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Geisinger Kidney Health Research Institute (Nephrology)

About

Kidney disease affects one in every seven adults, and is associated with diminished quality of life and excessive morbidity and mortality. Geisinger Kidney Health Research Institute (KHRI) is dedicated to decreasing the burden of kidney disease through a clinic-based, patient-oriented research program leveraging several system-level assets at Geisinger. Below are key features of research at the KHRI:

Patient-Centered Focus in the Clinical Setting
KHRI focuses its research efforts on objectives and outcomes important to our patients. Patient-reported data collection is being directly integrated with clinical care in order to enhance and inform comparative effectiveness studies designed to improve quality of life and decrease complications of kidney disease. The structure of KHRI is designed to enhance its capabilities as a micro-Learning Healthcare System, defined by the Institute of Medicine as "…one in which progress in science, informatics and care culture align to generate new knowledge as an ongoing, natural by-product of the care experience, and seamlessly refine and deliver best practices for continuous improvement in health and healthcare." The KHRI aims to seamlessly integrate patient-reported information with clinical data, delivering actionable knowledge and improving clinical care.

Multi-Dimensional Research Resources
Complementing the patient-reported data collection in the clinic are several large, Geisinger-wide resources. These include a comprehensive, enterprise-level data warehouse (electronic health record data since 1996), claims data through Geisinger Health Plan and genetic information with bio-banked blood samples via a system-wide project (MyCode established in 2007). More than 113,000 patients (~3,000 with kidney disease at baseline) have been consented for MyCode and have bio-banked blood samples.

Capacity for Longitudinal Study
Kidney disease and its complications typically require many years to develop and progress. The KHRI effort benefits from Geisinger's low, one percent annual out-migration rate. The KHRI sees patients from across the region, covering extensive portions of central and northeast Pennsylvania and northern Maryland (2.6 million people in 44 counties). Together, this degree of stability and longitudinal follow-up allows for robust investigations into disease development, progression and outcomes.

Active areas of research include the following:

  • Risk factors for adverse outcomes
  • Health literacy and outcomes
  • Dietary modification to prevent/treat kidney disease
  • Weight loss to combat kidney disease
  • Population health management

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Leadership

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Investigators

Biostatisticians

Research Support Staff

  • Yule, Christina, BS -- project manager
  • Graboski, Elisabeth, BS -- senior research assistant

Nephrology Associates

  • Anderson, Stacey, MD
  • Bermudez, Maria, MD
  • Bucaloiu, Ion, MD
  • Govindasamy, Rajesh, MD
  • Oncu, Kerim, MD
  • Schultz, Michael, MD
  • Yahya, Taher, MD

KHRI researchers are engaged in projects with other health services researchers, social scientists, dietitians, biostatisticians, informaticists, health economists and geneticists at Geisinger's research institutes and centers.

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Initiatives & Projects

Risk Factors for Adverse Outcomes

Using the large, dynamic Geisinger clinical chronic kidney disease (CKD) cohort and through collaborations with external investigators Chronic Kidney Disease - Prognosis Consortium (CKD-PC), researchers at the KHRI continue to investigate novel approaches to risk identification and prognosis among those with CKD and other kidney conditions. CKD is defined by decreased kidney function or presence of kidney damage, often measured by urinary protein excretion. These efforts have shown that CKD increases the risk of cardiovascular disease, death and end-stage kidney disease. Novel approaches to incorporating longitudinal changes in glomerular filtration rate into risk assessment continue to be an area of focus for the nephrology team. Additional studies have identified dietary factors and obesity as important determinants of urine protein levels, a major risk factor for the development and progression of kidney and cardiovascular diseases. Social determinants play an important role in health as well. A critical research effort of the KHRI investigative team is the development of improved knowledge of the relationship between health literacy and clinical outcomes.

 

Health Literacy Assessment

Health literacy refers to the constellation of skills needed for an individual to function effectively in the healthcare environment and act appropriately on health information. Patients with limited health literacy may have difficulty understanding written medical information, communicating with healthcare providers and navigating the healthcare system. This translates into a series of adverse patient outcomes and increased healthcare costs.

In patients with kidney disease, limited health literacy has been associated with poorer disease understanding, worse blood pressure control, decreased adherence, increased health resource utilization and mortality. Researchers at the KHRI are investigating the relationships between health literacy and health outcomes, and designing interventions to improve both.

