Academy Comments to CMS re: RDNs and Nutrition in Prevention and Treatment of Renal Disease

August 23, 2016

Andrew M. Slavitt, MBA
Acting Administrator, Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1651-P, P.O. Box 8010
Baltimore, MD 21244-8010

Re: Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model (CMS–1651–P)

Dear Mr. Slavitt:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Medicare and Medicaid Services (CMS) at the United States Department of Health and Human Services (HHS) related to its June 30, 2016 proposed rule, "Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model (CMS–1651–P)." Representing more than 100,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle. RDNs provide medical nutrition therapy in dialysis facilities, clinics, hospitals, university settings, and private practice. Through their direction and leadership, RDNs strive to advance the nephrology nutrition clinical practice, education, and research while promoting continuing education programs for dietitian nutritionists and other healthcare professionals.

The Academy generally supports CMS’s continued implementation and improvement of the case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient End-Stage Renal Disease (ESRD) and efforts to develop and improve the Comprehensive ESRD Care Model. The Academy also continues to support quality improvement programs (QIPs) when conscientiously designed to effectively assess facility performance measures and assure and incentivize quality ESRD services that foster improved patient outcomes. The Academy offers these comments to CMS regarding certain factors and reported performance measures, including:

  • ESRD PPS base rate and the labor-related share;
  • Fluid ultrafiltration rate;
  • CMS’s drug designation process;
  • Quality measures for hypercalcemia; and
  • Comprehensive ESRD Care Model.

A. ESRD PPS Base Rate and High Cost Outliers

The Academy supports CMS's adjustment of payment amounts based upon the updated regression analysis and urges CMS to ensure stagnation in the payment rate does not negatively impact patient care. Specifically, the Academy is concerned about payments to rural ESRD facilities and for facilities that treat pediatric patients and appreciates CMS's consideration of the potentially disproportionate impact on them. The Academy supports CMS's proposed low-volume and rural payment adjustments that are necessary to ensure beneficiaries' access to services where they may otherwise lack dialysis options.

The Academy continues to support CMS's implementation of section 1881(b)(14)(D)(ii) of the Social Security Act allowing for a payment adjustment and the proposed recalibration of the fixed dollar loss amounts "for high cost outliers due to unusual variations in the type or amount of medically necessary care, including variability in the amount of erythropoiesis stimulating agents (ESAs) necessary for anemia management."

CMS notes that "[s]ome examples of the patient conditions that may be reflective of higher facility costs when furnishing dialysis care would be frailty, obesity, and comorbidities such as cancer." RDNs are uniquely positioned in their skills and competencies to address these issues in a cost effective and clinically effective manner, but resources must be made available to enable reimbursement for provision of medical nutrition therapy for these conditions.

The Academy also supports CMS's continued labor-related share of 50.673 percent that recognizes the enhanced role of RDNs and other providers in improving outcomes and promoting therapy adherence, including dialysis treatments, dietary recommendations, and medication regimes.

B. Ultrafiltration Rate Reporting Measure

The Academy supports CMS's proposed ultrafiltration rate reporting measure pursuant to its authority under section 1881(h)(2)(B)(ii) of the Social Security Act. The ultrafiltration rate reporting measure has been studied for some time and the consensus is that rates higher than 13 ml/hr/kg increase the risk of cardiovascular mortality in patients.2 Rapid ultrafiltration is associated with nausea, vomiting, headache, fatigue, cramping, hypotensive episodes during dialysis, and feeling sick after dialysis. Patients remain fluid overloaded, which then causes poor blood pressure control leading to left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality.

We support efforts by CMS to ensure that time of dialysis should be adjusted in such a way that patients would not suffer from symptoms related to rapid ultrafiltration. Monitoring Kt/V solely instead of taking into consideration the greater role of fluid management and removal is likely to result in more problems and sickness for patients, potentially impacting quality of life. While correction of uremia remains important, limiting our focus on the rate of fluid removal is to the detriment of our patients, leading to an increase in the risk of cardiovascular death. The Academy is mindful of the need to pursue a rate that further lowers the mortality rate in our patient population.

