Daniel E. Weiner, MD, a nephrologist at Tufts Medical Center and associate professor of medicine at Tufts University School of Medicine in Boston, Massachusetts, received the National Kidney Foundation’s top research award—the Dr J. Michael Lazarus Award—during the organization’s 2022 Spring Clinical Meetings. Dr Weiner was recognized for his contributions to clinical science and care of patients receiving dialysis. His clinical interests include home and in-center dialysis, hypertension, and chronic kidney disease (CKD). His research has focused on cardiovascular and cerebrovascular disease in CKD; clinical trials in CKD, dialysis, and hypertension; decision-making in advanced CKD; and policy. Dr Weiner is Medical Director of Clinical Research for Dialysis Clinic Inc. and editor-in-chief of the foundation’s newest journal Kidney Medicine.
You’ve been involved extensively with NKF’s Kidney Disease Outcomes Quality Initiative (KDOQI) program. In your view, what are the biggest successes of KDOQI to date?
Dr Weiner: The establishment of a definition of chronic kidney disease and standard nomenclature. This work was pioneered 20 years ago by Dr Andrew Levey at Tufts in collaboration with other experts and leaders in the field. They defined kidney function thresholds and identified markers for chronic kidney disease. This enabled all kidney stakeholders to talk about the same thing. We finally had a shared vocabulary. Additionally, the groundwork that the workgroup on the original CKD guideline laid emphasized the role of albuminuria as an identifier of risk. Combining glomerular filtration rate as a marker of kidney function with albuminuria and other markers of kidney damage has allowed nephrologists to identify people with kidney disease and risk stratify them for complications of kidney disease and progression to kidney failure and cardiovascular complications.
Are there any areas of clinical investigation that deserve far greater attention from the research community than they currently receive?
Dr Weiner: A major area that has not received anywhere near enough attention is whole field of dialysis. If you look at the dialysis that we’re doing in 2022, and you look at dialysis that was being done in 2002 and in 1992, it looks pretty much the same. The machines are a little bit more sophisticated, but we have not had any paradigm shifts, we have not had any major breakthroughs. We do not have any great new interventions. We still don’t know whether we should anticoagulate people receiving maintenance dialysis for atrial fibrillation. We do not even know how to measure blood pressure in someone who is receiving maintenance dialysis. Given the number of people in the United States and worldwide who depend on dialysis, the lack of progress in this field needs to be addressed urgently.
Many nephrologists and other kidney care professionals have advocated greater use of home dialysis because it can improve patients’ quality of life while protecting them from potential exposure to infectious diseases at dialysis facilities. Do you agree that home dialysis should be used more?
Dr Weiner: I do think we should use more home dialysis, but I don’t think the push for it should be extreme. I think home dialysis can improve many patients’ quality of life, but that is very much an individual decision. I have patients who view coming to in-center dialysis facility as their chance to socialize and to get out and see other people. Some people do not have suitable home environments for home dialysis. Anytime you have a real push for a paradigm change, I do think you need to respect individualization of care and care choices and make sure you are not pushing so hard that you force people to choose treatments that might not be the best for them.
That stated, we are using home dialysis about half as much as Canada and many countries in Europe. Although home dialysis rates have risen in the last year or so, before that, approximately 13% of patients receiving maintenance dialysis in the US were treated with home dialysis. I think we probably can get up to 25% without any unintended consequences, without sacrificing the ability of patients and their care partners to pick the treatment modality that is best for them.
What stands in the way of greater acceptance of home dialysis?
Dr Weiner: Many factors. One major issue is that nephrologists, non-nephrologist clinicians, and people with kidney disease are just not as familiar with home dialysis, particularly peritoneal dialysis. Our training in home dialysis is not great. This is particularly problematic for patients receiving peritoneal dialysis when they are hospitalized. Very few hospitals are good at peritoneal dialysis, which is much less systematized than hemodialysis. The most troubling aspect of this limitation is when a patient requires post-acute care treatment at a rehabilitation or other long-term facility, as very few of these are prepared for or familiar with peritoneal dialysis.
