What to Know About Telehealth for Kidney Disease

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The COVID-19 pandemic provided unique challenges for people living with kidney disease, particularly those with advanced chronic kidney disease (CKD) who are at risk of serious complications from coronavirus infection.

Telehealth, initially seen as a means to alleviate the burden on overstressed healthcare systems, is now regarded as a viable and effective tool to manage many chronic health conditions, including kidney disease.

woman with renal failure adjusting tube of her glucose meter at her stomach while speaking with her doctor online
YakobchukOlena / Getty Images

Telehealth is not without its challenges and limitations. But, when used appropriately with the right tools and technologies, it can provide people with kidney disease high levels of care and oversight, even those on home dialysis.

Telehealth can also be used to monitor recovery from an acute kidney injury (AKI) or make life easier for those who would otherwise have to travel long distances to see a nephrologist.

When to Use Telehealth for Kidney Disease

When people hear about kidney disease, they most often take it to mean chronic kidney disease, a progressive condition in which the kidneys are less able to filter the blood as they should. But nephrologists also treat acute kidney injuries (also known as acute renal failure), which can suddenly develop for many reasons.

Generally speaking, telehealth is best suited to remotely monitor the care of people being treated for CKD or recovering from AKI. This is largely described as ambulatory care, which involves observation, consultation, treatment, rehabilitation, and intervention.

Telehealth cannot entirely replace in-person care, particularly for people with late-stage CKD who are undergoing dialysis. With that said, nephrology-specific telehealth tools are even making those individuals easier to manage remotely.

Telehealth and CKD

One of the biggest challenges in managing CKD is access to care. Currently, around 20% of people in the United States live in rural communities where there is a high prevalence of CKD but limited access to nephrology-specific care. And this is a problem.

According to a 2020 study published in the American Journal of Kidney Disease, the majority of nephrologists reside in urban centers where there is only a moderate incidence of CKD.

Because of this, people in rural communities often have to travel long distances to hospitals or clinics for routine diagnostics or dialysis treatment—a task that is not only time consuming but expensive.

Much of this burden can be lifted with nephrology-specific telehealth services. Some of the telehealth services offered to people with CKD include:

  • Initial consultations: The diagnosis of CKD can be a protracted process involving lab tests, physical exams, imaging tests, and an assessment of risk factors. Telehealth allows doctors to review the results remotely once they are compiled and formulate a treatment plan without the need for an in-office visit.
  • Glucose monitoring: For people undergoing dialysis, continuous glucose monitoring is vital as it influences how well creatinine and other waste products are being removed during the procedure. Wearable glucose monitoring devices can measure glucose and hemoglobin A1C, and feed the results live or asynchronously to the telehealth provider.
  • High blood pressure: Hypertension (high blood pressure) is a major cause of CKD, and the ongoing control of blood pressure is central to the management of the disease. Wearable blood pressure monitoring tools can be attached to your mobile device to deliver real-time readings during the telehealth visit.
  • Follow-up visits: Telehealth allows you to get bloodwork or imaging tests performed locally, which can be compiled and reviewed during your consultation. These findings, along with a review of symptoms, can often provide enough evidence to change treatment without the need for a hands-on exam.
  • Home dialysis: Peritoneal home dialysis uses the lining of your abdomen (peritoneum) to filter your blood. It is an option for some people with end-stage renal disease (ESRD) and generally comes with 24/7 access to a nephrology nurse. Telehealth expands upon these services by providing real-time monitoring of vital signs and glucose control.
  • Postoperative rehabilitation: People who have undergone a kidney transplant will invariably have impaired immunity and require immunosuppressants to avoid organ rejection. Telehealth allows multiple providers to participate in the rehabilitation process without the undue risk of infection to the recipient.
  • Lifestyle management: Managing CKD often involves lifestyle changes (such as weight loss and smoking cessation) and dietary changes to address deteriorations in kidney function. Telehealth enables other providers, such as dietitians and counselors, to participate in the holistic management of kidney disease.
  • Kidney cancer: While an oncologist will oversee the treatment of kidney cancer, a nephrologist may play a role in monitoring renal function, optimizing blood pressure, and participating in treatment decisions. Telehealth is the ideal way to ensure coordination and interaction among multiple care providers.

