January 17, 2020

John O. Colonna, II, MD, FACS

Dr. John Colonna can still clearly remember the first time he watched a newly-transplanted kidney pink up with blood and begin to produce urine inside another body.

Then a third-year student at Medical College of Virginia, Dr. Colonna had already decided to specialize in general surgery. That moment in the operating room more than three decades ago, part of a two-week rotation with the hospital’s kidney transplant service, would reshape his career.

“It was just amazing to see,” Dr. Colonna says. “These surgeries are not just about transplanting an organ, they’re about transforming a life. You can take some of the sickest people around, renal failure patients, and turn them around very quickly.”

Since arriving in Norfolk in 2002, Dr. Colonna has performed well upward of 1,000 kidney transplants as Surgical Director of the Renal & Pancreas Transplant Program at Sentara Norfolk General Hospital. Last year alone, the program handled 101 kidney transplants, along with seven combined pancreas-kidney transplants. Dr. Colonna performed the first pancreas transplant in Hampton Roads in 2008.

Dr. Colonna also serves as Surgical Director of the Renal Transplant Program at Children’s Hospital of The King’s Daughters, where he handles five to 10 pediatric cases a year. Until about five years ago, he was essentially the only surgeon for both programs, leaving him on 24-hour call for his patients with renal failure and advanced diabetes being admitted for transplant. “That’s part of the job,” he says, “and I love my job.”

The continuing emergence of more effective immunosuppressants has greatly improved transplant outcomes and patient experience, notes Dr. Colonna, also an Associate Clinical Professor of Surgery and Urology at Eastern Virginia Medical School. Drugs to prevent and treat organ rejection with less toxicity have spared many patients from infections and other post-surgical complications as they move beyond the grueling grind of dialysis.

“More than 95 percent of kidneys are functioning well after a year, and more than 90 percent after three years,” Dr. Colonna says. “The average patient in renal failure will live twice as long with a transplant as compared to with dialysis. The difference in both quality and quantity of life is enormous.”

More patients also are qualifying for transplant. One factor is new therapies that target hepatitis C and HIV infections; another is a recent adjustment to the national kidney allocation system to benefit people who once endured long waits for an organ. That includes a significant number of minority patients on the transplant list in Hampton Roads.

Sentara’s program partners with the National Kidney Registry, which connects donors and recipients across the country. “It provides a much better opportunity to find matches for the toughest cases, even people who have antibodies to virtually 99 percent of donor kidneys,” Dr. Colonna says. “In many cases, we don’t have to try to make kidneys artificially compatible via medications.” Donor exchange programs also can turn a single kidney into 30 or more transplants, he adds.

Dr. Colonna enjoys working with a multidisciplinary team of outstanding nurses and specialists on each transplant, from nephrologists to nutritionists, as well as keeping in touch with patients over time. He still receives Christmas cards from families he met 20-plus years ago. “Unlike many types of surgeons who don’t see a patient again unless there’s a complication, I have the chance to really get to know people,” he says.

Born in Germany into an Army family, Dr. Colonna wanted to be a doctor by the time he was in high school in Springfield, Va. His mother went to nursing school later in life and frequently came home with stories about helping patients. As a teenager, Dr. Colonna also severed a tendon in a finger while working for a moving company, when the hood of a van crashed down on it. “I ended up needing plastic surgery, and I found the whole process fascinating,” he recalls.

Dr. Colonna studied for a degree in biology from Virginia Military Institute before earning his medical degree at MCV. He spent the next nine years at the University of California, Los Angeles, completing a general surgery residency, a two-year research fellowship in liver transplantation and a two-year clinical fellowship in liver transplantation.

From 1992 to 1998, Dr. Colonna served as Director of the Liver Transplant Program at Walter Reed Army Medical Center, where he also transplanted kidneys. He then became Director of Liver Transplantation & Hepatobiliary surgery at the University of Maryland Medical System in Baltimore, a busy program that handled highly complex cases.

In 2002, Dr. Colonna and his wife jumped at the chance to relocate to Norfolk. “We had always loved it here when we visited, and Virginia Beach was THE place to go in high school,” he notes. A father of five and grandfather of five, he enjoys boating, running and playing with his young grandkids.

A Diplomate of the American Board of Surgery and member of the American Society of Transplant Surgeons, Dr. Colonna has authored or co-authored numerous manuscripts on liver, kidney and pancreas transplantation, as well as hemoaccess intervention. Not surprisingly, he’s also a champion of organ donation from cadaver and living donors, including non-directed donations.

As a professor, Dr. Colonna likes to operate alongside general surgery and urology residents from EVMS and Naval Medical Center Portsmouth whenever possible. After all, he was once that awed student witnessing a kidney spring back to life.

“That opportunity changed my life,” he says. “I want to give them the same glimpse into the world of transplant surgery.”

Steven V. Lewinski, MD, FACP

Tidewater Kidney Specialists, Inc.

For 20 years, Dr. Steven Lewinski’s job has boiled down to one vital goal: protecting his patients’ precious kidneys for as long as possible. The difference is that today, he has many more weapons at his disposal.

Patients with vasculitis are no longer inevitably placed on steroids, for example, thanks to new medications without side effects such as weight gain, skin changes and an increased risk of high blood pressure and diabetes. Patients with high blood pressure can take advantage of a variety of effective, once-daily drugs. Those on hemodialysis can benefit from improved vascular access techniques.

“This field has come such a long way,” Dr. Lewinski says. “While it is very difficult to replicate everything a healthy kidney does, we have a much better repertoire of treatments to try.”

Since 2012, Dr. Lewinski has been President of Tidewater Kidney Specialists, or TKS, a major provider of comprehensive nephrology services in Hampton Roads. He is affiliated with all Sentara and Obici hospitals in Virginia Beach, Norfolk and Suffolk, as well as Chesapeake Regional Medical Center; he served as President of Chesapeake Regional’s medical staff from 2016 to 2017.

