Needs and Considerations for Standardization of Kidney Disease Education in Patients with Advanced CKD

Abstract

Kidney health advocacy organizations and leaders in the nephrology community have repeatedly emphasized the need to increase home dialysis utilization in the United States. Limited awareness and understanding of options for the management of kidney failure among patients living with advanced CKD is a significant barrier to increasing the selection and use of home dialysis. Studies have shown that providing targeted comprehensive patient education before the onset of kidney failure can improve patients' awareness of kidney disease and substantially increase the informed utilization of home dialysis. Unfortunately, in the absence of validated evidence-based education protocols, outcomes associated with home dialysis use vary widely among published studies, potentially affecting the routine implementation and reporting of these services among patients with advanced CKD. This review provides pragmatic guidance on establishing effective patient-centered education programs to empower patients to make informed decisions about their KRT and, in turn, increase home dialysis use.

Introduction

Studies have shown that home dialysis provides equivalent survival rates compared with in-center hemodialysis, while leading to better patient-centered and health services outcomes.^1–4 Increasing its use has been a major focus of US stakeholder advocacy and policy initiatives, including a recent presidential order.^5–7 Many patient-related, provider-related, and system-related barriers limit home dialysis use in the United States.⁸ Such use, at the minimum, requires those confronting kidney failures to choose them as their preferred KRT. Because patient choice is predicated on their awareness of the modalities, targeted education that enhances patient-centered informed KRT utilization is recognized as the basic prerequisite for greater home dialysis use.⁹

Numerous studies confirm that KRT-targeted education provided before the development of kidney failure substantially increases informed home dialysis selection and use. However, owing to a lack of validated protocols, these studies have reported positive but heterogeneous outcomes with widely varying home dialysis rates. The lack of clear outcomes, compounded by potential disincentives involving resource–reward considerations, hampers nephrologists from consistently providing targeted education to all their patients with advanced CKD. Currently, the occurrence of targeted education is not precisely known but is likely uncommon or inconsistent.¹⁰ Standardizing patient-centered, pre-kidney failure education may enable patients to receive it more consistently and stimulate an across-the-board increase in informed home dialysis utilization.¹¹

The Template for Intervention Description and Replication (TIDieR) framework was created to facilitate the development, illustration, and comparative evaluation of any intervention.¹² In this review, the TIDieR framework is used to examine the existing evidence related to each of its characteristics in the context of kidney disease education programs. This synthesis aims to assist US nephrology practices in developing education interventions capable of facilitating informed KRT selection for their patients with advanced CKD.

Nomenclature

Kidney disease education has been variably described as “Multidisciplinary Predialysis Education,”^13–15 “CKD Education,”^16–18 “Predialysis Education,”^11,19,20 “Dialysis (modality) Education,”^21,22 “Renal (kidney) Replacement Therapy Options Education,”²³ “Comprehensive Pre-ESKD Patient Education,”^24–26 and so on. These studies have enrolled patients of nearly all stages of CKD and targeted a variety of outcomes, including CKD progression, survival, health-related quality of life, vascular access, dialysis modality, and health care cost. Across the studies, the same terminology, e.g., “multidisciplinary,” has been applied with different meanings and targeted different outcomes. Evaluating the effect of such varied interventions targeting a variety of outcomes on home dialysis is problematic, leading to widely disparate (13%–85%) home dialysis rates. There is a need to use uniform terminology for a process that aims to achieve informed KRT utilization.²⁷ Because informed KRT selection requires patient's comprehension of kidneys' role in health, causes and effects of CKD, and factors affecting the timings and options for KRT, we use the term “Comprehensive Pre-kidney failure Education” (CoPE) for describing this all-inclusive type of education.

Why is CoPE Necessary?