C. Drug Designation Process

The Academy recognizes the additional costs and benefits associated with furnishing new injectable and intravenous renal dialysis services not currently reflected in the ESRD PPS bundled payment, and agrees that the benefits of new injectables must be accounted as an increase in the bundle. Academy members' experiences confirm recent research, which show that oral-only calcimimetics increase patients' pill burden. These are dependent upon the physician's willingness to prescribe them, are costly, are not demonstrably cost-effective in the long-term,3,4 and that their use is dictated by patients' tolerance and willingness to regularly take the medications that may not be assuredly proven to enhance quality or length of life (even with a concomitant decrease in parathyroidectomy surgeries).5,6

The Academy notes that we can expect approval of new injectables that will be used to treat or manage CMS's bone and mineral metabolism category. Although calcimimetics are presently oral-only drugs, effective IV calcimimetics have successfully completed stage 3 clinical trials that should make them available in the very near future. In fact, the Food and Drug Administration (FDA) approved a new drug application from Amgen on August 25, 2015 for its injectable calcimimetic: Etelcalcetide.7 These promising new injectables are likely to reduce or discontinue the use of oral-only calcimimetics. We appreciate CMS's recognition that it must implement "a drug designation process for: (1) Determining when a product is no longer an oral-only drug, and (2) including new injectable and intravenous renal dialysis service drugs and biologicals into the bundled payment under the ESRD PPS."

D. Updates to the Clinical Measures for Hypercalcemia

The Academy remains concerned about the proliferation of quality measures generally and appreciates CMS's willingness to review measures used in the ESRD QIP for reasonableness. We recognize the statutory mandate in The Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93) requiring the Secretary to adopt measures in the ESRD QIP that are specific to the conditions treated with oral-only drugs for 2016 and subsequent years, but have concerns about whether the proposed hypercalcemia clinical measure can be appropriately characterized as a measure specific to conditions treated with oral-only drugs either (1) at present or (2) for the PY 2018 ESRD QIP.

Our first concern is that hypercalcemia is not presently a condition only treated with oral-only drugs. Hypercalcemia may be treated with calcimimetics or bisphosphonates or Anti-RANKL agents (i.e., intravenous osteoporosis drugs that can lower calcium levels quickly and help rebuild weakened bone). The latter option, however, is not always feasible in anuric dialysis patients and is more of an acute treatment.

The Academy's second concern is that hypercalcemia might be treated with a calcimimetic when the calcium has risen due to treatment with active Vitamin D, which is typically given intravenously during hemodialysis. The Academy questions whether the regular use of IV Vitamin D in conjunction with calcimimetics (that are as of now "oral-only") for a patient's hypercalcemia negates the inclusion of that patient as having a condition treated with oral-only drugs.

The Academy recommends that CMS continue to track hypercalcemia, but believes that linking hypercalcemia to specific medications without including the influence of active Vitamin D is problematic and is unlikely to provide reliable data. In addition, the likelihood of FDA approval of new injectables to treat hypercalcemia before the PY 2017 collection period begins requires CMS to reconsider its proposed approach. Renal bone disease is a complex problem that is also significantly impacted by length and type of dialysis treatment, nutrition, and length of time with chronic kidney disease (prior to and when on dialysis).

E. Comprehensive ESRD Care (CEC) Model and Future Payment Models

1. How could participants in alternative payment models (APMs) and advanced alternative payment models (AAPMs) coordinate care for beneficiaries with chronic kidney disease and to improve their transition into dialysis?