Practicing nephrology is a joy for Dr. Lewinski, a Buffalo, NY, native who decided on a career in medicine very early in life. As in, when he was kindergarten.

“I never considered anything else,” he recalls. “My mom was a nurse, and our family doctor was a grandfatherly, Marcus Welby-type of man. He was always there when you needed him. He had an office in his home, and I remember that he came to my house when my brother had scarlet fever. I thought, ‘I want to help people like he does.’”

After earning his undergraduate degree at the State University of New York at Buffalo, Dr. Lewinski completed a master’s in Natural Sciences as part of the university’s Department of Biophysics. He then stayed on for 1½ more years as an Assistant Cancer Research Scientist, where his laboratory team studied interferon as a therapy for deadly diseases such as leukemia and melanoma.

In 1981, Dr. Lewinski headed to medical school at the Uniformed Services University of Health Sciences in Bethesda, MD. Just before he started there, he married his wife Doreen, who he’d originally met at age 17 and taken to his high school prom. “We didn’t have any money,” he says with a laugh. “The military offered me a great opportunity to study medicine without going into debt.”

Nephrology attracted Dr. Lewinski for being both challenging and what he calls “objective”, or largely numbers-based. “A urinalysis or blood sample is either abnormal or it isn’t,” he explains. “Even with dialysis, there are always numbers to look at, with guidelines based on those findings. I’m a concrete person, and I like that there isn’t a whole lot of guesswork to determine the best treatment approach.”

Dr. Lewinski completed a General Medicine internship and Internal Medicine residency at National Naval Medical Center in Bethesda. To fulfill his military commitments, he also spent two years based at Camp Lejeune in North Carolina. As a Battalion Surgeon and later a Regimental Surgeon for the Fleet Marine Force, his deployment sites included California, Wisconsin, Panama, Japan, Korea and Norway. “My dad was a Marine, so I was proud to serve,” he says. He retired as a Captain in the Naval Reserves in 2007.

After two years as a Staff Internist at a Navy medical clinic in New Orleans, Dr. Lewinski finished a two-year fellowship program in Nephrology at Naval Medical Center Portsmouth and was a member of the center’s staff for three years. He joined TKS full-time in 1998. He also has been Medical Director of the DaVita Dialysis Chesapeake unit since 2006 and an Assistant Professor of Internal Medicine at Eastern Virginia Medical School since 1999. His colleagues have voted him a “Top Doc” for four straight years.

Just like his childhood doctor, Dr. Lewinski enjoys developing personal relationships with patients. “After we cover health issues – medication changes, the right foods to eat, the importance of compliance with their treatment regimens – we just chat about life,” he says. “They’re comfortable with me. They tell me about their families, their travel. I know who roots for what football team. I hope that these positive interactions help them leave my office or the dialysis center feeling good.”

Outside work, Dr. Lewinski is a huge sports fan, cheering for his hometown Buffalo Bills and Sabres and Old Dominion University’s athletic teams. He also is a regular runner who enjoys competing in 5K and 10K races. He and Doreen, a longtime teacher, have two grown children and live in Chesapeake with their Basset Hound, Penny.

The future of nephrology is bright, Dr. Lewinski believes. One promising possibility is a portable dialysis machine that functions much like an insulin pump for diabetics, allowing for constant filtering of blood. Models in clinical trials are either implanted or anchored by a pack outside a patient’s abdomen.

“Healthy kidneys filter blood 24 hours a day, seven days a week,” Dr. Lewinski says. “If you can achieve that continuous filtration with a machine, a patient is going to feel much better.”

And one day, he hopes, stem cell injections may even rejuvenate reusable tissue within the kidney. “If we can give more life to an original kidney, that person might never have to go on dialysis or get a transplant,” he says. “That would truly be a game-changer.”

Thomas R. McCune, MD, FACP

Nephrology Associates of Tidewater, Ltd

Dr. Thomas McCune has worn many hats during his long, successful career as a nephrologist: physician, researcher, educator, author, soldier, leader in national transplant societies and international lecturer.

After nearly three decades in practice, he can look back in gratitude at how much kidney care has advanced, even as he embraces the multiple medical breakthroughs he sees on the horizon.

“Some of the discoveries being made today will reshape this specialty,” Dr. McCune says. “It is very exciting and gratifying to be able to give more and more people with kidney disease or total organ failure – people relying on a dialysis machine to stay alive – a chance for a healthy, normal life.”

As a partner at Nephrology Associates of Tidewater in Norfolk, Dr. McCune commonly treats patients with diabetes complications, severe hypertension and genetic disorders such as polycystic kidney disease. He is proud to say he has managed the care of some patients for decades, from their initial diagnosis of kidney disease, through dialysis and on to successful transplantation.

Dr. McCune serves as Primary Physician for the Pancreas Transplant Program at Sentara Norfolk General Hospital and Medical Director of Fresenius Kidney Care of Greater Norfolk. At Eastern Virginia Medical School, he is the Chair of the Division of Nephrology and Fellowship Program Director. He holds the rank of Associate Professor and has won several teaching awards.

As a researcher and instructor, Dr. McCune has had a hand in developing some of the newest medical tools in his specialty. One example is tolvaptan, a promising medication for adults with Autosomal Dominant Polycystic Kidney Disease that could gain FDA approval later this year. “In clinical trials, this drug slowed the decline in kidney function, keeping patients off dialysis longer,” Dr. McCune says.

Researchers also have identified a genetic marker highly associated with the development of kidney failure in young African-Americans. The next step is to identify which secondary factors might trigger the disease in affected carriers, such as certain infections, and develop treatment and prevention plans.