Studies in several chronic disorders, including diabetes, cardiovascular disease, psychiatric disorders, and so on, have shown that patient education improves patient awareness, motivation, and self-efficacy leading to improved clinical outcomes.²⁸ Several cohort and a few randomized studies show that CoPE has a positive effect on awareness of kidney disease, CKD progression, BP control, hospitalizations for dialysis initiation, vascular access outcomes, and survival.^29–31 Ethicists in clinical medicine consistently advocate for shared decision-making as a guiding therapeutic principle, especially where no clearly superior option exists.³² As such, the American Society of Nephrology (ASN)/Renal Physician Association (RPA) guidelines recommend shared decision-making to guide KRT selection by patients.⁵ Patients with CKD have limited disease awareness and high levels of decisional conflict, defined as the degree of uncertainty about choosing the most suitable among the available KRT options with differing pros and cons.³³ Nearly all studies to date show that when provided with CoPE, patients with advanced CKD choose and use home dialysis at substantially higher rates (approximately 45%–50%) compared with contemporaneous population statistics (Figure 1).⁴⁸ Together, available evidence and guidelines suggest that the principles of ethical medicine and the health care system's goal of increasing home dialysis are aligned and achievable through the implementation of CoPE.

Figure 1.

Home dialysis selection and utilization rates among the published reports of CoPE. Home KRT includes the home peritoneal dialysis and home hemodialysis with a fraction of self-care dialysis in isolated studies. Each bar represents a separate publication/year.^{13,17,19–21,24–26,34–47} *Study was a randomized trial comparing between the two different types of education; **the upper and lower limit of prevalent national dialysis rates were established by examining the United States Renal Data System–reported rates of home dialysis for the respective country of publication, for the publication year±1 year. CoPE, Comprehensive Pre-kidney failure Education.

Who Should Receive CoPE?

ASN/RPA guidelines recommend that all patients transitioning to kidney failure should have the opportunity for shared decision-making when choosing their KRT.⁵ Referencing a prospective study showing that most (78%) US and Canadian patients with incident kidney failure lack significant contraindications for home dialysis,⁴⁹ a recent US presidential order encouraged greater use of patient-centered KRT and a lofty goal of 80% use of home dialysis (or transplantation) in the United States by 2025.⁷ A few countries, such as Hong Kong and New Zealand, have shown the feasibility of maintaining high rates of home dialysis (40%–70%) with excellent population-level outcomes.⁵⁰ These data suggest that the US target for CoPE and informed KRT selection should be higher, essentially universal for all patients with advanced CKD, irrespective of age, socioeconomic status, or comorbidity burden.

Currently, there is a significant gap between the need for CoPE and the reality of delivered CoPE. Studies have shown substantial sociodemographic and comorbidity-based disparities in home dialysis use, with patients on home dialysis having consistently higher disease awareness compared with their in-center counterparts.^51,52 Several US studies have shown significant selection bias even in the clinical practice of CoPE.^21,52 A recent United States Renal Data System (USRDS) analysis showed that while pre-kidney failure education coding is associated with a doubling of home dialysis use, fewer than 1% of patients with incident kidney failure receive these services. Considering that incident home dialysis rates in the noneducation population were stagnant at 7%–10% during the study period, these data highlight significant concerns related to both the occurrence and coding for CoPE. Nonetheless, the disparities in education services mirrored those existent in home dialysis use.¹⁰ Together, these evidence suggest that referral biases for CoPE may be an important factor in unrealized home dialysis utilization. Provider education is needed to create a system that not only provides CoPE to all patients with advanced CKD and their caregivers but is also capable of capturing its occurrence and determining its effect.

Who Should Provide CoPE?

