This is unpublished

Nisha Bansal

September 13, 2022
Conversation 5


Welcome to Collective Conversations, a series of discussions aimed at highlighting people and groups working to improve health through better health care systems.

Join us in this conversation to learn more about Dr. Bansal's research and expertise on the intersection of kidney and heart disease. I'm confident you'll be eager to hear more updates on her work, in the future.

Joy Lee: To start us off, can you share about your journey to becoming the Director of the Kidney Heart Service at the UW and why you’re dedicating your energy to patients with cardiorenal disease?

Nisha Bansal: I first became interested in the study of cardiorenal disease back when I was a resident. I learned that patients who have kidney disease are more likely to die from cardiovascular causes than of kidney disease. And to me, this was really shocking. And from my work, both in clinical medicine as well as research, I learned that patients with kidney disease have different disease manifestations, different pathophysiology, and therefore, differential responses to traditional cardiovascular treatments, which are different for patients without kidney disease. And that really motivated my interest to study these patients. And the best way to move innovation to the bedside is to integrate new clinical care models. The Kidney Heart Service is a product of that. The goal of the Kidney Heart Service is to provide sub-subspecialized care for patients who suffer from both kidney and heart disease.

JL: For those who may be hearing about it for the first time, could you describe the Kidney Heart Service model? From a patient perspective, how does the service look different than traditional models of care?

NB: The Kidney Heart Service is an inpatient, as well as an outpatient consultation service. It’s led by a group of nephrologists (kidney specialists), who have specialized expertise in the care of kidney and heart disease. And so, what we have learned is that physicians are trained in nephrology and often cardiology, but they don’t often get training about the intersections of these two diseases. And so, the physicians that work on this service actually have unique, distinct expertise in the intersection of these two disease processes. These physicians will see patients who are hospitalized with a kidney or heart condition, as well as see patients in the outpatient setting.

From a patient perspective, I think this has really allowed for a lot of advances. One, like I mentioned, it’s a sub-specialized fund of knowledge that is needed to really think about how these two disease processes are interacting and how that should affect treatment decisions, so we are able to provide a very personalized approach to care for our patients. And two, through this service, we are also able to introduce a lot of innovation into our clinical care models that directly improve the care of patients. For example, we’ve incorporated new evidence-based algorithms of clinical care that have become a routine part of our practice. We’ve introduced new diagnostic testing that we’re using routinely that also enhanced the care that we are able to deliver for our patients.

JL: What are some of the early clinical results you’ve seen after year one?

NB: It’s been an exciting first year. We’ve been really pleased with the outcomes we’ve seen so far.

First and foremost, we are seeing that physicians are talking to each other across specialties, which seems pretty basic in terms of an outcome, but can be remarkably difficult to achieve in the real world when people are so busy and taking care of lots of different patients in different settings. But we’ve really built this strong collaborative, very productive relationship between cardiology and nephrology. So, that’s been really wonderful to see. And those collaborations have resulted in improvements in how we are managing patients and co-managing patients.

Two, like I mentioned, we’ve introduced a lot of new clinical algorithms that are based on evidence and physiology into our practice. And from that, we’ve seen that patients are receiving newer therapies earlier than what we would have anticipated. And preliminarily, we have seen, actually, patients are spending less time in the hospital. So, for patients who have concomitant kidney and heart disease, we have seen shorter lengths of stays by about three days compared to before we started this service.

JL: Given the academic mission, are there any education or scholarship outcomes that you can share?

NB: When we launched this service, we had a three-fold mission. First and foremost, to improve the clinical care of patients who have kidney and heart disease. Two, to augment scholarship opportunities in the study of kidney and heart disease. And three, to train the next generation of physicians and providers who have a passion for caring for patients with kidney and heart disease. And I am pleased that we have been able to really make steps towards achieving each of these goals.

