Author Interview: Lesley Gardiner MD,PhD
Medical Pharmacology and Physiology
University of Missouri School of Medicine
MA 415 Medical Sciences Building
One Hospital Drive Columbia, MO 65212
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Publication:
Structural Equation Modeling Highlights the Potential of Kim-1 as a Biomarker for Chronic Kidney Disease
Gardiner L, Akintola A, Chen G, Catania JM, Vaidya V, Burghardt RC,
Bonventre JV, Trzeciakowski J, Parrish AR.
Am J Nephrol. 2012 Jan 20;35(2):152-163. [Epub ahead of print]
College of Medicine, Texas A&M Health Science Center, Bryan, Tex., USA.
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What are the main findings of the study? |
The findings are two pronged.
The first exciting component is the demonstration of the applicability and validity of structural equation modeling (SEM) as a tool for modeling and examining biomarkers in Chronic Kidney Disease (CKD). This tool is relatively novel in the biological sciences, and our study demonstrates the potential benefits of utilizing it in the field of CKD.
Secondly, the models generated from SEM identified Kim-1 as a sensitive indicator of CKD in the rat. Kim-1, a type I transmembrane protein is an urinary biomarker, which could potentially be used to noninvasively screen and monitor patients with CKD or with risk for CKD.
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Were any of the findings unexpected?
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Going into the study Kim-1 was hypothesized to be a biomarker of CKD; however, I believe we were all a bit surprised by what a strong indicator Kim-1 is of “Kidney Damage” as compared to the gold standard measurements of histological evaluation.
Our findings suggest that changes in Kim-1 levels are just as sensitive an indicator of renal damage in the rat as direct measures of renal pathology, such as glomerulosclerosis and tubular damage.
This is pretty astounding when you consider the ramifications this could have on the clinical diagnosis and monitoring of CKD in the patient, as a simple, non-invasive urine measurement could give you just as good of indication of damage as an invasive biopsy.
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What should clinicians and patients take away from this study?
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Hope.
Although this is an unusual response for a scholarly media interview, it is a word that is used and important to the patient and clinician at the bedside, especially with a diagnosis such as CKD that can have such dramatic effects on the patient’s quality of life and lifestyle.
More precisely, that there is a new tool on the horizon that may help us further elucidate the complex pathophysiology of CKD and lead to developments in therapeutics and management of the disease.
There has been a great need in the field of CKD for improvements in therapeutics and identifying the disease in patients. SEM as a novel tool in the field adds an increased level of sophistication in examining the complex interplay of factors contributing to CKD.
Data and knowledge that have been generated from the work of dedicated labs and scholars from around the world could be assimilated, analyzed, and evaluated in a new way, possibly highlighting connections and potential directions and paths not previously surfaced.
SEM has the potential of allowing us to view the problem with “fresh eyes” and “see” things that before were hidden/ buried beneath the data.
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What recommendations do you have for future studies as a result of your study?
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Through the assessment of SEM as a possible tool for CKD and utilizing the multivariate approach of examining questions, the great need for coordination of efforts among different lab groups was brought to light. SEM allows for a way of examining the complex question from a “big picture” view, standing back and looking at the complex interplay of relationships, identifying novel relationships. In this sense, it offers a tool for approaching the problem by identifying key relationships which could be targeted for further study. SEM could potentially highlight key measurements that have the greatest value in disease prediction and detection. It may also uncover new relationships among environmental, physiologic, and pathophysiologic processes. These relationships could then be subjected to further investigation and validation.
For SEM to have the greatest probability of success and benefit, however, it must build upon a foundation of known relationships, basic knowledge, and guiding principles within the field. This kind of information is typically gleaned from “ground up” research, building from the molecular and cellular level, to tissues, organ systems, and finally the patient. SEM not only makes use of this basic information, but can inform investigators of hitherto unforeseen aspects and avenues for research.
Ultimately, this process requires a better level of integration and coordination between basic and clinical studies if it is to have the greatest success for advancing the field.
Such a coordinated approach would have numerous advantages, such as maximizing resources in knowledge, time, money, and energy, and hasten attaining the goal we all are striving for: innovations that would help the patient.
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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