Assisting patients and their caregivers to make informed and educated dialysis selection requires educators with proficiencies in all KRTs and motivational counseling.^6,23 Thus, experts recommend trained personnel and a validated protocol for CoPE.¹⁸ Several reports emphasize the importance of a multidisciplinary approach with broad, complementary expertise achieved through a combination of providers, dialysis nurses, dietitians, and social workers. A few programs also incorporate peer support.⁴⁸ In a series of retrospective and prospective studies using identical CoPE protocols across different US geographic areas, we found that a multidisciplinary approach involving a physician, advanced practitioner, dialysis nurse, and dietitian significantly improves confidence in dialysis decision-making in over 90% of participants and yields a consistent high rate of selection (70%–74%) and use (61%) of home dialysis.^25,26 However, multidisciplinary teams require substantial and often unavailable resources. Therefore, several studies have used individually proficient clinical educators for CoPE. Over 90% of the self-referred patients with advanced CKD attending the state-wide Missouri Kidney Program rated trained social workers as either “good” or “excellent,” with 56% choosing home dialysis.³⁴ Liebman et al. showed that education by home dialysis nurses also results in high selection (57%) and use (31%) of home dialysis.²¹ In a multicenter initiative within a large dialysis organization where trained local dialysis staff provided education, Lacson et al. reported home dialysis rates that were marginally lower (24.7%) but still significantly higher compared with their control group (3.7%).²⁰ Overall, although nearly all studies to date report significantly higher home dialysis among CoPE recipients compared with the contemporaneous control group or wider population rates (Figure 1), none have compared the outcomes between different educator characteristics, prohibiting clear recommendations for a preferred approach. Currently, it seems reasonable that individuals with adequate knowledge of KRT options and their lifestyle implications provide CoPE, with a preference for a multidisciplinary approach with high-level providers, i.e., a physician or dialysis nurse as the program champions.

What Constitutes CoPE?

For informed KRT selection best suited for personal values, lifestyle, and goals, individual patients should/must have access to useable information to understand the medical, social, and financial aspects of their KRT options.^5,53 National organizations, such as the National Kidney Foundation, American Association of Kidney Patients, Department of Veterans Affairs, and Center for Medicare & Medicaid Services (CMS), have outlined detailed versions of their education programs.^{16,22,54–57} Many individual institutes and commercial dialysis companies have designed their protocols on the basis of these opinion-based illustrations.^58,59 Apart from minor differences, these protocols are surprisingly consistent in the syllabus and typically include a combination of knowledge domains related to earlier stages of CKD and kidney failure. An example of the domains and missions for the education protocol implemented in the Trial to Evaluate and Assess the effect of CoPE on Home dialysis among VETerans (TEACH-VET)⁵⁸ is presented in Table 1. Despite these broad agreements, there is a lack of empiric evidence to inform the importance and utility of individual domains in improving shared decision-making and informed KRT selection, and it requires prospective studies.

Table 1.

The domains and the missions of education for a traditional Comprehensive Pre-kidney failure Education protocol

Domains of the CoPE

Missions/Messages of the CoPE for Patients

• Overview of kidneys in human health ○ Location and function of the human kidneys ○ Excretory functions of the kidneys ○ Nonexcretory functions of the kidneys • CKD and classification of severity of CKD ○ Differentiate CKD from AKI • Understand kidney failure ○ Dietary, lifestyle, and drug interventions to slow the progression of CKD • Options for the management of kidney failure ○ Kidney transplantation ○ Medical management or conservative care ○ Dialysis therapies ⁃ Home-based peritoneal dialysis ⁃ Home-based hemodialysis ⁃ Center-based hemodialysis • Lifestyle on dialysis • Frequently asked questions

• Individual values, goals of care, and health care preferences should be established early in advanced CKD • For eligible patients, transplantation is the best modality of KRT • All dialysis modalities have equivalent survival • Unless deemed medically/socially unsuitable by the provider, the choice of dialysis modality is a patient and caregiver's decision • Actively attempt to avoid fear and uncertainties regarding the logistical requirements of home dialysis as overbearing motivators for dialysis modality selection • The decision for dialysis should be initiated early in the course of advanced CKD • All reasonable attempts should be made to reach informed dialysis selection in a time-based manner, and patients should be advised regarding the harms of indecision • All education should be evaluated by one parameter of the patient decision process and firm selection of individual KRT modality

CoPE, Comprehensive Pre-kidney failure Education.

How and How Much CoPE?