Since the kidney has so many functions in the body, one discovery goes well beyond nephrology, Dr. McCune adds. A recently recognized hormone called klotho is produced by healthy kidneys and appears to improve memory and motor skills in mice. In humans, researchers have discovered high levels of the chemical in very elderly people who have no cardiovascular disease or cognitive impairment. “There is great hope that klotho may be part of the recipe that we use to lengthen life,” Dr. McCune notes.

Those potential breakthroughs are on top of improved diagnostic techniques and post-transplant drugs that help physicians quickly identify complications and prevent organ rejection. Today, the different types of rejection can be quickly diagnosed and treated, and opportunistic infections can be identified and controlled before the patient develops infection symptoms. These successes now allow virtually all patients functional transplanted kidneys a year after surgery.

Medicine was a natural choice for Dr. McCune, a lifelong learner and “Army Brat” who grew up primarily in Northern Virginia, Germany and Charlottesville. “I knew I wanted to be a doctor by junior high,” he recalls. “I wanted to understand all I could about the science of the body and what made it work.”

Dr. McCune majored in biology at The Virginia Military Institute and went on to medical school at EVMS, where he was drawn to the variety of nephrology, with a particular interest in how the kidneys helped maintain a precise fluid and electrolyte balance for good health.

Dr. McCune completed an internship and a residency in internal medicine at EVMS and two fellowship programs at Vanderbilt University Medical School, one in nephrology and one in transplantation. He then returned to Hampton Roads to establish his medical career, which has included frequent participation in clinical trials and publication of peer-reviewed manuscripts, chapters and commentaries.

In addition, Dr. McCune has served for 32 years in the Army Reserve and National Guard. He was deployed to Germany during Operation Desert Storm and to Afghanistan and Iraq in 2004, 2006 and 2010, serving as a forward-deployed surgeon for an infantry battalion, an air assault aviation battalion and an aviation brigade. He retired in 2016 as a Colonel in the Medical Corps.

Dr. McCune returned to Iraq just last year at the invitation of the Kurdish Regional Government to lecture and participate on teaching rounds. While there, he treated patients at hospital clinics and visited refugee camps close to the Syrian border.  “As a former soldier in Iraq, it was good to see the region limp toward an improved future,” he says.

Recognizing that medicine is advanced through policy as well as practice, Dr. McCune has led the South-Eastern Organ Procurement Foundation and served on many of its committees. He is also active with the American Transplant Society, having chaired scientific sessions and the Patient Care and Education committee, which was responsible for rewriting the society’s ethics statement.

Married with three grown children, Dr. McCune enjoys travel, cooking and advancing his knowledge of the wines of the world. As he edges closer to retirement, his work with fellowship students has left him confident about the future of kidney care in the region.

“All patients deserve the best of care,” he says. “Fortunately, this is a place they can find it.”

Dan A. Naumann, MD

Family Practice, Hampton Roads Urgent Care

Last August, Dr. Dan Naumann spent two weeks on a humanitarian medical mission in Malawi, Africa. When he came home, he had one day to rest.

Another mission called: Dr. Naumann, a family practice physician with Hampton Roads Urgent Care in Newport News, headed to the Smokey Mountains of North Carolina for two more weeks, this time with a military team. As a Lieutenant Colonel and Flight Surgeon in the U.S. Air Force Reserve, he led hundreds of doctors, dentists, optometrists and public health officials who together provided free care to more than 1,000 underserved patients.

“The turnaround was brutal, but I feel very blessed to be able to do this work,” Dr. Naumann says. “People deserve access to care that most of us take for granted, wherever they live.”

Humanitarian work has long been central to Dr. Naumann’s life. Over the past three decades, he has traveled to Malawi twice, Vietnam three times and the Dominican Republic and Jamaica once apiece, either through the military or church groups. This summer, he will lead another domestic military mission to central Georgia, with plans to construct health centers in five different counties.

“These are people who support our military, whether by paying taxes or praying for us or having family members who serve,” he says. “It’s important to give back to them.”

The military missions, which combine all service branches, target communities chosen by the Department of Defense based on various health and income indicators. Teams care for everything from simple sore throats to complex stroke complications, while connecting patients with local resources for longer-term treatment.

Many patients live far from a medical center, lack transportation or don’t have money for health insurance. One man in North Carolina had suffered horrible toothaches for years and was ready to sell his truck to pay for care. “He needed his truck, but he was desperate,” Dr. Naumann relates.

Missions also are important training grounds for young enlisted men and women, he adds: “They learn to create medical facilities out of nothing. Mentoring is a huge part of military life, so that if one person goes down, the next person below can step up.”

The son of an Air Force father, Dr. Naumann is a Newport News native who knew by middle school that he wanted to be a doctor. He earned a biology degree at Virginia Tech before completing medical school at Medical College of Virginia and an internship and residency at the York Hospital Family Practice Residency Program in Pennsylvania.

At MCV, Dr. Naumann loved each specialty rotation and eventually realized family medicine was a combination. “I love the variety,” he says. “I might see a 75-year-old with heart issues in one room and a 2-month-old baby with a cold in the next.” He worked at several local practices before joining HRUC, a division of Hampton Roads Orthopaedics & Sports Medicine, last fall.

Kim W. Liebold, aNP-C

Riverside Cardiology Specialists

The woman who inspired Kim Liebold to go into nursing also taught her that good work – and any recognition that came with it – should never be about her.

Liebold’s grandmother had to drop out of nursing school due to family needs, yet she still became a much-loved unofficial caregiver for her community. She believed God worked through her and many others to help people who were sick or struggling. And she was thrilled her granddaughter, now an Adult Nurse Practitioner specializing in cardiology for more than 21 years, could finish what she started.

“I remember giving her my ‘white nurse’s cap’ when I graduated because she always admired what it stood for,” Liebold says. “My love for the practice of nursing, medicine and my faith all work together to be a gift that I cherish and am blessed to have.”