Telehealth services can be individualized based on the underlying cause, including glomerulonephritis, interstitial nephritis, polycystic kidney disease, vesicoureteral reflux, prolonged renal obstruction, recurrent pyelonephritis, and certain autoimmune diseases (like lupus).

Telehealth and AKI

Acute kidney injury can occur for many reasons, including some of the same ones involved with CKD. The three main causes of AKI are:

  • A sudden drop in blood flow to the kidneys caused by an injury, heavy blood loss, a heart attack, sepsis, or other causes
  • The sudden blockage of urine from the kidneys caused by kidney stones, severe urinary tract infections, or other causes
  • Exposure to toxic substances that impair kidney function, including certain medications, contrast agents, and poisons

Telehealth can be used effectively during the home recovery stage of an acute kidney injury. Depending on the cause, the nephrologist may participate alongside other practitioners, such as a primary care physician or cardiologist.

Nephrologists are typically sought whenever there are symptoms of kidney failure and/or tests (such as estimated glomerular filtration rate or urine albumin/creatinine ratio) indicate kidney failure.

When to Seek In-Person Care

Telehealth is not intended as a substitute for the diagnosis of any kidney condition or when severe symptoms occur. Seek emergency care if you experience signs and symptoms of kidney failure, including:

  • Sudden difficulty urinating or the inability to urinate
  • Swelling in the legs, ankles, or feet
  • Nausea or vomiting
  • Dizziness or fainting
  • Confusion or “brain fog”
  • Shortness of breath
  • Chest pain or pressure
  • Irregular heartbeat

Benefits and Challenges

Telehealth has quickly gained acceptance among doctors and patients alike. From the nephrologist’s perspective, it increases patient outreach and retention with little increase in staff hours. Studies also show that it reduces the number of “no-shows” and avoids unnecessary referrals from family physicians.

From the patient’s perspective, telehealth has many pros but also several cons that limit its usefulness in certain people.

Benefits

The benefits of telehealth extend beyond the fact that it makes life easier. An increasing body of evidence suggests that it translates to improved health outcomes in some people.

The advantages of telehealth in people with kidney disease include:

  • Convenience: Telehealth eliminates travel time and expense, plus the cost of childcare or eldercare. It can be ideal for people with late-stage CKD who often have impaired mobility. People are also less likely to skip appointments if they don’t feel well enough to travel.
  • Choice: In the past, people in rural areas had a limited choice of nephrologists to work with. With telehealth, they can now work with doctors in different cities and even seek a second opinion from nephrologists in different states.
  • Safety: In the age of COVID-19, telehealth supports social distancing and the avoidance of infection—of special concern to transplant recipients or people with ESRD who may be severely immunocompromised.
  • Cost: Although the cost of telehealth services can vary significantly, it appears to reduce overall costs due to the reduction of travel expenses and the avoidance of service duplication. According to a 2018 study in Transplantation, people with ESRD pay an average of 41% less if using telehealth services than those who don’t.
  • Group teleconferencing: Telehealth can enable the participation of multiple providers during the virtual visit, reducing miscommunications and better enabling informed consent. It also allows family members, friends, or health advocates to sit in on the consultation, especially if the person is infirm.
  • Asynchronous consultation: Not every health concern requires a live consultation. Some non-urgent matters can be addressed with asynchronous messaging between one or more linked providers. Some “store-and-follow” systems allow multiple people to contribute reports or images that can then be viewed collectively by the treating specialist.
  • Reduced hospitalizations: A 2013 review of studies in Telemedicine Journal and E-Health reported that people with ESRD who utilized nurse-led telehealth had better health outcomes and fewer hospitalizations than those who relied solely on in-person care.
  • Better glucose control: A 2015 Cochrane review of studies concluded with a high level of certainty that people with diabetes who utilized telehealth had significantly lower hemoglobin A1C levels after nine months than those who didn’t. This has a significant impact on people with late-stage CKD, influencing disease progression and the need for dialysis.