Substantial heterogeneity in the literature exists regarding the methods of delivering CoPE, e.g., active instructor-led education,^25,26 passive education with self-learning printed or electronic/online materials,⁵⁹ or combination curricula. Considering that instructor-led education requires proficient educators and substantial resources, passive learning seems to be the most common in practice, but it is largely ill-quantified and of uncertain efficacy. Modern improvements in digital literacy and access have the potential to increase the self-learning abilities of patients from online resources; however, it is frequently challenging for patients to determine the legitimacy of the source. In recent years, several online self-directed protocols for CoPE have been established through public–private partnerships. The efficacy of these tools on the selection and use of home dialysis at present, though uncertain, seems promising.^35,60 Additionally, reimbursement source for these tools is unclear, and as such, few providers participate in this CoPE format. Finally, disparities in access or patient use lead to selection bias.⁶⁰ For example, in one study where 156 eligible patients with advanced CKD were invited, investigators were able to enroll only 28 (18%) patients.³⁵ Overall, although several publicly available resources are adequate for a patient with average CKD, currently, self-learning seems to be largely limited to those with higher literacy.^6,61

Telemedicine provides an alternate and efficient method to increase the reach of proficient educators with limited resources. Tele-education has been shown to improve patient outcomes in diabetes, congestive heart failure, psychiatric disorders, and so on.^62–64 A few reports show that telemedicine-based multidisciplinary CKD and dialysis care is feasible and noninferior to conventional care.^65,66 In a prospective study, we found that the home dialysis selection rates and confidence in dialysis decision-making were similar in patients receiving CoPE using the telemedicine or face-to-face method.²⁴ Recent developments with the coronavirus epidemic have rapidly expanded telemedicine landscape. On the basis of these data and current limitations in CoPE delivery, a greater role for telemedicine can be visualized in the dissemination of quality CoPE with validated protocols.⁶⁷ The results from the ongoing TEACH-VET study evaluating the comparative efficacy of pragmatically allocated telemedicine versus face-to-face CoPE on patient and health services outcomes should provide more guidance.⁵⁸

Similar concerns also exist regarding the format of delivery, e.g., group, individual, or combined approach. In patients already receiving multidisciplinary advanced CKD care, Mann et al. found that the addition of a targeted second phase comprised of small group-based session increased self-care dialysis selection from approximately 50% to 85% among those already educated through printed and audiovisual material.³⁶ In two separate clinical education programs with a two-phase approach (initial audiovisual session followed by patient-centered one-on-one counseling), we have achieved similar results with consistent rates (70%–74%) of home dialysis selection across different US geographical regions.^25,26

Few studies have evaluated the feasibility and sustained benefits of single versus repeated sessions of education. Setting up a specialty advanced CKD clinic where all patients were encouraged to receive repeated sessions of CoPE, we found that approximately half (45%) attended only one session and only 15% attended ≥3 sessions. Although repeated sessions led to higher home dialysis selection, the effect plateaued at three sessions, with only 26% attending repeated sessions changing their initial KRT selection.²⁵ In another retrospective study where universal stand-alone CoPE was separated from ongoing CKD care, we found that 28% of referred patients did not attend despite repeated invitations. Of those attending, 77% participated in only one session and <1% participated in ≥3 sessions.²⁶ Similar declining trends for attendance were also evident among the self-referred patients in the Missouri Kidney Program, which provided six separate sessions of education, each covering a different domain.³⁴ Finally, in a prospective study examining the effect of repeated group sessions on informed KRT selection, we found that the odds of being confident in KRT selection were more than nine times higher, with over 90% of patients being able to achieve informed KRT decision after three sessions. Nonetheless, the efficacy defined by home dialysis selection rose marginally and statistically insignificantly, from 50% after one session to 67% after three sessions.²⁴

Together, these data suggest that CoPE should be structured in a flexible manner, preferentially using a two-phase approach following Kolb's experiential learning theory.⁶⁸ An example could be an initial session, delivered in a group or audiovisual format to improve efficiency while providing a knowledge base, followed by a focused one-on-one session for decision support and personalizations.⁶⁹ The determinations regarding the delivery method and number of sessions can be based on the combination of patient-centered factors likely to affect efficacy and feasibility (Table 2).

Table 2.