The Academy supports alternative payment models focused on providing value-based care, particularly where, as here, they can bridge a gap in the coordination of effective care. CMS and patients receive the best value when 1) the degree and duration of patient well-being is maximized, 2) disease progression is prevented or delayed, and 3) communication between all parties is effective, efficient and transparent. Substantial evidence confirms nutrition is a key driver of CKD patient well-being and disease stability. Thus, CMS should ensure patients are referred to an RDN with concomitant reimbursement for MNT to directly impact short-term well-being as well as long-term disease progression. Referral and MNT should occur as soon as possible after diagnosis and no later than CKD Stage 3 or 4.8 The referral process to an experienced RDN should be as efficient as possible and should include provider verification of patient understanding and post-referral follow-up. Additionally, alternative payment models should include provider incentives for referral and subsequent improvement in clinical parameters.

2. How could participants in APMs and AAPMs target key interventions for beneficiaries at different stages of chronic kidney disease?

Automatic referral to an experienced RDN should be completed upon diagnosis of any stage CKD, which would promote utilization of the Medicare benefit for the purpose of delaying progression of disease, preventing/treating complications including malnutrition, improving quality of life, and reducing healthcare costs.9 At early stages (through Stage 2), providers should reinforce the recommendations from the RDN, specifically focusing on controlling the risk factors associated with CKD (e.g., diabetes and hypertension) and addressing any food insecurity concerns arising through a nutrition screening and assessment. Patients should be counseled to control intakes of sodium, refined carbohydrates and sugars; and optimize intake of fruits, vegetables, beans and whole grains, manage stress and engage in regular physical activity 3-4 times/week. At Stages 3 and 4, recommendations should shift to delaying progression to end-stage, and managing the developing co-morbidities (e.g., anemia, bone loss, concerns about mineral intakes). Specifically, this should include emphasis on reducing protein intake to 0.6 g/kg/day – 0.8 g/kg/day and 0.7 g/kg/day for people with diabetes and limiting phosphorus and potassium intakes.10,11

3. How could participants in APMs and AAPMs better promote increased rates of renal transplantation?

The Academy recommends building work flow into the electronic health record that facilitates automatic referral of all potential transplant candidates (if medically appropriate) as the default care plan as eGFR declines. Timelier referral, preferably when eGFR of 30 is noted, is recommended in OPTN (Organ Procurement and Transplantation Network) guidelines as patients begin accruing wait time at eGFR 20 if they are already approved for wait listing by the transplant center. The longer referral is delayed, the lower the chances are of the patient progressing toward successful transplant in a timely manner.12

4. How could CMS build on the CEC Model or develop alternative approaches for improving the quality of care and reducing costs for ESRD beneficiaries?

Since costs per ESRD patient (dialysis and transplants) may be as much as 3.5 times that per CKD patient,13 limiting costs while providing effective care and beneficial outcomes is contingent upon reducing the frequency of progression to end-stage renal disease. Delaying MNT referrals to Stage V patients not only reduces quality of outcomes, but necessarily increases costs. However, the Medicare MNT benefit for CKD is significantly underutilized,14 and the Academy seeks an opportunity to discuss with CMS strategies for streamlining and strongly incentivizing or mandating referrals for MNT to save money and improve care. Without enhanced utilization of MNT, costs can only be expected to increase with stagnant or declining quality of outcomes.15

Protocols for pre-dialysis MNT must also be adjusted, given the substantial evidence that RDN-provided MNT improves health and reduces costs. It is the position of the Academy that "long-term high intakes of dietary protein (above 0.8 g/kg/day for a person with kidney disease not undergoing dialysis or above the Dietary Reference Intake for protein of 0.9 g/kg/day for people with diabetes) from either animal or vegetables sources, may worsen existing chronic kidney disease or cause renal injury in those with normal renal function. This may be due to the higher glomerular filtration rate associated with a higher protein intake."16 Other sources also confirm that a low protein diet should be the "recommended nutritional intervention for non-dialysis" patients.17 Soy protein, specifically, may improve serum parameters indicative of renal damage, even if function is already impaired,18 and may delay progression to ESRD.19