 

Dietary Modification to Prevent and Treat Kidney Disease

The KHRI is interested in determining whether dietary modification strategies can prevent or slow progression of kidney disease. Investigators in the KHRI have shown that high phosphorus intake is associated with increased risk of death. One major source of dietary phosphorus is phosphorus-based food additives, which are commonly used by food manufacturers to enhance flavor and other purposes in ready-to-eat foods and beverages. While these additives can significantly increase an individual's daily phosphorus intake, little is known about the effect of dietary phosphorus on kidney health. Dr. Chang is examining the effects of these phosphorus-based additives on kidney health in a collaboration with Johns Hopkins University.

With the help of a multidisciplinary team (renal dietitians, social scientist, nutritional epidemiologist, informaticists), we are developing a smartphone counseling program, FITKIDNEY, to help patients with early kidney disease improve dietary quality through self-monitoring, education, personalized feedback messages and a patient-provider portal to communicate with a renal dietitian. The efficacy of this smartphone counseling program will be evaluated in a future clinical trial to see if FITKIDNEY can improve dietary quality and slow kidney disease progression by using innovative, scalable, remote technology.

 

Weight Loss to Combat Kidney Disease

The prevalence of obesity has risen dramatically in the last few decades, affecting more than one in three adults in the United States. Presence of class II and III obesity [body mass index (BMI) >=35 kg/m2] is associated with a greater than six-fold increased risk for end-stage renal disease. We and others have shown that reductions in weight are associated with decreased urine protein, which is a marker of kidney damage. However, there is little data on long-term effects of weight loss on kidney function. At Geisinger, one in five primary care patients has a BMI >= 35 kg/m2, and over 300 patients undergo bariatric surgery each year. We are conducting retrospective studies to examine the effect of bariatric surgery-induced weight loss and kidney function. Future study includes conducting a prospective study to investigate the effect of bariatric surgery on measured kidney function. Through funding from the National Institutes of Health, we are conducting studies to determine the long-term effects of bariatric surgery on kidney function. Future goals will be to test remote dietary counseling strategies in patients with kidney disease.

 

Population Health Management

The majority of care of patients with chronic kidney disease occurs through primary care providers. Given rising costs of healthcare and the high burden of kidney disease, population health management strategies need to be tested. KHRI researchers are conducting a pilot study using pharmacists to improve kidney disease screening and management. Future goals are to use the electronic health record to improve the management of kidney disease for the entire patient population that Geisinger serves. Geisinger, with its low population out-migration rate, extensive network of primary care clinic sites and integrated healthcare system, is uniquely positioned to take novel approaches in managing kidney disease.

 

Patient Centered Care

Kidney failure affects more than 115,000 U.S. adults every year. Patients who develop this condition must choose from a variety of treatments, such as dialysis or a kidney transplant, each of which has advantages and disadvantages that may vary depending on the individual. Unfortunately, kidney failure often occurs before patients are aware of the extent of their illness, forcing them to quickly make decisions with lifelong consequences without being fully prepared or able to make informed decisions. KHRI researchers are partnering with patients and a team of researchers at Duke and Johns Hopkins to measure the effectiveness of a new healthcare delivery process to improve the care of patients with advanced kidney disease. The PREPARE NOW study will employ a new care strategy to help patients understand their risks of kidney failure, understand their treatment options, obtain needed support and choose treatments that are aligned with their personal values. In a randomized controlled trial, researchers will measure the effectiveness on the new care strategy on patients’ outcomes.

 

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Publications

2016

Wolf JL, Berger A, Clarke D, Green JA, Stametz R, Yule C, Darer JD. Patients, care partners and shared access to the patient portal online practices in an integrated health system. J Am Med Inform Assoc. 2016 MArch 28. pii: ocw025.

Chang AR, Chen Y, Still C, Wood GC, Kirchner HL, Lewis M, Kramer H, Hartle JE, Carey D, Appel LJ, Grams ME. Bariatric surgery is associated with improvement in kidney outcomes. Kidney Int. 2016 May 12. pii:S0085-2538(16)30059-X.

Chang AR, Sang Y, Leddy J, Yahya T, Kirchner HL, Inker LA, Matsushita K, Ballew SH, Coresh J, Grams ME. Antihypertensive medications and the prevalence of hyperkalemia in a large health system. Hypertension. 2016 Jun:67(6):1181-8.

Williams JL, Rahm AK, Stuckey H, Green J, Feldman L, Zallen DT, Bonhag M, Segal MM, Gan AL, Williams MS. Enhancing genomic laboratory reports: A qualitative analysis of provider review. Am J Med Genet A. 2016 May:170(5):1134-41.