So, we’ve already talked briefly about some of the clinical outcomes we’ve seen. In terms of scholarship, this has been a really exciting time. In the years since we have launched the service, we now have two NIH-funded grants to specifically study patients who are hospitalized with kidney and heart disease. And these grants bring together, again, expertise in many specialties including nephrology, cardiology, pulmonary critical care, bioethics, palliative care medicine, and geriatrics. So, it’s been a really, really exciting collaboration and steps towards improving outcomes in these patients. We have a number of other scholarship activities, which are bringing together providers and experts across disciplines to study other key questions related to this patient population.

In terms of education, that’s an important part of this service. We want to continue to build and train the next workforce who can care for these patients. And so, we have been delighted to see a lot of interest from trainees in participating in this service. Nephrology Fellows, as well as Cardiology Fellows, both participate in this service, which is quite unusual to have trainees from across specialties. And it’s been wonderful to see both of those sets of trainees come through. Then, this summer actually we will be welcoming internal medicine residents onto the service as well. And so, it’s just a wonderful way to learn and train, and to pass knowledge on. And honestly, we learn from them as much as they learn from us, so it has been fun.

JL: What’s the bigger picture for the future of the Kidney Heart Service?

NB: I think the future is that we want to continue to grow. So, this has been a very productive first year. Thinking back to the missions that drive us – the clinical mission, the scholarship mission, and the education mission – we have big goals in each of those domains.

So, for the clinical mission, we want to continue to expand and think about patients who we can serve best by bringing unique expertise. We will continue to monitor outcomes to see what we can be doing better (e.g., where are our opportunities of improvement that we can continue to address).

From a scholarship mission, I think we’re just in the infancy of what we can do with this. This has really created a strong cross-disciplinary platform to think about the important questions and problems that our patients are facing, and how we can answer those questions through scholarship and research and bring those answers back into the clinical setting. So, I see that there has been more interest in delving into some of the issues that we are seeing from a research perspective, and we have several more ongoing research projects.

And then from an educational perspective, we continue to welcome trainees onto the service and will continue to grow and think about innovative models of education as well, which may involve both hybrid inpatient and outpatient models, it may involve scholarship, but really thinking about how we can best train the next generation of physicians as well as scientists that are focused on cardiorenal disease.

So, I think we’re really in a growth phase. What’s fun is that in something like this, because it is so new and there really is no template for it – we are one of the first centers in the country to do something like this – there are a lot of opportunities to adapt and grow as there is a need, and to fill that need.

JL: Even though this series is focused on systems issues, we like to connect topics back to as everyone, including those who may not be in clinical medicine or systems experts. In this case, there seems like an opportunity for people to understand more about cardiorenal disease, and how to talk about it with friends and family who might be at risk or are currently diagnosed. How and where could we look to learn more?

NB: So, there’s lots of great resources. I think education to the community is a big part of what our job is as physicians working in the healthcare system. Kidney disease is often silent – patients don’t realize they have kidney disease. Either in the hospital or outside of the hospital, they don’t have symptoms of it traditionally. It’s traditionally detected through blood testing. So, for that reason, it sometimes goes missed. And so, if a patient has heart disease, I suggest that they talk to their doctors about their risks for kidney disease and what that would look like. Conversely, patients who have kidney disease, they should also be talking to their nephrologist about their risk of heart disease. And so, your own medical community and your providers are a wonderful resource for learning more.

In addition, there are several large advocacy groups that can provide a lot of critical information in terms of patient education, including cardiology groups such as the American Heart Association or the American College of Cardiology, as well as nephrology groups such as the American Society of Nephrology and the National Kidney Foundation. All of them will have great information about what this intersectionality about kidney and heart disease looks like, as well as what you should know as a patient – what you should be looking for and what questions you should be asking your doctor, and how to prevent the onset of these diseases, more importantly.

JL: Dr. Nisha Bansal, thank you so much for your time and all the work that you’re doing. I think we’re really excited to see and hear about the growth of the Kidney Heart Service as time goes on.

NB: Thank you so much for inviting me to participate today. It has been a lot of fun.