Considerations for designing a Comprehensive Pre-kidney failure Education program

TIDieR Characteristic	Possible Options	Pragmatic or Preferred Options
Why should we provide CoPE?	• Ethical • Recommended • Effective	N/A
Who should get CoPE?	• All patients with advanced CKD • Patients with CKD at high risk of developing kidney failure • Incident kidney failure patients	• Stage 4 and stage 5 CKD • Incident kidney failure patients
What should be included in CoPE?	• Published protocols from national organizations • Local institutional protocols • Targeted modality-specific education	• See Table 1
Who should provide CoPE?	• Clinical provider • Dialysis nurse • Social worker • Dietitian • Other trained staff	• Multidisciplinary team • Educator proficient in all medical/social aspects of dialysis • Engage the highest level of provider feasible
When should we provide CoPE?	• Earliest possible time in stage 4 or 5 CKD • Development of incident kidney failure	• At the earliest after the diagnosis of stage 4 CKD • During the early incident kidney failure period
Where should we provide CoPE?	• In-clinic • Remote at home • Remote at clinic • Dialysis providers • Online	• In-person or telemedicine-based, instructor-led education • Self-learning online material
How should we provide CoPE?	• Self-learning through printed, audiovisual, or online material • Instructor-led group or individual education	• Two-stage approach, with stage one aimed at transmitting knowledge and stage two aimed at improving understanding
How much CoPE should be provided?	• Single versus multiple sessions	• Maximize the gains in the first session • Limited benefits beyond three sessions
How should CoPE be tailored?	• Language preferences • Cultural preferences	• Patient-centered education
Assessment and modification	• Knowledge of CKD and KRT options and implications • Satisfaction with CoPE • Confidence in dialysis decision-making • Rates of clinical outcomes, i.e., home dialysis or conservative care • Clinical outcomes, i.e., rates of vascular access or hospitalization for dialysis initiation	• One of the parameters of informed dialysis decision-making • Rates of home dialysis selection and/or use

TIDieR, Template for Intervention Description and Replication; CoPE, Comprehensive Pre-kidney failure Education; N/A, not applicable.

When and Where to Deliver CoPE?

Early referral to nephrology is associated with higher home dialysis use and improved clinical outcomes, including quality of CKD care, and survival after kidney failure.³¹ Considering the low health literacy and awareness among patients with advanced CKD, it seems logical that CoPE implementation should also be early in this population.¹⁸ A recent trial evaluated the effect of an interactive audiovisual decision aid (versus passive education) on decisional conflict about KRT selection among patients with advanced CKD.⁵⁹ This study showed significant and sustained improvements in CKD knowledge and decisional conflict through the entirety of the 18-month study period. Although the modality outcomes were unavailable, these results provide evidence for the sustained benefits of early educational interventions. However, most studies reporting on modality selection or use have conventionally focused on the immediate period surrounding the initiation of KRT.²⁵ In a retrospective evaluation, we found that the patient selection of home dialysis is similar (81% versus 66%, P > 0.05) in both stages 4 and 5 CKD.^24,25 Finally, patient education is an existing quality measure for dialysis units. Several dialysis organizations have established systems and nation-wide resources for nursing expertise, environment, and peer support to provide modality-specific education for their patients with incident kidney failure.⁷⁰ A few studies have reported that such education can be effective, with home dialysis rates ranging between 28% and 48% among studies.^37,38,71,72 Nonetheless, the overall effect of such programs at a system's level seems to be limited. USRDS analyses show that <5% of patients initiating dialysis with in-center hemodialysis ever transfer to home dialysis.⁷³ Collectively, these data suggest that patient education provided before the development of kidney failure is the dominant driver of current home dialysis use. CoPE and opportunities for informed KRT selection should be provided to all patients with a high likelihood of progressing to kidney failure, especially those with stages 4 and 5 CKD and even those early in their incident kidney failure.

How to Tailor CoPE?

An adequate evidence base exists for some disorders, e.g., diabetes and discharge education, to establish clear patient and caregiver education standards. Standardizing CoPE can benefit its universal delivery and efficacy evaluation. However, as the target is to achieve greater informed home dialysis use, for now, it can be recommended that CoPE, like other patient education endeavors, be provided in a value-based, patient-centered manner and in accordance with the patients' language, literacy, and cultural preferences.^6,61 A recent retrospective analysis showed that patients of Hispanic ethnicity are 24% less likely to receive kidney disease education—arguing for culturally sensitive protocols in languages other than English.¹⁰ An additional consideration could be for using decision aids available in the form of a value-based questionnaire. These aids stimulate patient engagement, improve knowledge and risk perceptions, reduce decisional conflict, and thus, achieve shared decision-making by improving congruence between patients' values and choice.^74,75 Overall, the balance between a standard universal curriculum and one that is flexible for personalization to patients' needs remains an important challenge without clear evidence yet to guide best practice.