As a result of reduced protein intake, patients consuming vegetarian diets are also likely to produce fewer uremic toxins, which may produce better outcomes. In one study, such patients were found to have lower serum concentrations of two toxins, indoxyl sulfate and p cresyl sulfate,20 which increase the rate of disease progression21 and are indicative of poor outcomes.22 Vegetarian diets may also increase outcome quality by reducing inflammatory processes and optimizing overall nutrient delivery.23 Plant-based diets may also reduce phosphate absorption, despite absolute content, thus limiting the risk of adverse serum phosphorus levels.24 Additionally, phosphorus excretion appears to be more efficient in CKD patients on vegetarian diets.25 Being able to consume appealing diets of sufficient quality and quantity without adversely affecting serum parameters is a key quality-of-life measure for CKD patients. RDNs' expertise can guide the patient on how to integrate these multiple parameters.

6. How could primary-care based models better integrate with APMs or AAPMs focused on kidney care to help prevent development of chronic kidney disease in patients and progression to ESRD? Primary-care based models may include patient-centered medical homes or other APMs.

The Academy supports models that more effectively target the top two causes of CKD (diabetes and hypertension) and focus resources on early treatment for prevention of renal complications and delay of progression. Including automatic MNT referrals at diagnosis of diabetes, hypertension, and CKD will delay progression of ESRD, prevent and treat complications including malnutrition, improve quality of life, and reduce healthcare spending.26

7. How could APMs and AAPMs help reduce disparities in rates of CKD/ESRD and adverse outcomes among racial/ethnic minorities?

The disproportionate prevalence of the prime risk factors for renal failure (hypertension and diabetes) in African-Americans, and poor knowledge of the effects of these risk factors produces disproportionate prevalence of renal failure, increased risk of progression to end-stage and increased risks of implications of poor care.27 These significant racial and ethnic disparities not only in rates of CKD and in adverse outcomes, but also in patients' knowledge and understanding of CKD risk factors.28 This trifecta suggests an even greater importance in promoting and incentivizing early prevention and education programs29 for other populations, with a particular focus on accessibility. Widespread screening programs should be implemented in Federally Qualified Health Centers (FQHCs) with suitable incentives not only for screening, but for clinical improvement. Given the disparities in prevalence and risk, inclusion of an RDN skilled in MNT for pre-dialysis renal disease should be mandated or incentivized in all FQHCs. Contingent upon proper supervision of content, community nutrition education and wellness programs such as the Diabetes Prevention Program or intensive behavioral therapy for hypertension should be expanded to meet this important need before expensive Medicare coverage is triggered.30>

8. Are there innovative ways for APMs and AAPMs to facilitate changes in care delivery to improve the quality of life for CKD and ESRD patients?

The Academy encourages CMS to shift the existing payment model to a model which would provide resources for prevention, including automatic referral to RDNs for evidence based MNT at the diagnosis of renal disease. CMS should also endeavor to identify successful models in which nephrologists either share practice space or directly hire RDNs to maximize referral efficiency, enhance access to effective nutrition care, and limit patients failing to show for treatment after referral. We also encourage CMS to evaluate the amount of time spent by RDNs in administration and care coordination in addition to direct patient care and whether adequate compensation exists for these administrative responsibilities.31

9. Are there specific innovations that are most appropriate for evaluating patients for suitability for home dialysis and promoting its use in appropriate populations?

The Academy recognizes the value and importance of home dialysis options and looks forward to the opportunity to work with CMS to promote and develop models that will maximize the access to all home options to all patients, with proper nutrition engagement and follow-up.

10. Are there specific innovations that could most effectively be tested in a potential mandatory model?

As detailed above, given the effectiveness of MNT to improve outcomes and limit costs, CMS should consider mandating early referral for MNT at or before CKD Stage 3 with continued care to dialysis. Such referral, along with successful follow-up by the patient, can be easily monitored by existing reporting procedures.

F. Conclusion

The Academy sincerely appreciates the ongoing opportunity to offer comments regarding the ESRD PPS and associated future payment models. Please contact either Jeanne Blankenship by telephone at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma by telephone at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int. 2011;79(2):250-7.

