3 months is required to confirm chronic kidney disease. 1 Stevens PE Levin A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013; 158: 825-830https://doi.org/10.7326/0003-4819-158-11-201306040-00007 Crossref PubMed Scopus (1982) Google Scholar If a patient is dialysis-dependent and enrolled in Medicare based on ESKD, Medicare coverage begins on the first day of the fourth month of outpatient dialysis treatment, when “Form 2728” goes into effect. 2 Medicare. Medicare Coverage of Kidney Dialysis & Kidney Kidney Dialysis & Kidney Transplant ServicesTransplant Services. Secondary Medicare Coverage of Kidney Dialysis & Kidney Kidney Dialysis & Kidney Transplant ServicesTransplant Services 2007. https://www.medicare.gov/Pubs/pdf/10128-medicare-coverage-esrd.pdf. Google Scholar A particularly strong variation of this theme is taking place in kidney transplant recipients. Non-function of a kidney transplant is defined by the United Network of Organ Sharing 3.6.B.i guideline as either kidney graft removal (documented in the operative report) or failure with documentation that the candidate is on dialysis or has a measured creatinine clearance or calculated GFR of less than or equal to 20 mL/min within 90 days after kidney transplant. The kidney waiting time will be reinstated without interruption when the Organ Procurement and Transplantation Network receives a complete Waiting Time Reinstatement Form. As per Organ Procurement and Transplantation Network policy 18.1, transplant centers must submit an organ-specific transplant-recipient follow-up (TRF) within 14 days following graft failure. 3 UNOS/OPTN. Organ Procurement and Transplantation Network Policy. Secondary Organ Procurement and Transplantation Network Policy 2022. https://optn.transplant.hrsa.gov/media/eavh5bf3/optn_policies.pdf. Google Scholar This means that to reinstate the waiting time of a kidney transplant recipients without interruption, the transplant center has to submit the TRF within 104 days post-transplant. At this time, the transplant nephrologist may still be evaluating the graft function and monitoring for recovery. Submitting the TRF later than 104 days means that the transplant recipient will wait for a long time for a second transplant since the waiting time will start from the date of declaring the graft failure. We highly recommend that this policy is thoughtfully revisited and revised. Nephrologists must be cognizant of the fact that recovery from acute kidney injury in dialysis-dependent patients is still possible, even after the statutory 90 days of dependency. According to several large-scale studies, the recovery rate following an ESKD diagnosis is around 1-2%. These studies have been affirmed in both peritoneal and hemodialysis patient cohorts. 4 Macdonald JA McDonald SP Hawley CM et al. Recovery of renal function in end-stage renal failure–comparison between peritoneal dialysis and haemodialysis. Nephrol Dial Transplant. 2009; 24 ([published Online First: 20090514]): 2825-2831https://doi.org/10.1093/ndt/gfp216 Crossref PubMed Scopus (25) Google Scholar , 5 Goldstein A Kliger AS Finkelstein FO. Recovery of renal function and the discontinuation of dialysis in patients treated with continuous peritoneal dialysis. Perit Dial Int. 2003; 23: 151-156 Crossref Scopus (20) Google Scholar , 6 Craven AM Hawley CM McDonald SP Rosman JB Brown FG Johnson DW. Predictors of renal recovery in Australian and New Zealand end-stage renal failure patients treated with peritoneal dialysis. Perit Dial Int. 2007; 27: 184-191 Crossref PubMed Scopus (24) Google Scholar , 7 Sekkarie MA Port FK Wolfe RA et al. Recovery from end-stage renal disease. Am J Kidney Dis. 1990; 15: 61-65https://doi.org/10.1016/s0272-6386(12)80593-2 Abstract Full Text PDF PubMed Google Scholar A single-center study in Spain reports an 8% kidney recovery rate after being considered ESKD and remaining on dialysis for 3 months. 8 Fernández-Lucas M Teruel-Briones JL Gomis A et al. Recovery of renal function in patients receiving haemodialysis treatment. Nefrologia. 2012; 32 ([published Online First: 201202›04]): 166-171https://doi.org/10.3265/Nefrologia.pre2011.Dec.11194 Crossref Scopus (9) Google Scholar We were not able to find in the literature, a certain percentage of recovery from dialysis after being dialysis dependent for 90 days in kidney transplant recipients whose posttransplant course is complicated by delayed graft function (DGF), which is defined as the need of dialysis in the first week after kidney transplant. A major problem is that kidney recovery may pass unnoticed. There is an abundance of guidelines on when to initiate kidney replacement therapy, but the literature on kidney recovery in patients who were considered to have definite ESKD is scarce. A study showed that dialysis intolerance in the form of feeling washed out post-dialysis and severe leg cramps may in fact be related to kidney recovery. 9 Agraharkar M Nair V Patlovany M. Recovery of renal function in dialysis patients. BMC Nephrology. 2003; 4: 9https://doi.org/10.1186/1471-2369-4-9 Crossref Scopus (13) Google Scholar Also, an increase in urine output while on dialysis or at least maintaining good urine output may predict kidney recovery. 9 Agraharkar M Nair V Patlovany M. Recovery of renal function in dialysis patients. BMC Nephrology. 2003; 4: 9https://doi.org/10.1186/1471-2369-4-9 Crossref Scopus (13) Google Scholar In the current climate of dialysis treatment provision in the United States, it is possible that these symptoms will go unnoticed. Dialysis intolerance may only be linked to severe ultrafiltration, and nephrologists do not usually inquire about the urine output of ESKD patients on regular hemodialysis. Weekly labs can be helpful, but capitated funding only covers the monthly monitoring of kidney function tests. Another constraint is the limited exposure of attending physicians to their own patients - in many units, faculty physicians are only able to round once a month for the comprehensive assessment. This US healthcare delivery paradigm differs greatly from that of many countries in the European Union, where a qualified physician is required by law to be physically present in the outpatient dialysis unit or floor. Dialysis without a valid indication results in unjustified expenditures, exposure to temporary catheters with attendant infections, and negative effects on quality of life in addition to jeopardizing kidney ischemia. To some extent, we need to change our practices and become more open-minded about the concept of kidney recovery after ESKD diagnosis, as well as pay attention to kidney recovery predictors.