Rebholz CM, Anderson CA, Grams ME, Bazzano LA, Crews DC, Chang AR, Coresh J, Appel LJ. Relationship of the American Heart Association's impact goals (Life's Simple 7) with risk of chronic kidney disease: Results from the Atherosclerosis Risk in Communities (ARIC) Cohort Study. J. Am Heart Assoc. 2016 Apr 6:5(4).

Jain D, Green JA. Health literacy in kidney disease: Review of the literature and implications for clinical practice. World J Nephrol 2016 Mar 6:5(2):147-51.

Lazarus B, Chen Y, Wilson FP, Sang Y, Chang AR, Coresh J, Grams ME. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Inter Med, 2016 Feb:176(2):238-46.

Grams MD, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR, Chow EK, Kasiske BL, Kovesdy CP, Nadkarni GN, Shalev V, Segev DL, Coresh J, Lentine KL, Garg AX, Chronic Kidney Disease Prognosis Consortium. Kidney-failure risk projection for the living kidney donor candidate. N Engl J Med. 2016 Feb 4:374(5):411-21.

 

2015

Lazarus B, Chen Y, Wilson FP, Sang Y, Chang AR, Coresh J, Grams ME. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016 Jan 11:238-246. Impact factor of 15.04.

Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR, Chow EK, Kasiske BL, Kovesdy CP, Nadkarni GN, Shalev V, Segev DL, Coresh J, Lentine KL, Garg AX; Chronic Kidney Disease Prognosis Consortium. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med. 2015 Nov 6. Impact factor of 55.873.

Crotty BH, Anselmo M, Clarke DN, Famiglio LM, Flier L, Green JA, Leveille S, Mejilla R, Stametz RA, Thompson M, Walker J, Bell SK. Opening Residents' Notes to Patients: A Two-Institution Qualitative Study of Resident and Faculty Physician Attitudes on Open Notes Implementation in Graduate Medical Education. Acad Med. 2015 Nov 17.

Stuckey H, Williams JL, Fan AL, Rahm AK, Green JA, Feldman L, Bonhag M, Zallen DT, Segal MM, Williams MS. Enhancing genomic laboratory reports from the patients' view: A qualitative analysis. Am J Med Genet A. 2015 Oct;167A(10):2238-43.

Anderson CA, Cobb LK, Miller ER 3rd, Woodward M, Hottenstein A, Chang AR, Mongraw-Chaffin M, White K, Charleston J, Tanaka T, Thomas L, Appel LJ. Effects of a behavioral intervention that emphasizes spices and herbs on adherence to recommended sodium intake: results of the SPICE randomized clinical trial. Am J Clin Nutr. 2015 Sep;102(3):671-9.

Grams ME, Li L, Greene TH, Tin A, Sang Y, Kao WH, Lipkowitz MS, Wright JT, Chang AR, Astor BC, Appel LJ. Estimating time to ESRD using kidney failure risk equations: results from the African American Study of Kidney Disease and Hypertension (AASK). Am J Kidney Dis. 2015 Mar;65(3):394-402.

James MT, Grams ME, Woodward M, Elley CR, Green JA, Wheeler DC, de Jong P, Gansevoort RT, Levey AS, Warnock DG, Sarnak MJ; CKD Prognosis Consortium. Electronic address: ckdpc@jhmi.edu. A Meta-analysis of the Association of Estimated GFR, Albuminuria, Diabetes Mellitus, and Hypertension With Acute Kidney Injury. Am J Kidney Dis. 2015 May 6.

Jain D, Sheth H, Green JA, Bender FH, Weisbord SD. Health literacy in patients on maintenance peritoneal dialysis: prevalence and outcomes. Perit Dial Int. 2015 Jan-Feb;35(1):96-8.

Green JA, Cavanaugh KL. Understanding the influence of educational attainment on kidney health and opportunities for improved care. Adv Chronic Kidney Dis. 2015 Jan;22(1):24-30.

Jain D, Sheth H, Green JA, Bender FH, Weisbord SD. Health literacy in patients on maintenance peritoneal dialysis: prevalence and outcomes. Perit Dial Int. 2015 Jan-Feb;35(1):96-8.