Assessment and Modification of CoPE

Considering the limited CKD awareness and health literacy among patients with advanced CKD, patient education may not guarantee patient understanding. Current CMS guidelines recommend evaluating the efficacy of delivered kidney disease education but do not declare the evaluation methods.¹⁶ We suggest the use of the final items in the TIDieR checklist as measures for evaluation and quality improvements.

Improvements in patients' knowledge or awareness may be a measure of the effectiveness of a CoPE program. Available correlative data suggest that education improves disease awareness and improved awareness increases home dialysis use.^58,59 However, few studies have prospectively examined the effect of change in awareness on greater home dialysis use. Importantly, although several instruments exist to evaluate patients' CKD awareness, the specific domains of education related to greater informed KRT and home dialysis utilization have not been defined.^76,77

The use of motivational counseling within the framework of the CoPE should also be considered when evaluating the efficacy of a CoPE program. Motivational counseling can improve self-efficacy and reduce decisional conflict, which can increase confidence in dialysis decision-making. A recent study showed that compared with the usual care, provision of education significantly reduces the uncertainties in KRT decision-making and improves the decisional conflict scores.⁵⁹ Unfortunately, practical application of decisional conflict or shared decision-making instruments is difficult in clinical care, and their efficacy regarding home dialysis selection and use is unclear. A simplistic option may be to ask the patients to rate their confidence in their dialysis decision-making and score this on a “0%–100% confident” scale as a marker of informed decision-making.⁵⁸ This brief screening item may inform providers of patients who are experiencing uncertainty or decisional conflict that may benefit from additional support.

Finally, when evaluating CoPE programs, caution must be exercised in applying home dialysis utilization rate as a sole metric. A patient-centered informed choice may be not to select or use home dialysis. The patient nor the program should be penalized when the patient is confident in their decision for the type of KRT that best suits their livelihood.

To summarize, our recommendation is that the assessment of a CoPE program should include a combination of standardized measures, such as patient satisfaction, usage of motivational counseling, or patient confidence in decision-making, in addition to the rates of home dialysis. Using these data, the nephrology health service research community can be engaged to discern the key drivers of a high-quality CoPE program.

Future Needs

Considering the clear benefits in outcomes and the stakeholders' concurrence for its need, it is alarming that the evidence for the routine occurrence of CoPE in advanced CKD is limited.¹⁰

While standardizing CoPE may help improve its utilization, low Medicare reimbursements and the need for a high-level provider are likely to continue to limit its universal implementations at practice levels.¹⁶ A major barrier is the discrepancy between the responsibilities and rewards for patient education. Typically, the responsibility and resources for CoPE (expertise, effort, and infrastructure) are required on the individual provider side, whereas the rewards of greater home dialysis are primarily experienced by the dialysis organizations. These practice patterns create an undue burden for individual practices that have limited resources, resulting in suboptimal delivery and possible delaying of CoPE until just before initiating KRT. Anchoring education to dialysis organizations may also present an inherent conflict of interest for the firm for financial incentives or performance metrics.

Finally, coding or billing for CoPE services is currently limited, creating uncertainties about the real-world provision and efficacy of CoPE. Studies have demonstrated that patient education efforts are associated with substantial health care savings resulting from greater home dialysis use as well as improved outcomes and health care utilization.^15,78 Accommodations by CMS to allow greater reimbursements for fewer sessions to more closely capture the effort and expertise can incentivize wider adoption and better evaluation of the efficacy of real-world CoPE. Pending these, practitioner education is required to ensure that the limitations of routine clinical visits concerning shared decision-making are recognized. Establishing opinion-based recommendations promoting the concept of universal CoPE can expedite the goals of achieving equity in advanced CKD and home dialysis care.