Challenges

Telehealth is not a one-size-fits-all solution. Some people have structural limitations that make telehealth less than ideal, while telehealth itself has limitations on what it can and cannot achieve medically.

Some of the key challenges include:

  • Lack of broadband access: Even today, nearly 7% of the United States population (roughly 24 million people) have no access to broadband services. For those who do, spotty Internet connection, poor host reliability, and outdated hardware/software can make telehealth visits difficult to impossible.
  • Cost: However cost effective telehealth is, high copay and coinsurance costs may still be a burden for those with insurance. For people without insurance, telehealth may be unattainable. Low-income people in the United States are 40% less likely to access telehealth due to affordability (including acquiring a mobile device or broadband services).
  • Diagnostic limitations: Kidney disease has many causes, and the physical exam plays a central role in the initial diagnosis as well as in the evaluation of side effects and complications. Moreover, people with CKD often have multiple comorbidities, such as liver and heart diseases, the symptoms of which may be missed when telehealth is overused.
  • Durable treatment response: There are some mixed findings regarding telehealth’s long-term efficacy in nephrology. Studies have shown blood pressure control among telehealth users with hypertension may improve over the short term, but often steadily decline over the long term. This can have dire consequences for people with ESRD.
  • Security: Internet security remains a concern, particularly for those who don’t readily use the Internet. The temporary decision by the Centers for Medicare and Medicaid Services to relax HIPAA requirements and allow consultations with everyday tools like Skype and FaceTime may increase access, but they raise concerns about data security and privacy.

Will Insurance Cover Telehealth for Kidney Disease?

The decision by the Centers for Medicare and Medicaid Services to pay for telehealth services at the same rate as in-person visits was intended to increase access to not only primary care services, but specialist care services as well.

Even so, the cost of telehealth can vary considerably depending on which type of insurance coverage you have:

  • Medicare: Medicare Part B covers certain telehealth services with deductibles. With Original Medicare, you pay 20% of the Medicare-approved amount. With Medicare Advantage Plans, benefits and coverage may be expanded. Check your plan to see which telehealth services are covered.
  • Medicaid: Telehealth benefits for Medicaid and the Children’s Health Insurance Program (CHIP) vary by state. Even if a state decides to cover telehealth, it may only do so for certain providers. Call your state Medicaid office for more information.
  • Private insurance: Telehealth benefits for private insurance (including employer-sponsored health insurance) vary. While more private insurers offer telehealth for primary or urgent care, they may not do so for specialists like nephrologists. Check with your insurer to see which services are covered (including copay/coinsurance costs for in-network or out-of-network providers).

Audiovisual vs. Audio-Only Telehealth

Medicare and Medicaid currently only cover certain audio-only telehealth services, including diabetes managementspeech therapy, psychotherapy, smoking cessation, and alcohol/opioid treatment. Other telehealth services typically require audiovisual communication.

To avoid a benefits denial, contact the Centers for Medicare and Medicaid Services hotline at 1-800-633-4227 to confirm that your audio-only telehealth visit is covered.

How to Prepare for a Telehealth Visit for Kidney Disease

A telehealth appointment involves a few more preparations than what is required for a traditional in-office visit. These preparations can ensure your appointment goes smoothly and that you receive the best care possible.

Choosing a Doctor

If your nephrologist offers telehealth services, you are pretty much all set. You simply need to check that their services are covered by your insurance and that a virtual visit is appropriate for your condition.

If you don’t have a nephrologist, many insurance companies offer a directory of in-network specialists. Your primary care physician can also provide referrals. You can then call the office directly and ask what telehealth services, if any, are offered.

