ESRD: State of the Art and Charting the Challenges for the Future Beth Israel Deaconess and Harvard Medical School April 23 – 26, 2009 A teaching hospital of Harvard Medical School

Steering Committee Chairmen: Tom F. Parker and Theodore I. Steinman William M. Bennett, MD Allan J. Collins, MD Richard J. Cronin, MD Francis L. Delmonico, MD Raymond Hakim, MD William L. Henrich, MD Alan Hull, MD: –Honorary Chairman Prof. Norbert Lameire J. Michael Lazarus, MD Edmund Lowrie, MD Andrew S. Narva, MD Allen R. Nissenson, MD Eberhard Ritz, MD

A teaching hospital of Harvard Medical School Sponsors with appreciation Platinum Level –Amgen –Genzyme

A teaching hospital of Harvard Medical School Sponsors with appreciation Gold Level –Abbott Laboratories –American Renal Associates, LLC –Dallas Nephrology Associates, PA –Renal Ventures Management –Watson Pharmaceuticals

A teaching hospital of Harvard Medical School Sponsors with appreciation Silver Level –AMAG Pharmaceuticals, Inc –NxStage –U. S. Renal –Fresenius Medical Care, NA Contributors –B. Braun Medical, Inc. –DaVita

A teaching hospital of Harvard Medical School Program Endorsements American Society of Nephrology National Kidney Foundation Renal Physicians Association International Society of Nephrology European Dialysis and Transplant Association/European Renal Association

A teaching hospital of Harvard Medical School Immediate Legacy Publication in CJASN Talks before –ISN –ASN –(NKF) –(RPA) Letters to KCP and CMS

A teaching hospital of Harvard Medical School Immediate Legacy Response by Steering Committee to Notice of Proposed Rules for Bundling Marc Neumann NNI Editorial Gary Peterson RenalWeb D and T

A teaching hospital of Harvard Medical School The Setting Our Milieu –20% of facility patients die each year –A program that costs $34,000,000,000/year –$20,000 per patient per year in hospitalizations –Less than 20% rehabilitation –Survival results worse than colon ca.

A teaching hospital of Harvard Medical School A different world than 20 years ago in Dallas More complex reimbursement Misalignment of various stakeholders –Providers –Nephrologists –Payors –Regulators An understanding of the spectrum of disease from early CKD to RRT The complexity of the science

A teaching hospital of Harvard Medical School A different world than 20 years ago in Dallas How to apply what we have learned in the emerging environment we face: –Bundling in 2011 –Capitation to soon follow –Overall change in healthcare policy Science should drive reimbursement and delivery, but is this true in ESRD?

A teaching hospital of Harvard Medical School Because things are the way the are, we cannot stay the way we are. So what do we do? With what we have learned?

A teaching hospital of Harvard Medical School What are the critical lessons Cardiovascular Disease Infection

A teaching hospital of Harvard Medical School But, first the overall problem

A teaching hospital of Harvard Medical School

What are the critical scientific elements Cardiovascular Disease Infection

A teaching hospital of Harvard Medical School ASCVD is apparently not the leading cause of CV death

A teaching hospital of Harvard Medical School

Can we now say that sodium modeling is detrimental to outcomes?

A teaching hospital of Harvard Medical School

Cardiovascular Bottom Line It’s not ASCVD We have the knowledge to make a difference in managing the LV –Better volume management –Less salt load –Better BP control –Better ultrafiltration –Consideration of aldosterone antagonists Awareness of fibrosis

A teaching hospital of Harvard Medical School What are the critical elements Cardiovascular Disease Infection

A teaching hospital of Harvard Medical School

Secondary, yet very important, even contributory issues Inflammation –Malnutrition –Infection –Cardiac and Vascular Disease Dialysis dose

A teaching hospital of Harvard Medical School

Secondary, yet very important, even contributory issues Inflammation Dialysis dose

A teaching hospital of Harvard Medical School

What to do about the problem of Kt/V Understand that it is not the “Holy Grail” and has enormous shortcomings Be aware of emerging formulas that ignore V Change TD

A teaching hospital of Harvard Medical School

If we were going to design a dialysis system today, we know what we would do And it’s not what we do now It would be longer and more frequent It would emphasize individualized care

A teaching hospital of Harvard Medical School Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump

A teaching hospital of Harvard Medical School Making an Immediate Difference Support CKD initiatives The First Year

A teaching hospital of Harvard Medical School

Not to be ignored Other processes of care –Emerging UCLA data Do not ignore “fixable” inflammation issues Research and investigation into such things as the fibrosis and inflammation stories

A teaching hospital of Harvard Medical School If it were a perfect world There would be informed and interested caregivers to support patients with CKD There would be enough donors for pre- emptive transplantation Dialysis would be longer and smoother with a dentist and a podiatrist and an exercise trainer in every facility …

A teaching hospital of Harvard Medical School

The “PolyPill” for CKD/ESRD (circa 2029) SESSTOL (generic) Sirolimus (0.5mg) Enalapril (10 mg) Sprironolactone (12.5 mg) Sildenafil (25 mg) Atenolol (25 mg)

A teaching hospital of Harvard Medical School It now seems so simple, after 1711 slides and 4 days Cease to spend so much time on traditional clinical outcomes measurements that may only account for 14% of the morbidity and mortality Save the left ventricle at all costs Do not tolerate catheters or those who place them Intensify the care of the incident patients Do not be satisfied with a formulaic approach to conventional dialysis

A teaching hospital of Harvard Medical School

(Our) world is (what it is), not because of those who do bad things, but because of those who look on and do nothing." -Albert Einstein