Liebold’s philosophy of gratitude has guided her in her career, volunteer work and personal life, even after she lost her son when he was 20. Following Hunter’s death six years ago of complications linked to a sports injury, she found herself and others continuing in service projects in his honor – thereby spending extra time with their loved ones.

“I pledged through my grief journey to find the good in all things,” she explains. “We called this “The Hunter Effect’. There’s so much negative in the world, but equally so much good to be done.”

Liebold grew up in Smithfield, where she met her future husband, Scott, at age 15. The high school sweethearts, now married 32 years, raised two children, Hunter and Samantha; Scott is a retired Fire Chief of Newport News.

Encouraged by a biology teacher, Liebold trained as a registered nurse at Riverside School of Professional Nursing after her 1984 graduation from high school. While working full-time at Riverside’s CCU, she earned a bachelor’s in nursing from Christopher Newport. She later completed a master’s for ANP at Medical College of Virginia.

The complexities of the cardiovascular system always fascinated her, even in high school. As a CCU nurse in the late 1980’s, Liebold helped care for cardiac patients with newer technologies at Riverside such as thrombolytics, IV amiodarone and balloon angioplasty, and she embraced the challenges of learning about advanced cardiac life support as an early instructor. One of the region’s first specialty NPs in cardiology, she went on to specialize in arrhythmia management, cardiac device therapy, congestive heart failure management and risk factor reduction.

“I am honored to help patients through their journey, optimizing their health and quality of life,” she says. “I’ve been blessed to work with the most amazing cardiologists and now fellow NPs. I always want to take care of the person in front of me like I would want to be cared for.”

Alongside co-workers and their families, Liebold has volunteered extensively at the Peninsula Rescue Mission, which helps the homeless and less fortunate, from cooking and serving meals to handing out Halloween candy and Easter Baskets.

As co-youth director for Bethany United Methodist Church in Smithfield for 15-plus years, Liebold has helped educate more than 1,000 local residents in hands-only CPR. In addition, her young flock has encouraged placement of automated external defibrillators throughout the community and done home repair in rural Appalachia.

In her spare time, Liebold enjoys running, taking violin lessons and visiting the Outer Banks with her family. She also has a second-degree black belt in Tae Kwon Do, which she originally started with Hunter as a hobby.

Liebold is quick to share all her successes with God and many other people in her life, including those under her care: “I get more out of helping others, and from my patients, then they ever get from me.”

Trust your Patients to the Care of Peninsula Kidney Associates

Peninsula Kidney Associates has been serving patients with chronic kidney disease, electrolyte imbalances and hypertension since 2003. Their highly skilled physicians develop strong relationships with each patient that are built on individualized treatment and quality care. Each care provider is dedicated to improving the health and quality of life for each patient they serve.

Over the past 15 years, Peninsula Kidney Associates has grown rapidly from a two-physician practice with one location to a team of eight providers in three locations. The caring team of board-certified nephrologists and certified advance practice providers includes:

Joanne Siu, MD

• Joanne Siu, MD. Dr. Siu is a general nephrologist who specializes in renal ultrasound to diagnose kidney conditions. She also works with the practice’s Clinical Trials program. Using her 16 years of experience, she also helps patients prevent and manage kidney disease through the Chronic Kidney Disease Education program.



Olayiwola Ayodeji, MD, MPH, FACP

• Olayiwola Ayodeji, MD, MPH, FACP. Dr. Ayodeji serves as the director of the clinical research program. He is a founding member of Peninsula Kidney Associates and has 25 years of experience caring for patients with kidney disease. He also serves as the medical director of DaVita Newmarket Dialysis Center and the DaVita Home Training Center.




Hoang-Hai Nguyen, MD

• Hoang-Hai Nguyen, MD. Dr. Nguyen is a general nephrologist who specializes in providing expert care for patients before and after kidney transplant. He also serves as medical director for the DaVita Home Center of Excellence.




Shuping Wang, MD

• Shuping Wang, MD. Dr. Wang provides outstanding care to patients in Williamsburg. She has 13 years of experience in nephrology and is passionate about geriatric care. She is fluent in both Chinese and English.




Linda Jones-Brandon, CFNP

• Linda Jones-Brandon, CFNP. Ms. Jones is a Certified Clinical Research Professional with years of nursing experience caring for patients with kidney disease, heart disease and other internal medicine concerns. She works as the Lead Study Coordinator for the Clinical Research Program in addition to caring for patients.



Jessica Willis MSN, FNP-BC

• Jessica Willis MSN, FNP-BC. Ms. Willis has more than 5 years of experience caring for patients undergoing dialysis and treatment for kidney disease.

With so many providers on staff, Peninsula Kidney Associates generally sees new patients within one week of referral. They partner with referring physicians to ensure each patient receives the care they need, when they need it.

Peninsula Kidney Associates offers comprehensive diagnosis and treatment of kidney diseases. They provide a wide range of services so patients can receive the care they need in one place. Services include:

• Anemia management. Using erythropoiesis-stimulating agents, nephrologists manage anemia and improve quality of life.

• Chronic kidney disease education. This free, one-on-one course helps patients understand their condition and their treatment choices.

• Chronic kidney disease treatment. For patients with chronic kidney disease, Peninsula Kidney Associates offers education, medicine management, dialysis and transplant management.

• Dialysis. Peninsula Kidney Associates offers hemodialysis and peritoneal dialysis both in centers and on an at-home basis. They provide training for at-home dialysis care for family members and patients.

• Hypertension treatment. Peninsula Kidney Associates physicians strive to help patients manage blood pressure and prevent damage to the kidneys.

• Post-transplant care. Dr. Nguyen provides expert, comprehensive management of all kidney transplant recipients, preventing infection and rejection of the new kidney. All physicians also offer kidney transplant referrals.

• Renal ultrasound. To identify masses on the kidneys or other kidney conditions, Dr. Siu offers expert assessment with renal ultrasound.