You will also need to ask:

  • What type of telehealth service do they provide? Is it audio-only, a one-on-one Skype-like call, or a multi-screen portal with image/file sharing? Depending on your needs, some services may be more appropriate than others.
  • Who will you be seeing? Will it be the nephrologist, a nurse practitioner, or another member of the care team? Again, different concerns require different personnel.
  • What costs are involved? The staff member should be able to confirm that they accept your insurance, what out-of-pocket costs you can expect, and what forms of payment they accept for copay or coinsurance.
  • What do they need in advance of the visit? This may include intake and consent forms (usually delivered by email or completed via a secure portal). They may request updated bloodwork or a copy of your most recent ultrasonography scan if you are a new patient. Providing everything they need in advance can save time on the day of your appointment.

Preparing for the Visit

You need to do several things a day or two in advance of your appointment to ensure that there are no glitches. Among them:

  • Check that your broadband connection is working. You can organize a test run with a friend to see how smoothly a Skype, FaceTime, or Zoom call goes. You can also adjust the volume and ensure that your camera is set at the highest resolution.
  • Prepare your space. Find a quiet, private, well-lit place in your home. Avoid sitting in front of a sunny window, as you will likely blackout on the provider’s screen.
  • Prepare everyone in the house. Let everyone know what time your appointment is so you won’t be interrupted. This includes turning down the TV, music, or video games for the duration of your visit. If someone plans to join you, make sure they arrive at least 15 minutes before the appointment.
  • Prepare questions. This ensures that you don’t forget anything during the visit. You can also add questions that come up during the call that you can share at the end of your appointment.
  • Dress for the appointment. If you’re going to need a blood pressure reading during the visit or have physical symptoms to share, wear clothes that you can easily remove, lift, or unbutton.
  • Prepare a list of your providers. This includes the name, address, email address, telephone number, and fax number of your primary care provider, pharmacy, or other specialists involved in your care. If you need lab reports shared or prescriptions filled, having this information on hand can help you avoid scrambling at the last minute.

What Happens During the Visit

Telemedicine visits are typically conducted using secure Internet technology that transmits voice, images, and sound. Some nephrologists employ user-side tools that allow them to remotely monitor blood pressure and glucose levels or listen to your heartbeat using a virtual stethoscope.

A telehealth visit with a nephrologist follows the same basic steps as any other telehealth appointment:

  1. You will usually be contacted by a staff member 15 to 30 minutes in advance of your appointment to confirm that you are ready and to take any upfront payment by credit card or debit card.
  2. A link will be sent to your smartphone (by text) or laptop (by email) to connect you to the secure portal. Once you are signed in, you will wait in the virtual “waiting room.”
  3. You will then be greeted by a doctor, nurse, or other healthcare professional who will review your case in the same way they would any in-person visit.
  4. If a virtual examination of any sort is needed, the provider will walk you through the steps. This may involve taking a live blood pressure reading or remote “snapshots” for close inspection.
  5. If lab reports or imaging scans are reviewed, ask what the findings mean. Be sure that the reports are copied to your primary care provider and any other relevant specialists.
  6. If you have any additional questions, don’t hesitate to ask. Be sure to take notes so that you don’t forget what has been said.
  7. The provider will then summarize what has been discussed, including any tests, procedures, treatments, or follow-up visits you have agreed to.
  8. If a follow-up appointment is needed, a member of the care team will schedule a date and time and send you an email or text to confirm.
  9. If medications are prescribed, a member of the care team will need the name, address, and phone number of the pharmacy you use.
  10. If further tests are needed, a member of the care team will provide you with instructions on where to go, who to contact, and how to prepare. Detailed instructions may also be forwarded by email.

A Word From Verywell

Telehealth services for nephrology have been little used. But with advances in technologies and changes in regulations and insurance coverage, telehealth is fast becoming an attractive option for many people with kidney disease, as well as their providers. It is important to remember, however, that telehealth has its limitations.

In-person visits are not only important when a problem arises, but are useful for assessing things that your doctor may not be able to see on a video monitor—like changes in your mobility or strength, the loss of lean muscle mass, changes in skin texture, or symptoms like restless leg syndrome.

Although you may not recognize these signs yourself, they play an integral part in deciding how treatment is dispensed and what types of supportive care you may need as a person with kidney disease.

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