3 Narayan R, Perkins RM, Berbano EP, et al. Parathyroidectomy versus cinacalcet hydrochloride-based medical therapy in the management of hyperparathyroidism in ESRD: a cost utility analysis. Am J Kidney Dis. 2007;49(6):801-13 ("In conclusion, in this analysis, we found that in patients with hyperparathyroidism refractory to conventional medical therapy who were candidates for either parathyroidectomy or cinacalcet therapy, the cost and cost utility of cinacalcet was most advantageous for patients who could expect a brief stay (16 months) on dialysis therapy.  This would include those with a high risk of mortality or those who could expect to receive a transplant quickly. For other sub-groups, parathyroidectomy dominated.").

4 Narayan R, Perkins RM, Berbano EP, et al. Parathyroidectomy versus cinacalcet hydrochloride-based medical therapy in the management of hyperparathyroidism in ESRD: a cost utility analysis. Am J Kidney Dis. 2007;49(6):801-13.

5 Ballinger AE, Palmer SC, Nistor I, Craig JC, Strippoli GF. Calcimimetics for secondary hyperparathyroidism in chronic kidney disease patients. Cochrane Database Syst Rev. 2014;12:CD006254.

6 Tentori F, Wang M, Bieber BA, et al. Recent changes in therapeutic approaches and association with outcomes among patients with secondary hyperparathyroidism on chronic hemodialysis: the DOPPS study. Clin J Am Soc Nephrol. 2015;10(1):98-109.

7 FDA Accepts Amgen's New Drug Application For Novel Intravenous Calcimimetic Etelcalcetide. PR Newswire. Available at http://www.prnewswire.com/news-releases/fda-accepts-amgens-new-drug-application-for-novel-intravenous-calcimimetic-etelcalcetide-300174208.html.  November 6, 2015.  Accessed August 21, 2016.

8 de Waal D, Heaslip E and Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers & Slows Time to Dialysis, J Renal Nutr, 26(1) Jan 2016, pp 1-9; Slinin Y1, Guo H, Gilbertson DT, Mau LW, Ensrud K, Collins AJ, Ishani A.  Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.  Am J Kidney Dis. 2011 Oct;58(4):583-90.

9 De waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. J Ren Nutr. 2016;26(1):1-9.

10 Craig WJ1, Mangels AR; American Dietetic Association.  Position of the American Dietetic Association: vegetarian diets.   J Am Diet Assoc. 2009 Jul;109(7):1266-82.

11 Evidence Analysis Library.  Accessed August 21, 2016.  Available at http://www.andeal.org/template.cfm?key=2409.

12 HHS website. OPTN Minority Affairs Committee.  Education Guidance on Patient Referral to Kidney Transplantation.  Accessed August 21, 2016.  Available at https://optn.transplant.hrsa.gov/resources/guidance/educational-guidance-on-patient-referral-to-kidney-transplantation/.

13 de Waal D, Heaslip E and Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers & Slows Time to Dialysis, J Renal Nutr, 26(1) Jan 2016, pp 1-9.

14 Slinin Y1, Guo H, Gilbertson DT, Mau LW, Ensrud K, Collins AJ, Ishani A.  Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.  Am J Kidney Dis. 2011 Oct;58(4):583-90

15 De waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. J Ren Nutr. 2016;26(1):1-9.

16 Craig WJ1, Mangels AR; American Dietetic Association.  Position of the American Dietetic Association: vegetarian diets.   J Am Diet Assoc. 2009 Jul;109(7):1266-82.

17 Cristiane Moraes, Denis Fouque, Ana Claudia F. Amaral, Denise Mafra.  Trimethylamine N-Oxide From Gut Microbiota in Chronic Kidney Disease Patients: Focus on Diet.  J Renal Nutr. Nov 2015., 459-465. 