To conclude, as demonstrated by our own and others' research, implementation of CoPE can lead to a rapid expansion of the home dialysis population within individual nephrology practices, while substantially offsetting the practice resources required to provide CoPE. We leveraged the TIDieR checklist to offer recommendations related to CoPE programs that will enable their replication and analyses of efficacy. Prospective studies are needed to rigorously evaluate the components and processes of delivering CoPE (Table 2) and to discern their value in augmenting patient preference and use of home dialysis.

Disclosures

K.L. Cavanaugh reports employment with Tennessee Valley Health Systems-Nashville VA; consultancy for Kidney Health Initiative (KHI) and Responsum Health; ownership interest in HCA Healthcare; and advisory or leadership roles for National Kidney Foundation—KDQOI education committee, American Journal of Kidney Diseases Editorial Board, CJASN Editorial Board, Hypertension Editorial Board, and Medical Decision Making Editorial Board. S.T. Crowley reports employment with and an advisory or leadership role for Veterans Health Administration. M.J. Fischer reports employment with Department of Veterans Affairs and advisory or leadership roles for National Kidney Foundation of Illinois Scientific Advisory Board and Executive Committee, National Quality Forum Renal Endorsement Maintenance Steering Committee, Department of Veterans Affairs Dialysis Steering Committee, Department of Veterans Affairs VAi2 Renal Information System Technical Expert Panel, Renal Physicians Association Kidney Quality Safety Accountability Committee, and Department of Veterans Affairs Renal Field Advisory Board. L.F. Fried reports employment with VA Pittsburgh Healthcare System; having consultancy agreements with 3D Communications, Akebia, Bayer, and Fibrogen; having stock in Amgen, Archer Daniels Midland, ATT, Dow, Kroger, Procter & Gamble, and Walmart; receiving research funding from AstraZeneca; and serving on data safety monitoring boards for CSL Behring and Novo Nordisk. P.M. Palevsky reports employment with US Department of Veterans Affairs and VA Pittsburgh Healthcare System and consultancy for Janssen Research and Development, LLC. P.M. Palevsky reports advisory or leadership roles for National Kidney Foundation: Immediate Past President, Member, Scientific Advisory Board; Renal Physicians Association: Member, Quality, Safety and Accountability Committee; Quality Insights Renal Network 4: Chair, Medical Review Board; UpToDate: Acute Kidney Injury and Section Editor; and Journal of Intensive Care Medicine: Editorial Board and Member. S. Reule reports employment with VA Health Care System–Minneapolis. A.M. Shukla reports employment with North Florida/South Georgia VHA; ongoing research support from the Department of Veterans Affairs, Office of Rural Health, Health Service Research and Development award I01HX002639 and Clinical Science Research and Development award I01CX001661; consultancy agreements with Chemocentryx and Elsevier Inc.; and serving in an advisory or leadership role for the VHA National Peritoneal Dialysis Workgroup. A. Wadhwa reports serving on the medical advisory board of ESRD Network 10 and in an advisory or leadership role for Illinois NKF. All remaining authors have nothing to disclose.

Funding

None.

Author Contributions

Conceptualization: Kerri L. Cavanaugh, Susan T. Crowley, Linda F. Fried, Ashutosh M. Shukla, Anuradha Wadhwa.

Data curation: Linda F. Fried, Jennifer Hale-Gallardo, Huanguang Jia, Ashutosh M. Shukla.

Formal analysis: Linda F. Fried, Ashutosh M. Shukla.

Investigation: Ashutosh M. Shukla.

Methodology: Kerri L. Cavanaugh, Michael J. Fischer, Linda F. Fried, Jennifer Hale-Gallardo, Ashutosh M. Shukla, Anuradha Wadhwa.

Project administration: Ashutosh M. Shukla.

Supervision: Susan T. Crowley, Paul M. Palevsky.

Visualization: Ashutosh M. Shukla.

Writing – original draft: Ashutosh M. Shukla.

Writing – review & editing: Kerri L. Cavanaugh, Susan T. Crowley, Michael J. Fischer, Linda F. Fried, Jennifer Hale-Gallardo, Huanguang Jia, Paul M. Palevsky, Scott Reule, Anuradha Wadhwa.