In the NEWS: US Nephrologists, dialysis and pregnancy

Pregnancy occurs among 1–7% of women on chronic dialysis. Data on how dialysis is provided in ESRD patients who get pregnant in the US is lacking. A recent survey published reveals the latest update on this topic. 

While the response rate is small, the information might be important. Limited providers might have this experience of providing for dialysis for the pregnant patient. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. More dialysis time is associated with better volume and electrolyte control. The frequency of preterm delivery and intrauterine growth restriction tends to correlate with BUN levels. There is an inverse association between BUN level and birthweight and adverse fetal outcome, with more favorable outcomes when the serum urea level is <75 mg/dL. The survey shows that most US nephrologists target a BUN of <50 mg/dL (66%) and 21% aim for a target predialysis BUN of <20 mg/dL. Intensive dialysis is a necessary important finding that is now becoming norm for patients who are pregnant.  Both maternal and fetal outcomes have improved.

What was interesting in the study was "Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week."
Why would that be?.  The authors think that it might be for two reasons: increased hours on HD leading to more vasoconstriction and tighter volume control leading to pre eclampsia. Also since this was a survey, the diagnosis of preeclampsia was dependent on the nephrologist recognizing it and perhaps a "diagnosis" labeling problem. 

Pregnancy on dialysis is becoming frequently encountered, pregnancy care should be part of the health maintenance plan of women of childbearing age on dialysis. OB-Nephrology should be considered a sub field in Nephrology and should become part of academic centers as a career paths for nephrologists and training of fellows. 

IN the NEWS: Intensive treatment during end of life for dialysis patients?

Type of care	Dialysis patients	Cancer patients
Hospitalization	76.0%	61.3%
Average number of days hospitalized	9.8	5.1
Intensive care unit	48.9%	24.0%
Average number of days in ICU	3.5	1.3
Ventilator, feeding tube or CPR	29.0%	9.0%
Hospice	20.0%	55.0%
In-hospital death	44.8%	29.0%

Source: “Treatment Intensity at the End of Life in Older Adults Receiving Long-term Dialysis,” Archives of Internal Medicine

This is a table just seen in a recent article in Archives of Internal medicine on intensity of treatment at the end of life in older adults receiving long term dialysis.  It is an interesting comparison of cancer patients to dialysis patients and one notices that while cancer patients are sick, dialysis patients are sicker and have a higher mortality. Hospitalizations are more, average length of stay and even average intensive care stays are higher. Hospice is rarely offered or chosen in dialysis patients. Check out a post regarding this topic recently as well. Part of this is perhaps Nephrologists are not comfortable offering end of life care to the elderly sick patients during their end of life. Forgoing dialysis is hard for the practicing Nephrologists. 

Are our Nephrologists in training comfortable in dealing with end of life issues and providing "No dialysis" in the right circumstance. 

And how are they compare to their counterparts in cardiology, oncology, and critical care? 

We don't know. 

For that, we have created a survey for our fellows to take. Please pass this along to all nephrology fellows you know as this is very important question to answer.

https://www.surveymonkey.com/s/fellowspalliative

Palliative Care Experience of US Fellows Survey

Not offering renal replacement therapy might not be an easy task. Withdrawing therapy when appropriate also might not be easy. Are our fellows comfortable in doing this? Are even the fellows in cardiology, gastroenterology, and other specialty training comfortable not offering aggressive therapy. 

We are conducting the Palliative Care Experience of US Internal Medicine Subspecialty Fellows Survey. By completing this anonymous online survey, you consent to participate in this research project. This survey will help us understand the palliative care experience of current US internal medicine subspecialty fellows during their residency and fellowship training. This survey will take approximately 5-10 minutes. Your help is greatly appreciated. Thanks for your time and participation.

Here is the link to the survey:


https://www.surveymonkey.com/s/fellowspalliative

Asian Dialysis Modality Survey by Pediatric Nephrology

https://www.pediatric-nephrology.com/index.php?view=entry&year=2011&month=05&day=16&id=495%3Aadms

It is important to understand the preference of the RRT modality

used by various physicians specially in Asia, as it would help to

focus our preventive strategies for the future.

https://qtrial.qualtrics.com/SE/?SID=SV_7OMA39VmMSlzOvi

All Asian physicians involved in the care of children with

renal disorders are welcome to fill up this survey.

Nephrology Fellow Career Choice Satisfaction Survey

Dear Nephrology Fellows,

We are conducting the Nephrology Fellow Career Choice Satisfaction Survey.  We are conducting this survey to determine your satisfaction with nephrology as a career choice. This brief survey will take approximately 5-10 minutes. Your help is greatly appreciated. We will share the results of the survey with all of you. Thanks for your time and participation.

https://www.surveymonkey.com/s/renalfellowssatisfactionsurvey 

Hitesh H. Shah, MD

Prasanth Krish, MD 

Matthew Sparks, MD

Kenar D. Jhaveri, MD