 

2014

Le M, Ravin K, Hasan A, Clauss H, Muchant DG, Pasko JK, Cipollina G, Abanyie F, Montgomery SP, Loy M, Ahmed M, Mathur M, Chokkalingam Mani B, Mehr J, Kotru A, Varma C, Maksimak M, Schultz M, Obradovic G, Alvarez R, Toyoda Y, Birkenbach M, Brunner E, Nelson J. Single donor-derived strongyloidiasis in three solid organ transplant recipients: case series and review of the literature. Am J Transplant. 2014 May;14(5):1199-206.

Weisbord SD, Mor MK, Sevick MA, Shields AM, Rollman BL, Palevsky PM, Arnold RM, Green JA, Fine MJ. Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis. Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1594-602.

Tyson CC, Kuchibhatla M, Patel UD, Pun PH, Chang AR, Nwankwo C, Joseph MA, Svetkey LP. Impact of Kidney Function on Effects of the Dietary Approaches to Stop Hypertension (Dash) Diet. J Hypertens (Los Angel). 2014;3.

Jain D, Sheth H, Bender FH, Weisbord SD, Green JA. Evaluation of a single-item screening question to detect limited health literacy in peritoneal dialysis patients. Adv Perit Dial. 2014;30:27-30.

Chang AR, Grams ME. Serum Phosphorus and Mortality in NHANES III: Effect Modification by Fasting. AJKD. [In Press] Chang AR, Grams ME. Serum Phosphorus and Mortality in the Third National Health and Nutrition Examination Survey (NHANES III): Effect Modification by Fasting. Am J Kidney Dis. 2014 Jun 14.

Coresh J, Turin TC, Matsushita K, Sang Y, Ballew SH, Appel LJ, Arima H, Chadban SJ, Cirillo M, Djurdjev O, Green JA, Heine GH, Inker LA, Irie F, Ishani A, Ix JH, Kovesdy CP, Marks A, Ohkubo T, Shalev V, Shankar A, Wen CP, de Jong PE, Iseki K, Stengel B, Gansevoort RT, Levey AS; for the CKD Prognosis Consortium. Decline in Estimated Glomerular Filtration Rate and Subsequent Risk of End-Stage Renal Disease and Mortality. JAMA. 2014 Jun 3. Impact factor of 35.289.

Perkins RM, Kirchner HL, Matsushita K, Bucaloiu ID, Norfolk E, Hartle JE. Bisphosphonates and Mortality in Women with CKD and the Presence or Absence of Cardiovascular Disease. Clin J Am Soc Nephrol. 2014 May;9(5):874-80.

Erdley SD, Gellis ZD, Bogner HA, Kass DS, Green JA, Perkins RM. Problem-solving therapy to improve depression scores among older hemodialysis patients: a pilot randomized trial. Clin Nephrol. 2014 Apr 22.

Green JA, Gonzaga AM, Cohen ED, Spagnoletti CL. Addressing health literacy through clear health communication: a training program for internal medicine residents. Patient Educ Couns. 2014 Apr;95(1):76-82.

Li L, Chang AR, Rostand SG, Hebert L, Appel LJ, Astor BC, Lipkowitz MS, Wright JT, Kendrick C, Wang X, Greene TH. A within-patient analysis for time-varying risk factors of CKD progression. J Am Soc Nephrol. 2014 Mar;25(3):606-13.

Chang AR, Lazo M, Appel LJ, Gutiérrez OM, Grams ME. High dietary phosphorus intake is associated with all-cause mortality: results from NHANES III. Am J Clin Nutr. 2014 Feb;99(2):320-7.

Jain D, Green JA, Bastacky S, Theis JD, Sethi S. Membranoproliferative glomerulonephritis: the role for laser microdissection and mass spectrometry. Am J Kidney Dis. 2014 Feb;63(2):324-8.

Mor MK, Sevick MA, Shields AM, Green JA, Palevsky PM, Arnold RM, Fine MJ, Weisbord SD. Sexual function, activity, and satisfaction among women receiving maintenance hemodialysis. Clin J Am Soc Nephrol. 2014 Jan;9(1):128-34.

 

2013

Perkins RM, Rahman A, Bucaloiu ID, Norfolk E, DiFilippo W, Hartle JE, Kirchner HL. Readmission after hospitalization for heart failure among patients with chronic kidney disease: a prediction model. Clin Nephrol. 2013 Dec;80(6):433-40.

Kramer H, Chang AR. Moving dietary management of diabetes forward. JAMA Intern Med. 2013 Oct 14;173(18):1692-3.

Perkins RM, Kirchner HL, Hartle JE, Bucaloiu ID. Estimated glomerular filtration rate variability and risk of end-stage renal disease among patients with Stage 3 chronic kidney disease. Clin Nephrol. 2013 Oct;80(4):256-62.

