Thursday, July 27, 2017

Nephrology News & Issues (NN&I) article Bill that gives Dialysis Clinics Option to Seek Certification from a Third Party Passes House by Rebecca Zumoff

Bill that gives dialysis clinics option to seek certification from a third party passes House

The Medicare Part B Improvement Act, HR 3178, has passed the House of Representatives. The bill includes a measure to give dialysis clinics the option to seek certification from an approved third party, and a measure to allow dialysis facilities and the home to be approved telemedicine originating sites for home dialysis.
CMS has struggled to keep up with requests for initial certifications and approving expansions on dialysis units and other health care facilities for years.  Most other health care providers are able to seek approval from independent third party accreditors.
“The Centers for Medicare and Medicaid Services classifies the inspection of new dialysis centers a ‘Tier III’ priority, meaning that facilities must wait months or even years to receive CMS certification,” said the bill’s lead sponsor Representative Lynn Jenkins, R-Kansas. “Though a new dialysis center in Topeka applied for inspection in October 2015, it was informed 10 months later that it would have to wait at least another 13 months (until September 2017) to be surveyed.”

Tuesday, July 25, 2017


Friday, July 21, 2017

Blog Post on Home Dialysis Central by Beth Witten on Self-Cannulation

Self-Cannulation: A Patient Right And CMS Expectation For Interested And Trained Patients

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on July 20th, 2017.
I recently heard through the grapevine that some dialysis clinics do not allow patients to cannulate their own vascular accesses. I thought I’d share some arguments in support of patients being allowed and encouraged to participate in this aspect of care.
The preamble to the ESRD Conditions for Coverage which were published in the Federal Register on April 15, 2008 includes comments from the community and CMS’ response:
  • On page 20373-20374, a comment was to add language to the CfC to state that a facility can teach a patient how to self-cannulate without certification as a self-dialysis unit. The CMS response was: “We agree with the commenters that any dialysis facility that is Medicare-certified to provide outpatient dialysis services may include instruction in self-cannulation in its dialysis program. We do not require any additional certifications, nor is a separate ‘‘self-dialysis’’ certification category available.”
  • On page 20389, a comment was that patients should be allowed to refuse a staff member’s cannulation after having problems with that staff’s cannulation. CMS’ response was: “‘‘Fistula First’’ is a nationwide initiative that promotes the adoption of recommended ‘‘best practices,’’ including cannulation methods, in dialysis facilities. Facilities are encouraged to implement these practices,including increased self-cannulation. The initiative encourages self-cannulation with the appropriate course of training, as part of an emphasis on broader patient involvement in care.”
The text of the ESRD Conditions for Coverage, includes these Conditions/Standards related to patient self-cannulation:
  • 42 CFR 494.70(a)(5) which states that the patient has the right to: “Be informed about and participate, if desired, in all aspects of his or her care...”
  • 42 CFR 494.80(a)(9) which states that the patient’s assessment includes, but is not limited to the following: “Evaluation of the patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process…”
  • 42 CFR 494.90 in the Condition statement it says: “The interdisciplinary team as defined at § 494.80 must develop and implement a written, individualized comprehensive plan of carethat specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition…”
Since CMS ESRD regulations and Fistula First encourage facilities to allow patients to self-cannulate after appropriate training, any facility that refuses to allow a patient to self-cannulate may find itself the subject of a patient complaint, a state survey, and citation. The ESRD Interpretive Guidance Version 1.1 published October 3, 2008, provides guidance to surveyors to help them interpret whether the dialysis clinic is complying with the regulations. Surveyors could cite any or all the following tags in the Statement of Deficiencies and Plan of Correction (Form CMS-2567):
  • V456 states: “Self-cannulation may be performed by the patient in any facility upon receiving appropriate training and demonstrating competence, should they so choose.”
  • V512 states: “If patients express a desire for enhanced participation in their own care (e.g., weighing themselves, monitoring blood pressure, holding needle sites, self-cannulation), the facility staff should evaluate and plan for applicable self-care training.”
  • V585 that describes components of home dialysis training states: “Specific (step-by step) instructions in home dialysis procedures (e.g. self-cannulation, peritoneal dialysis exchange) to facilitate adequate dialysis as prescribed by the physician…” Patients doing
On the other hand, teaching a patient how to self-cannulate can save staff time and patient accesses. Here are some resources to teach self-cannulation:
I hope this blog dispels any concerns that a dialysis clinic might have about a patient’s right to be trained and perform self-cannulation and to provide evidence that CMS does not limit any dialysis clinic providing training and allowing trained patients to self-cannulate.

