Improved survival in kids a boost for ESRD therapy

“In the United States, there was a significant decrease in mortality rates over time among children and adolescents initiating [ESRD] treatment with dialysis between 1990 and 2010.”

That conclusion from a study in the Journal of the American Medical Association released on May 8 was encouraging news for a modality in desperate need of a good story. The study, which included more than 20,000 patients, showed a significant decrease in the United States in mortality rates over time among children and adolescents initiating end-stage renal disease treatment with dialysis.

Recent data from the U.S. Renal Data System shows that mortality among the general dialysis patient population has been sliding down slowly over the last two decades, but we still have a lot of work to do. Cardiovascular disease and infection continue to take their toll on fragile, medically compromised patients, especially in the first year of care. We are still awaiting final results from the Performance Excellence and Accountability in Kidney Care program, or PEAK, which was launched community-wide in 2009 with the intention of reducing first-year mortality among adult hemodialysis by 20% by the end of 2012. Last fall, program manager Kidney Care Partners said they had hit the 12% mark.

Is there a nephrologist in the house?

In order to keep up that momentum, we need good nephrologists. But they may be harder to come by in the years ahead. Reports are that we will face a shortage of nephrologists and other specialists as federal health care reform adds more patients—many of them baby boomers with underling comorbid conditions like heart disease, diabetes and unregulated blood pressure--into the insurance pool. But fellows are not flocking to Nephrology Basics 101. Results from a survey of over 700 fellows published in the April issue of the American Journal of Kidney Diseases indicated that nephrology was not looked at as a desirable choice among available specialties. When asked why they passed over nephrology, the students cited concerns such as “work hours being too much” and “monetary benefit is not good.” They also labeled the subject matter as being “too difficult to grasp” and said patients were too complicated to take care of.

The study authors, led by Kenar D. Jhaveri, MD, of North Shore University Hospital and Long Island Jewish Medical Center, said improvements could be made: course material could be taught better and a greater emphasis on procedures – like those in interventional nephrology—could make the nephrology specialty more attractive. Mentorship could also improve, they said.

It may not be a problem with how nephrology is presented, the authors wrote, as other programs, such as cardiology and gastroenterology, have also seen enrollment drops. “For many, hospitalist jobs are more appealing and a better fit for their lifestyle, and strong efforts are being made to attract medical students and residents into hospital careers,” they said. Such positions have high job satisfaction, surveys show, and potentially offer a better lifestyle with better pay.

In an accompanying editorial, Nancy Day Adams, MD, a nephrologist at the University of Connecticut Health Center, suggested part of the problem with attracting fellows to nephrology was a lack of cheerleading from nephrologists themselves. “Critically, teachers and practitioners cannot be positive role models for potential nephrologists if they are dissatisfied with their work,” Adams wrote, citing a 2005 survey showed that a greater percentage of nephrologists said they were unhappy with their careers compared to respondents in surveys on job satisfaction from the late 1990s.

Might nephrology care one day be handed off to a generalist? There are many ways for the nephrology community to get involved in boosting their own profession and prevent that scenario: Improving mentorship efforts, the quality of course instruction, and a greater emphasis on options in nephrology is a good start. It’s up to the nephrology community to tend to its own garden and plant some new seeds. Better start now. -by Mark Neumann