Chang AR, Batch BC, McGuire HL, Vollmer WM, Svetkey LP, Tyson CC, Sanguankeo A, Anderson C, Houston J, Appel LJ. Association of a reduction in central obesity and phosphorus intake with changes in urinary albumin excretion: the PREMIER study. Am J Kidney Dis. 2013 Nov;62(5):900-7.

Chang AR, Appel LJ. Public health: Effects of sodium and potassium intake on health outcomes. Nat Rev Nephrol. 2013 Jul;9(7):376-7.

Norfolk ER, Glazier J, Hamilton E, Maddux FW. Electronic communication and text messaging among nephrology providers. Am J Kidney Dis. 2013 Oct;62(4):656-8.

Green JA, Mor MK, Shields AM, Sevick MA, Arnold RM, Palevsky PM, Fine MJ, Weisbord SD. Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis. Am J Kidney Dis. 2013 Jul;62(1):73-80.

Chang AR, Anderson EE, Turner HT, Shoham D, Hou SH, Grams M. Identifying potential kidney donors using social networking web sites. Clin Transplant. 2013 May-Jun;27(3):E320-6.

Chang AR, Van Horn L, Jacobs DR Jr, Liu K, Muntner P, Newsome B, Shoham DA, Durazo-Arvizu R, Bibbins-Domingo K, Reis J, Kramer H. Lifestyle-related factors, obesity, and incident microalbuminuria: the CARDIA (Coronary Artery Risk Development in Young Adults) study. Am J Kidney Dis. 2013 Aug;62(2):267-75

Schell JO, Green JA, Tulsky JA, Arnold RM. Communication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol. 2013 Apr;8(4):675-80.

Norfolk E, Hartle J. Nephrology care in a fully integrated care model: lessons from the Geisinger Health System. Clin J Am Soc Nephrol. 2013 Apr;8(4):687-93.

Weisbord SD, Mor MK, Green JA, Sevick MA, Shields AM, Zhao X, Rollman BL, Palevsky PM, Arnold RM, Fine MJ. Comparison of symptom management strategies for pain, erectile dysfunction, and depression in patients receiving chronic hemodialysis: a cluster randomized effectiveness trial. Clin J Am Soc Nephrol. 2013 Jan;8(1):90-9.

Jaar BG, Chang A, Plantinga L. Can we improve quality of life of patients on dialysis? Clin J Am Soc Nephrol. 2013 Jan;8(1):1-4. doi: 10.2215/CJN.11861112. PubMed PMID: 23296376.

Yahya TM, Dhanyamraju S, Harrington TM, Prichard JW. Spontaneous resolution of lupus nephritis following withdrawal of etanercept. Ann Clin Lab Sci. 2013 Fall;43(4):447-9.

 

2012

Perkins RM, Tang X, Bengier AC, Kirchner HL, Bucaloiu ID. Variability in estimated glomerular filtration rate is an independent risk factor for death among patients with stage 3 chronic kidney disease. Kidney Int. 2012 Dec;82(12):1332-8.

Chang A, Kramer H. CKD progression: a risky business. Nephrol Dial Transplant. 2012 Jul;27(7):2607-9. doi: 10.1093/ndt/gfs095. Epub 2012 May 3.

Hartle JE, Tang X, Kirchner HL, Bucaloiu ID, Sartorius JA, Pogrebnaya ZV, Akers GA, Carnero GE, Perkins RM. Bisphosphonate therapy, death, and cardiovascular events among female patients with CKD: a retrospective cohort study. Am J Kidney Dis. 2012 May;59(5):636-44.

Bucaloiu ID, Kirchner HL, Norfolk ER, Hartle JE 2nd, Perkins RM. Increased risk of death and de novo chronic kidney disease following reversible acute kidney injury. Kidney Int. 2012 Mar;81(5):477-85.

Green JA, Mor MK, Shields AM, Sevik MA, Palevsky PM, Fine MJ, Arnold RM, Weisbord SD. Renal provider perceptions and practice patterns regarding the management of pain, sexual dysfunction, and depression in hemodialysis patients. J Palliat Med. 2012 Feb;15(2):163-7.

Norfolk E, Hartle J. Nephrology care in a fully integrated care model: lessons from the Geisinger Health System. Clin J Am Soc Nephrol. 2013 Apr;8(4):687-93.

 

 

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Contact Us

Geisinger Nephrology
nephrologyresearch@geisinger.edu

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