Tuesday, July 18, 2017

BLOG POST ON Home Dialysis Central "Infection in Home Haemodialysis - It Can Be Sneaky!" By Dr. John Agar

Infection In Home Haemodialysis – It Can Be Sneaky!

This blog post was made by Dr. John Agar on July 13th, 2017.
Infection in Home Haemodialysis – it Can Be Sneaky!
Home haemodialysis (HD) permits both longer and more frequent dialysis and, as has often been discussed here and in the literature, offers the most efficient, effective and symptom-free dialysis of all HD modalities. But, there is a dark side to almost any good story, and home HD, while offering a number of significant benefits, is not immune to some risk.
While home patients and their supporting staff often fear venous disconnection most, and are correctly at pains to emphasize meticulous and careful taping, vigilance, and the use of leak detectors, the most insidious risk can be that of infection. Venous disconnection, in our experience, has not been a significant problem—providing that appropriate preventative measures and instruction is followed. But, infection? Well, that can be another matter altogether.
There is nothing that a home patient dreads more than having to be hospitalised. Their whole raison d’ĂȘtre is to be and to remain at home. To be admitted, to be forced back to facility care with facility rules and facility rosters—and, commonly, with far less dialysis than can be self-given at home—is anathema to home HD patients. It is everything that home patients go home to avoid. But, herein lies the chink in their armour!
Infection is the number one enemy of the home dialysis patient! Not obvious infection, like pneumonia, for most can identify chest infections more severe than a common cold, and seek help. No, the infection that can sneak under the guard of home patients is access infection.
There are three main types of access, and all—obviously—must penetrate skin to reach the venous blood stream. Peripheral access, an arteriovenous fistula (AVF) or graft (AVG), requires the insertion and removal of two needles each and every treatment through skin, while central access, commonly an internal jugular catheter (IJC), requires a double lumen (2 channel) catheter that also passes permanently through skin to dwell within the central venous system, the tip ideally floating free within the right atrium of the heart.
Peripheral access needs a minimum of 2 needles per treatment, and, while single needle dialysis is possible, for many reasons, it is not widely used. As a usual minimum of 3 treatments are delivered each week, 156 (3 x 52) treatments/year requires an annual minimum of 312 needle sticks with large bore (commonly 14 gauge) needles that remain (dwell) inside the access vessel for between 3 and 5+ hours (facility dialysis), or for between 8 and 9 hours (home nocturnal dialysis). Finally, as home dialysis is commonly delivered more frequently then centre-based dialysis, treatment frequencies anywhere between alternate day to 6 days/week are used. For the latter, 624 needle sticks—read breaches of skin—are required. Each breach carries risk, especially if using the buttonhole technique, and without meticulous care—or sometimes despite this—bugs get in!
In the case of a central access IJC, the catheter is, in effect, a foreign body that remains permanently in the venous blood stream...on, and on, and on. Even with the relative protection accorded by a cuffed catheter, the track from skin to central vein can be a highway for bug colonization and, ultimately, blood stream contact with the bugs that live outside.
Both carry risk: risk from poor skin preparation in the case of AVF or AVG needling; risk from tract infection or the introduction of bacteria or fungal spores if poor sterile technique complicates the connection and/or disconnection of a catheter. And, sometimes despite all care, bugs can be in the wrong place at the wrong time. The cannulation of the blood stream from the outside is undeniably a chancy business!
In addition, if an AVF or AVG needle is poorly secured and moves, sometimes almost imperceptibly, in and out of the skin (and vein) during the course of the dialysis, organisms may colonise the tract, or even be introduced without the “host” being aware of the invasion.
Shortly after the moment of bacteraemia (a shower of bugs released into the bloodstream) - a prodrome may occur. Prodromes are often not especially obvious, but may cause a sense of feeling a little “off color”…perhaps with a slight fever, or a shiver or two, and a sense of heat or coldness: vague, non-specific signs that a home patient may (indeed commonly will) shrug off, and ignore. This is especially so if the symptoms quickly settle – which they almost always do.
If a prodromal phase occurs to a patient on dialysis in a facility, more likely than not the temperature, the shiver, the complaint of ‘feeling unwell’ will be converted into a high index of suspicion by an alert nurse. Immediate blood cultures, blood tests, and a septic screen inevitably follow. home, the same symptom set is more commonly shrugged off, especially if (a) the symptoms settle and (b) there is a fear that over-reporting may lead to a “come in the ER” instruction…and the threat of admission!
So…undetected… a bacteraemia can occur—especially at home—without coincident reporting. Some may be lucky, the bacteraemic shower passing without systemic infection. But some will not be so lucky, especially if there is calcification or other known (or unknown) valvular abnormalities in the heart valves…and endocarditis (an infection on the heart valves) results. But, as endocarditis can take weeks to develop into a full blown illness, the prodrome may be long forgotten by the time the more serious outcome of endocarditis appears.
Surface infection—redness around the insertion site, or a bead of pus or ooze from a recent puncture point—these, too, can be ignored with an “it’ll settle down” approach until the whole AVF surface is angry and inflamed. Here, a stitch in time saves nine, as they say, and early action with cultures, exclusion of systemic spread of infection, and (commonly) oral antibiotics can save more severe consequences down the track. Again, the home patient, independent to a fault, is at greatest risk.
Infection, even the merest hint of it, must never be ignored. Constant vigilance is needed. Aseptic techniques must be reinforced—again and again —while patient self-needling techniques should be checked, regularly, so that poor habits and corner cutting can be nipped in the bud.
Rob Pauly from Edmonton has written a particularly good assessment of the risks of home HD: Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting.” While this deals with many other potential risks, infection is a central component in his paper. While Rob clearly points out the extremely low frequency of adverse events in home haemodialysis patients, nonetheless, he makes a strong case for taking a prudent approach. Home patients must remain alert to the risks of infection. They must report any prodromal symptoms and, at the least, present to their home training units for a septic screen. Early detection is critical. Ignorance—or the classic “ostrich” syndrome—is not a smart approach!