Since 2004, Peninsula Kidney Associates’ expert physicians have participated in national clinical trials and research to explore new and effective treatments. These studies into chronic kidney disease and end-stage renal disease give patients more treatment options and access to the latest medicines.

Since the practice opened, Peninsula Kidney Associates has continued to grow and expand. To support this growth, two nephrologists have joined the medical staff.

Merfake Semret, MD

Merfake Semret, MD, completed his medical education at Addis Ababa University Medical Faculty, his residency training at Wayne State University in Detroit, and his fellowship training at the Mayo Clinic in Minnesota before joining Peninsula Kidney Associates. He cares for patients at both the Newport News and Hampton locations, specializing in the management of hypertension and kidney disease.

Dr. Semret was inspired to join the nephrology specialty after conducting research with a nephrologist before his residency. He realized the patient population was in great need of medical care and attention.

“It’s a very complicated patient population,” says Dr. Semret. “It is very satisfying to help them and see them improving.”

Dr. Semret takes time to get to know all his patients so he can provide personalized care. He even calls each patient with their lab results, ensuring they understand what the results mean for their health.

Since 2011, he has enjoyed working with the great staff at Peninsula Kidney Associates and living in the Hampton Roads area with his wife and three children. He plans to practice on the Peninsula for many years.

Lei Chen, MD

In 2017, Lei Chen, MD, joined Peninsula Kidney Associates. After earning his medical degree at China Medical University, he moved to the United States to earn his PhD at University of Cincinnati School of Medicine. He completed his residency training at East Tennessee State University and his fellowship training at UT Southwestern in Dallas, Texas.

Prior to moving to Hampton Roads, Dr. Chen practiced in New Mexico. He now provides care at the Williamsburg office.

“I joined Peninsula Kidney Associates because of the quality of the physician partners,” says Dr. Chen. “They are very solid clinically as well as very amiable and easy to work with.”

Dr. Chen finds it rewarding to care for the same patients for years. He takes his patients’ needs seriously, always providing the highest quality care possible. He also helps to coordinate their care with their other specialty and primary care physicians, ensuring all physicians are up-to-date on the patient’s health.

Both Dr. Chen and Dr. Semret’s dedication to their patients is a reflection of the care all patients receive at Peninsula Kidney Associates. Each compassionate staff member strives to ensure patients have a positive experience from the moment they step in the door.

As the need for quality nephrology care continues to grow, Peninsula Kidney Associates plans to expand their services, offering more dialysis locations and education opportunities. They currently assist patients at hospitals throughout the area, including:

• Bon Secours Mary Immaculate Hospital

• Sentara CarePlex Hospital

• Sentara Williamsburg Regional Medical Center

They also manage care at nine DaVita Dialysis locations in the Peninsula and Williamsburg area and see patients in three conveniently located outpatient offices:

PKA Hampton
501 Butler Farm Road Suite I,
Hampton, VA 23666

PKA Newport News
716 Denbigh Boulevard Suite A5,
Newport News, VA 23602

PKA Williamsburg
205 Bulifants Blvd Suite A
Williamsburg, VA 23188

To refer a patient to Peninsula Kidney Associates, please determine which physician and location is right for your patient. For more information, you can call us at 757-251-7469 in Newport News or Hampton or 757-345-5876 in Williamsburg. Or, visit our website peninsulakidneyassociates.com

An Innovative Riverside Protocol is Extending the Window of Time to Successfully Treat Stroke Patients

It’s one of the undisputed tenets of stroke medicine: the sooner the patient is diagnosed and appropriate treatment rendered, the greater the chance for recovery and return to independent living.  For decades, that time has been measured not from the time the patient was discovered with symptoms, but from the actual time the symptoms began, or was last known to be well.

Prior to 1996, much of stroke care was focused on helping surviving patients manage the after effects: speech impediments, weakness, difficulty swallowing and other similar loss of brain function.  In that year, for the first time, an FDA approved treatment became available to treat ischemic strokes (about 85 % of all strokes) acutely: tPA (tissue plasminogen activator.)  Dubbed ‘the clot buster’, tPA was declared effective at breaking up these blocked arteries – if administered within three hours of onset of symptoms, or last known well.  Later studies published in the late 2000s demonstrated that some patients could benefit even if tPA was administered within 4.5 hours after last known well.  However, beyond 4.5 hours, the risk of bleeding was greater than any potential benefit.

Pankajavalli Ramakrishnan, MD, PhD

In the first years of the 21st century, scientists and physicians began looking for ways to extract the large clots that tPA could not break apart.  Devices were developed – the first generation resembled corkscrews – that could be sent up through the artery to engage and remove the clot.  In other iterations, a catheter with suction on the end attempted to aspirate  the clot out.  Although these treatments were groundbreaking in their ability to open up arteries blocked by large clots, that did not always translate into independent function.

“It was the newer generation of these devices, developed in 2010-2011, that truly revolutionized the field,” says Pankajavalli Ramakrishnan, MD, PhD, a neurointerventionalist with Riverside Neurovascular Specialists.   She explains: “The MR CLEAN trial came out at the end of 2014, the first large randomized endovascular trial to show the overwhelming efficacy of mechanical thrombectomy using devices to pull the clot out and open up these large blood vessel blockages.”  A series of similar trials came out in 2015 – ESCAPE, EXTEND IA, REVASCAT and SWIFT PRIME – but were halted early because of MR CLEAN trial’s overwhelming result in opening the large artery blockages and restoring patients’ independent function.  “It was standing room only at the International Stroke Conference in 2015 when this was presented,” Dr. Ramakrishnan remembers.  “What had been a good thing in theory became the standard of care that very day.”