18 Azadbakht L, Atabak S, Esmaillzadeh A.  Soy protein intake, cardiorenal indices, and C-reactive protein in type 2 diabetes with nephropathy: a longitudinal randomized clinical trial.  Diabetes Care. 2008 Apr;31(4):648-54.

19 Craig WJ1, Mangels AR; American Dietetic Association.  Position of the American Dietetic Association: vegetarian diets.   J Am Diet Assoc. 2009 Jul;109(7):1266-82.

20 Kandouz S, Mohamed AS, Zheng Y, Sandeman S, Davenport A.  Reduced protein bound uraemic toxins in vegetarian kidney failure patients treated by haemodiafiltration.  Hemodial Int. 2016 Apr 4.

21 "Metabocard for Indoxyl sulfate" http://www.hmdb.ca/metabolites/HMDB00682, accessed Aug 18, 2016

22 Meijers BK, Evenepoel P. The gut-kidney axis: indoxyl sulfate, p-cresyl sulfate and CKD progression. Nephrol Dial Transplant. 2011 Mar;26(3):759-61.

23 Steiber AL.  Chronic kidney disease: considerations for nutrition interventions.  JPEN J Parenter Enteral Nutr. 2014 May;38(4):418-26.

24 Chauveau P, Combe C, Fouque D, Aparicio M.  Vegetarianism: advantages and drawbacks in patients with chronic kidney diseases.  J Ren Nutr. 2013 Nov;23(6):399-405.

25 Moe SM, Zidehsarai MP, Chambers MA, Jackman LA, Radcliffe JS, Trevino LL, Donahue SE, Asplin JR.  Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.  Clin J Am Soc Nephrol. 2011 Feb;6(2):257-64. 

26 NKDEP/NIDDK, MNT for CKD Improves Biomarkers & Slows Time to Dialysis, JRN Jan 2016; De waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. J Ren Nutr. 2016;26(1):1-9.

27 Regunathan-Shenk R, Hussain FN, Ganda A.   Chronic kidney disease and end-stage renal disease in disadvantaged communities of North America: an investigational challenge to limit disease progression and cardiovascular risk.  Clin Nephrol. 2016 Jul 29.
Wu B, Bell K, Stanford A, Kern DM, Tunceli O, Vupputuri S, Kalsekar I, Willey V.  Understanding CKD among patients with T2DM: prevalence, temporal trends, and treatment patterns-NHANES 2007-2012.  BMJ Open Diabetes Res Care. 2016 Apr 11;4(1):e000154
Kazley AS, Johnson E, Simpson K, Chavin K, Baliga P.  African American patient knowledge of kidney disease: A qualitative study of those with advanced chronic kidney disease.  Chronic Illn. 2015 Dec;11(4):245-55.
Horowitz B, Miskulin D, Zager P.   Epidemiology of hypertension in CKD.  Adv Chronic Kidney Dis. 2015 Mar;22(2):88-95.
Porter A, Fischer MJ, Wang X, Brooks D, Bruce M, Charleston J, Cleveland WH, Dowie D, Faulkner M, Gassman J, Hiremath L, Kendrick C, Kusek JW, Norris KC, Thornley-Brown D, Greene T, Lash JP; AASK Study Group.  Quality of life and outcomes in African Americans with CKD.  J Am Soc Nephrol. 2014 Aug;25(8):1849-55.
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28 Id.

29 Kazley AS, Johnson E, Simpson K, Chavin K, Baliga P.  African American patient knowledge of kidney disease: A qualitative study of those with advanced chronic kidney disease.  Chronic Illn. 2015 Dec;11(4):245-55.

30 DASH – Dietary Approaches to Stop Hypertension - Diet and Risk of Subsequent Kidney Disease, published online August 9, 2016 by NKF in Am J Kidney Dis.

31 Hand RK and Burrowes JD. Renal Dietitians' Perceptions of Roles and Responsibilities in Outpatient Dialysis Facilities.  J Renal Nutr, Vol 25, No 5 (September), 2015: pp 404-411.