Looking Ahead: VA Kidney Research

Not many people know about the US Department of Veterans Affairs’ (VA) research program outside the Washington beltway. The lack of recognition may in part be because the program is dwarfed by the National Institutes of Health (NIH) budget ($589 million vs. $29.4 billion in 2015). Yet the VA is a leader in a number of research fields, including vision and hearing loss, orthopedics and prosthetics, and mental health issues such as posttraumatic stress disorder and traumatic brain injury. VA investigators—half of whom are clinician-scientists—have won three Nobel Prizes and seven Lasker Awards, the US equivalent of a Nobel Prize in medicine.

Similar to the NIH, VA research proposals are peer-reviewed and merit-based. Unlike the NIH, however, the VA research program is strictly intramural. Therefore, investigators generally must be employed at least five-eighths of the time by the VA to compete for research funding awards. Moreover, VA research must be veteran-focused. VA research program priorities today include women’s health, polytrauma, and the Million Veteran Program (MVP)—but the agency also conducts veteran-focused research in many other areas, including nephrology.

As the name implies, MVP’s goal is to collect health information and blood samples from one million veterans to enable researchers to study how genes affect health and disease, in order to improve healthcare for veterans. The VA has many advantages for conducting research like MVP, including a stable patient population, integrated electronic medical records, and numerous clinical research centers.

According to Veterans Health Administration (VHA) National Program Director for Kidney Disease and Dialysis Susan T. Crowley, MD, FASN, “The Million Veteran Program could help unlock the biological mechanisms that cause kidney disease, helping determine who is most susceptible to developing kidney disease and evaluating the most effective therapies for preventing progression of kidney disease based on an individual’s genetic makeup.”

Kidney disease is naturally a concern to the VA, considering the population it serves. Veterans are at especially high risk for chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Nearly 11% of patients using healthcare services have moderate and severe CKD, and VA enrollees make up approximately one-tenth of the annual US incident ESKD population.

The VA recently completed studies such as the Diabetes in Nephropathy (NEPHRON-D) Study and Acute Renal Failure Trial Network (ATN) Study (co-sponsored with the NIH). These studies have helped shed light on combined angiotensin inhibition for the treatment of diabetic nephropathy and renal replacement therapy for acute kidney injury in critically ill patients, respectively. Another VA clinical trial is currently underway to evaluate preventive strategies for reducing adverse events following angiography (Prevention of Serious Adverse Events Following Angiography Study).

The VHA is the largest provider of kidney care in the nation. Similar to that for non-veterans, mortality rates and healthcare resource utilization for veterans on dialysis remain notably high, and the cost of caring for patients with kidney disease in the VA is substantial. In fact, among the 30 most common chronic conditions in the VA, CKD and ESKD care accounted for the second highest mean VA total costs per person and similarly the second largest percentage of total VA annual medical costs, according to prior reports.

Despite the significant and growing cost of kidney care, VA dollars and awards for kidney research have been flat in recent years, at about $20 million for 95 awards. Recognizing the disparity between the cost of kidney care and its investments in kidney research, the VHA Kidney Disease and Dialysis Program Office delineated high-priority areas of kidney research in its recent strategic plan, including investigating barriers, facilitators, and outcomes associated with home dialysis.

Grant Olan (right) represents ASN at a Friends of VA Medical Care and Health Research briefing on March 25, 2015, with VA Chief Research and Development Officer Timothy O’Leary, MD, PhD (third from right).

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The outlook for VA research funding may be looking brighter: In his 2016 budget, President Barack Obama requested $622 million for the VA research program, an increase of 5.6% over the program’s 2015 budget (Table 1). ASN serves on the executive committee of the Friends of VA Medical Care and Health Research advocacy coalition, which has been meeting with the offices of members on the House and Senate Veterans Affairs Committees and appropriators in Congress over the past few months in support of the president’s request.

Table 1

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“ASN commends the president’s 2016 budget request for the VA research program,” ASN Research Advocacy Committee Chair Frank “Chip” Brosius, MD, stated. “The additional funds will provide the VA the resources it needs to maintain funding for current projects and bolster support for exciting new initiatives like the Million Veteran Program.”

Michael J. Fischer, MD, FASN, is Research Health Scientist at the VA Center of Innovation for Complex Chronic Healthcare. Grant Olan is ASN Senior Policy and Government Affairs Associate.