Wolfgang Leesch, MD

“Besides opening up the blood vessels, these trials also demonstrated that these mechanical thrombectomy procedures could be done effectively on patients presenting as much as six hours after last known well,” adds Wolfgang Leesch, MD, another Riverside neurointerventionalist.  “Now specific treatment became available for people whose large arteries are blocked – against which tPA is quite powerless.”

While the window of time to effectively treat stroke patients had clearly been expanded, minutes still count.  With this in mind, Riverside neurointerventionalists saw the power of this new data and immediately envisioned a further potential life-saving application.  Realizing that time will always be of the essence when dealing with stroke patients, they went to the Peninsula EMS Council in early 2016 to advocate for a change in protocol in the field.

Jesse F. Sanderson, MD

“Up to that point, suspected stroke patients were taken to the nearest stroke center, but not all of these centers had the specialists, facilities and equipment to perform these complex mechanical thrombectomies,” Dr. Ramakrishnan notes.  “Often patients with the severest strokes then had to be transferred to the Comprehensive Stroke Center at Riverside.  That involved phone calls, a second ambulance ride, intake and surgical suite preparation – costing precious time.”

The devastating effects of delay are well documented in stroke literature:  the brain loses two million neurons per minute when deprived of oxygen.  A 15-minute delay results in a loss of a quarter of a billion – with a B – neurons.  The Peninsulas EMS Council unanimously signed on, and set a start date of March 1, 2017.

Dean B. Kostov, MD

The immediate challenge for the neurointerventionalists was how to help EMS personnel identify stroke patients in the field who needed the more extensive treatment at the Comprehensive Stroke Center.  “For this, we relied on the previously validated RACE scale,” Dr. Leesch says, referring to the Rapid Arterial oCclusion Evaluation screening tool. This scale scores the severity of the patients’ deficits, and higher the score, the more severe the stroke is likely to be.

Two months prior to implementation, EMS staff were trained to use RACE.  “Any patient with a RACE score of five or greater would be taken directly to the Comprehensive Stroke Center,” Dr. Ramakrishnan says, “if it didn’t prolong the trip by more than 15 minutes.”

The data since the institution of the protocol was collected and compared to before its implementation. Dr. Ramakrishnan and her colleagues at the Riverside Comprehensive Stroke Center were selected to present their findings at the January 2018 International Stroke Conference.    The preliminary results show a clear benefit for the patients since its implementation: more patients were treated quickly and achieved independent outcomes than previously achieved. The implementation of this protocol highlights the successful partnerships between the Peninsulas EMS and the community hospitals.  “We are much better at triaging stroke patients, and getting them to appropriate, life-saving care,” Dr. Leesch says.  While patients and their families might worry that taking the extra 10 or 15 minutes in travel time to the Comprehensive Stroke Center might hurt them, in reality, the opposite proved to be true.  In fact, Dr. Ramakrishnan adds, “By taking these patients directly to the Comprehensive Stroke Center, we’re also able to treat more patients with tPA and mechanical thrombectomy in a timely manner, and more patients are achieving meaningful, independent outcomes.”

As reported in the January 4, 2018 issue of The New England Journal of Medicine, the DAWN trial  demonstrated that “among patients with acute stroke who had last been known to be well 6 to 24 hours earlier, and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone.”  A subsequent trial, the DEFUSE 3, published in the February 22, 2018 edition of NEJM, concluded that “endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well, plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone, among patients with proximal middle-cerebral-artery or internal-carotid artery occlusion and a region of tissue that was ischemic but not yet infarcted.”

These two studies, both randomized multicentric trials, came out overwhelmingly in favor of opening up the patient’s blocked arteries, provided it could be demonstrated ahead of time that the patient had more brain to lose than had already been lost.

Riverside’s Chief Clinical Operations Officer, Michael J. Dacey MD, recently joined the Riverside Health System and stated, “As a critical care physician for the last 20 plus years, I have seen strokes, case after case, lead to death or severe disability.  As noted, the recent DAWN trial is a huge benefit to our community.  Riverside Regional Medical Center’s physician and clinical team have clinical outcomes equivalent to any of the academic centers in the Boston area where I recently came from.”

Now the standard of care has changed again.  “If a patient has a large artery occlusion and last known well time was anywhere up to 24 hours, and it could be demonstrated that a significant portion of the brain, while still at risk, was not dead, that patient might benefit from thrombectomy to remove the clot,” Dr. Ramakrishnan says.  “So whereas previously, we could only treat patients up to six hours from last known well, we can now offer hope for recovery up to 24 hours.  It’s an enormous advance.”

For more information about our Neuro-interventional team go to Riversideonline.com/neurointervention

Riverside Hampton Roads Neurosurgical & Spine Specialists
Riverside Neurovascular Specialists
12200 Warwick Blvd, Suite 410; Newport News
(757) 534-5200

Medical Update: How Data Is Improving Community Health

By Kasey Fuqua

Health data can do more than demonstrate quality indicators or track reimbursement rates; it can provide a road map to improving community health.

As part of Affordable Care Act requirements, all non-profit or tax-exempt hospitals must complete community health needs assessments (CHNAs) every three years. These assessments use community member input to identify health needs, barriers to care and health disparities.

Cynthia Romero, MD

“From a regional standpoint in Hampton Roads, there are common themes that seem to emerge from all the community health needs assessments,” says Dr. Cynthia Romero, director of the M. Foscue Brock Institute for Community and Global Health at Eastern Virginia Medical School. “These are very consistent, so each community has to be addressing them in order to improve health.”

According to CHNA results, common health challenges across Hampton Roads include:

• Cancer

• Cardiovascular disease, including heart attacks and stroke

• Diabetes

• Lack of access to primary care or specialty care

• Lack of access to outpatient or inpatient mental health care

• Lack of transportation to medical facilities and grocery stores

• Obesity in adults and children

• Opioid addiction and other substance use disorders

• Tobacco use

While many of these factors, such as obesity, are receiving national attention, others are only obvious after feedback from the community.