Renal & Urology News Article on Mineral & Bone Disorder for CKD UPDATE

The 50 most active kidney transplant centers in 2016

Record number of organ transplants in the US shuffles ranking of transplant centers

University of California Davis Medical Center cracked the code as the busiest kidney transplant center in the U.S. in 2016, dethroning the University of California San Francisco Medical Center for the first time in seven years.
UC Davis’ #1 ranking among the 50 most active kidney transplant centers, published by NN&I since 2009, was aided by a three-month shutdown of UCSF’s transplant program after a donor death occurred in December 2015. The program reopened in March 2016 and still recorded 329 kidney transplants last year, moving to #5 in the ranking.
For 2016, UC Davis performed 402 kidney and kidney-pancreas transplants, based on data provided by the Organ Procurement and Transplant Network ( Both Methodist Specialty and Transplant Hospital (TX) and UCLA Medical Center maintained their #2 and #3 spots, respectively, from 2015.
During 2016, 33,606 transplants were reported, representing an 8.5% increase over the 2015 total and an increase of 19.8% since 2012. Transplants have increased nearly 20% in the past five years. The growth in overall transplants was largely driven by an increase of 9.2% in the number of deceased donors from 2015 to 2016, continuing a six-year trend of annual increases. Approximately 82% (27,628) of the transplants involved organs from deceased donors. The remaining 18% (5,978) were performed with organs from living donors.
The data used in this ranking is provided by the Organ Procurement and Transplant Network (, and includes deceased and living donor kidney and kidney/pancreas transplants. The OPTN recorded 9,116 deceased kidney donors in 2016 (8,250 in 2015) and 5,631 living kidney donors (5,630 in 2015), resulting in 5,630 living kidney donor transplants (5,628 in 2015) and 13,431 deceased donor kidney transplants in 2016 (12,250 in 2015). There were also 798 kidney/pancreas transplants in 2016 (719 in 2015).
50 busiest US kidney transplant centers in 2016

Delaware Public Media "Can Exercise do for your kidneys what it does for your heart?" by James Morrison