We recently had a few patients on peritoneal dialysis who had to transfer to hemodialysis in order to go to a rehabilitation facility because there just were no other options for doing peritoneal dialysis other than being at home or an acute care hospital. This is an area where I think we need government intervention to incentivize facilities of excellence in peritoneal dialysis among nursing homes and rehabilitation facilities as well as among acute care hospitals.
As medical director of clinical research for a dialysis chain, you have been involved in the care of patients with COVID-19. Has that experience caused you to rethink any aspects of clinical care in general?
Dr Weiner: Yes. The pandemic underscored just how vulnerable the dialysis patient population is. When dialysis patients get sick, they have such high rates of hospitalization and mortality that doing everything possible to protect your population is the most important thing you can do. This means vaccinations are important, making sure people are wearing masks is important, and making sure people are honest and admit to having symptoms and allow for testing is critical.
The other thing I came to appreciate is how amazing many of the staff who provide care to dialysis patients are. These are people who did not get the same recognition that those in acute care hospitals and ICUs got, but they were coming to work every day to care for people with serious acute and chronic medical conditions, working the best they could to keep them out of hospitals despite the tremendous uncertainty of what was going on with COVID and their own individual vulnerabilities to COVID. The dialysis staff, particularly nurses and patient care technicians in maintenance dialysis facilities are among the most underrecognized heroes of the pandemic.
Do you think the COVID-19 pandemic has brought about changes in kidney care that will linger after it ends?
Dr Weiner: The pandemic exposed how vulnerable the workforce is in the kidney care field. It highlighted that what we do is going to have to change because we do not have the people to do it anymore.
As with other specialties, nephrology is experiencing huge workforce issues, not just with nephrologists but also nurses, social workers and patient care technicians as well as others who take care of patients with advanced CKD, including those needing dialysis. Right now, we are struggling to recruit and retain a workforce to take care of this population, and we are going to need to figure out how we will continue to provide high-quality care to individuals requiring kidney replacement therapy and highly coordinated care for those with advanced CKD.
Many staff left the kidney care field during the pandemic, mostly notably in dialysis but really in every aspect of care. This exposed how important having high-quality staff is. Taking care of people with kidney disease is a hard job, and it does not pay that well for the degree of difficulty. There are other people who saw COVID and who were near retirement and ended up retiring early, reflecting that the dialysis nurse workforce included a large number of extremely experienced and qualified nurses who had been engaged in dialysis care for 30 years or more.
What do you consider the most significant development in the treatment of kidney disease in the past 10 years?
Dr Weiner: SGLT2 inhibitors. Up until the last few years, the only major meaningful recommendations to slow progression of kidney disease was to use ACE inhibitors and angiotensin receptor blockers (ARBs), control blood pressure, control diabetes, and to avoid use of nonsteroidal anti-inflammatory drugs. We gained an entire class of medication that, for people with and without diabetes, seems extremely effective in slowing kidney disease progression. This really changes the treatment paradigm. We may even see the US Preventive Services Task Force revisit their recommendation for kidney disease screening. Previously, they did not see a role for broadly screening for kidney disease in part, I think, because there was not much we could to slow progression and we were going to use ACE inhibitors or ARBs anyway. Now we have kidney disease drugs, most notably the SGLT2 inhibitors but include finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist. These are huge innovations that can apply to broad swaths of people with chronic kidney disease to hopefully keep them from ever needing dialysis or a kidney transplant.
What research projects are you working on now?
Dr Weiner: I have been focused on evaluating data from Dialysis Clinic Inc. on COVID-19, working with my colleagues at DCI to evaluate the impact of the pandemic on people requiring dialysis, the effectiveness of vaccines, how quickly immunity wanes, and the effectiveness of boosters. The immediacy of this research makes it both highly challenging and highly rewarding. Other research I am involved with looks at how older adults approach decisions regarding kidney failure treatment when they have advanced chronic kidney disease, highlighting the need to better inform people about options when they have CKD stage 4 and are vulnerable for progression to kidney failure.