Nancy Littlefield

“It is just so important for organizations to take the feedback and opinions of those within our service market to help us form a strategy to make sure that we are meeting a community need,” says Nancy Littlefield, Chief Nursing Officer and Senior Vice President at Riverside Health System. “We could never deliver health care effectively if we didn’t hear our community’s voice and just assumed we knew.”

The Changing Face of Community Health Data
While many city health departments and hospitals completed their own surveys in the past, CHNAs offer health systems an opportunity to work together to collect comprehensive data. Many health systems use CHNA data to collaborate on community health initiatives.

“Especially this last 2016 report, we really looked at what are some common services areas that we share with Sentara and Bon Secours,” says Littlefield. “In the service markets we overlapped, we actually worked together to form projects.”

These joint efforts allow community health officials to seek out more cost-effective ways of delivering care and preventing health problems. But preventing costly chronic conditions takes a community-wide effort to make health a priority.

Dr. Romero says the national conversation about health care reform has been shifting to focus not just on how health care is delivered, but on how social factors such as income and education play a role in health outcomes.

According to the Centers for Disease Control and Prevention, socioeconomic factors and health behaviors play a much larger role in health than clinical care. Stakeholders throughout the community must work together to influence these factors and make it easier for residents to improve behaviors.

“Everyone has a role to play to reduce disparities and help people stay healthy and well,’ says Dr. Romero. “Everyone should be accountable in their own way to contribute to the health of their community.”

Health data also helps community officials focus spending where it can do the most good.

“The need to be efficient and make sure resources are deployed where they are needed is so important today with reimbursement models changing,” says Littlefield.

Data-Driven Programming to Improve Community Health
As a result of CHNAs, hospital systems across Hampton Roads have instituted new, targeted programs to benefit community health. Hospitals are required to collect information about the participation and efficacy of these programs to demonstrate to the IRS how they have benefited the community.

Many hospitals and practice groups, including Riverside and TPMG, are improving access to care through extended hours, Saturday hours and after-hours clinics.

“Access is always important,” says Littlefield. “In many families in our community, both mom and dad work, so it’s important that we provide afterhours care in physician practices.”

EVMS works with hospitals and community organizations to offer many community health initiatives. Working with the Consortium for Infant and Child Health (CINCH), EVMS community health experts, CHKD team members and others focus on efforts such as:

• Asthma Action Plan to manage childhood asthma

• Reducing childhood obesity

• #757SmokeFreeRide to lower children’s exposure to secondhand smoke

• A strategic plan with March of Dimes to improve childbirth outcomes

• Reducing tobacco usage and vaping in teens

Riverside Health System has also initiated new programs, such as one in the Williamsburg market, to create a heart safe community. Collaborating with the American Heart Association, emergency medical services and others, they can now use a smartphone app to locate AEDs and trained users throughout the community.

On the Peninsula, the Peninsula Health Collaborative, with representatives from Riverside, Bon Secours, Sentara, TPMG and more, work together on issues such as food insecurity in patients with chronic diseases.

TPMG is also teaming up with Bon Secours Mary Immaculate Hospital to care for patients with congestive heart failure, reducing their readmissions and ER visits based on quality data.

Jennifer Sharp-Warthan, MD

Dr. Jennifer Sharp-Warthan, Family Medicine physician and Chief Medical Officer at TPMG, says that improving the speed that data is shared between hospitals, insurance companies and physicians can also greatly improve health.

“We try to contact patients within 48 hours of a patient being sent home to make sure they have their prescriptions and that they can be seen by the primary care provider or specialist,” says Dr. Sharp-Warthan. “We also receive direct feeds from hospitals of people who were discharged from the hospital or who went to the ER the day before so we can follow up with them.”

This quick follow-up from TPMG physicians helps patients avoid bouncing between acute care facilities, giving them high quality, cost-effective care on an outpatient basis. This program also highlights how physicians can use data to change how they deliver care.

The Vital Role of Physicians in CHNAs
Because of their everyday interactions with patients, physicians have valuable insight into how community health could be improved.

“The input of everyone is critical,” says Dr. Romero. “If physicians are asked to participate in a survey that looks at health issues within their community, we encourage everyone to participate.”

Dr. Romero says physicians should also strive to educate themselves and their staff about health disparities, cultural concerns and other factors that could lead to gaps in care. She encourages physicians to talk about approaches to community health within their practice.

To help guide conversations and practice policies, physicians can easily access community health data. They can even begin with quality data collected in their own practices for Medicare or Medicaid.

“Physicians can glean a lot of information by simply reviewing those reports in a proactive fashion,” says Dr. Romero. “They can see potentially where certain workflow or communication improvement could help address health disparities and quality of care.”

Physicians can also review community health needs assessments and other health data through sources such as:

• City health departments

• Health system websites

• County health rankings from the Robert Wood Johnson Foundation

• CDC health reports

• Virginia Department of Health resources

Though physicians are often overworked, taking time to review these resources can help them lead efforts to transform community health.

The Future of CHNAs
Dr. Romero sees the role of CHNAs continuing to expand among communities in the future, though physicians will likely remain leaders of public health movements.

“I see CHNAs becoming ongoing priorities for all organizations that are committed to improving the health of communities they serve,” says Dr. Romero. “CHNAs will help us recognize that health really should be considered in all policies in hospitals, at work or at home, because of the nature of health and how it is impacted by socioeconomic factors.”

In data-driven communities of the future, CHNAs will impact more than health delivery. They may lead to sidewalks in neighborhoods, farmer’s markets at elementary schools, increased public transportation and other efforts geared toward creating vibrant communities centered around health.

Medical Update: New Therapies Target Inflammatory Bowel Disease

By: Kasey Fuqua

As the number of patients with inflammatory bowel disease (IBD) grows, so does the number of effective, targeted treatment options.

For almost 20 years, monoclonal antibodies have been the main therapy patients with moderate to severe IBD. These medicines typically suppress inflammation in reaction to tumor necrosis factor (anti-TNF agents). While these drugs can help many patients, they don’t provide consistent relief for all patients with IBD.

Jeremy Domanski, MD

“Not every patient is going to respond to anti-TNF therapy, and some of these patients are really difficult to treat,” says Jeremy Domanski, MD, gastroenterologist at Gastroenterology Associates of Tidewater and Chesapeake Regional Medical Center. “The newer agents give us unique targets for treatment so we can better tailor therapy for patients.”

Newer monoclonal antibodies, such as vedolizumab, help prevent white blood cells from travelling to inflammation in the gut while others, such as ustekinumab, target pro-inflammatory cytokines. Though not all of these newer medications are approved for use in children, monoclonal antibodies still play a growing role in pediatric treatment.

“Sometimes we still have to use newer biologic agents when our first line medications have failed and kids still have issues,” says Michael Konikoff, MD, a pediatric gastroenterologist with Children’s Specialty Group, PLLC, at Children’s Hospital of the King’s Daughters. “Medicines that once worked for them no longer do, so we have to continually find new ones. About half of our more than 300 patients use monoclonal antibodies. In the past, it would have been a smaller proportion.”

While these new agents give patients more targeted treatment options, they also help them avoid the damaging side effects of long-term steroid use. Though patients using monoclonal antibodies do have a higher risk for infection or infusion reactions, overall the benefits of these drugs outweigh any potential risks, especially for patients with severe IBD.

For children with inflammatory bowel disease, the risk of side effects is especially important to consider.

Michael Konikoff, MD

“A lot of the same treatments are used between pediatrics and adults,” says Dr. Konikoff. “However, we use slightly different approaches just because when we diagnose a child with inflammatory bowel disease, we may be looking ahead to 70 or 80 years of life. We have to take that into account in terms of treatments we recommend.”

Both adult and pediatric patients with IBD in Hampton Roads have access to new treatments through clinical trials. At Gastroenterology Associates of Tidewater, patients are enrolled in trials to test medicines that target different aspects of the inflammatory process than drugs currently on the market. Janus kinase (JAK1) inhibitors affects signaling between cytokines and can be taken orally, instead of through injection or infusion. Other monoclonal antibodies in testing target different interleukins than current drugs.

“The biggest benefit for our patients is that we will have additional targets for therapy,” says Dr. Domanski. “If patients fail one drug, we’ll have options to give them a different targeted therapy.”

At CHKD, gastroenterologists participate in national research through the quality improvement network called Improve Care Now. Around 100 pediatric IBD treatment centers across the country design and participate in large-scale studies that offer promising data for the future of IBD treatment.

“I think participating in research has really energized our practice,” says Dr. Konikoff. “The strides we’ve been able to make for our patients in terms of remission rates and keeping kids in better health has been pretty amazing.”

Effective Therapies Delay—or Eliminate—the Need
for Surgery
Targeted therapies and advances in laparoscopic techniques are also helping patients with IBD avoid or delay more invasive surgical treatment.

“The medicines we have now have improved to the point where many kids who would have had surgery previously can now avoid it because we can keep their inflammation under better control,” says Dr. Konikoff.

Around 70 percent of patients with Crohn’s disease and 33 percent of patients with ulcerative colitis eventually require some form of surgical treatment.

“One of our goals as GI doctors is try to prevent surgery or at least to delay it when we can,” says Dr. Domanski. “Clearly there are patients who are going to benefit from surgical intervention, so we have to work closely with surgeons.”

Endoscopic procedures like balloon dilations of strictures in Crohn’s disease or endoscopic resection of visual dysplastic lesions in the colon offer patients some relief without invasive surgeries. These procedures offer quicker recovery times and less pain than surgeries used in the past.

Surgeries such as bowel resection can improve quality of life for patients with severe Crohn’s disease. However, up to 50 percent of these patients will require another surgery in the future due to recurrence within 5 years.

The Future of Noninvasive IBD Diagnosis
Just as surgeries become less invasive, researchers are working toward less invasive techniques to diagnose IBD. While colonoscopy and biopsy are the current hallmarks in IBD diagnosis, imaging techniques and laboratory testing continue to play a more prominent role.

Small bowel imaging using MRI or CT scans, as well as capsule endoscopy, allow physicians to study the small bowel and better identify patients with IBD who may not have colon disease. In some cases, gastroenterologists can also detect gut inflammation using fecal calprotectin and lactoferrin testing.

In the future, these stool-based tests may be enough to diagnose IBD without endoscopy. However, there is not currently enough data to use these tests alone.

“I think something like fecal calprotectin shows promise as a less invasive screening test,” says Dr. Domanski. “We see patients that have a variety of bowel complaints who come to the primary care provider. It would be helpful to have a less invasive marker looking for inflammatory bowel disease rather than going directly to something like colonoscopy.”

Diagnosing children with IBD can be especially challenging as they may not show symptoms, such as diarrhea or blood in stool, the way adults do. Instead, children may only show signs of growth failure, even if they have had IBD for years.

Dr. Konikoff encourages primary care providers to keep in mind that children may not show obvious symptoms and consider less invasive stool or blood testing to screen for the condition before referral to a pediatric gastroenterologist.

The Possible Role of Diet in IBD
Gastroenterologists and dietitians on their staff may also help patients manage nutrition during flare-ups or to promote growth in children. Though patients may try many diets, such as carbohydrate-specific diets or dairy-free diets, no research currently backs any specific dietary therapy to manage IBD.

“We are starting to see more of a focus in research on diet and how that interacts with Crohn’s disease,” says Dr. Konikoff. “There are some newer studies that we are participating in looking at the role of diet in Crohn’s disease. Moving forward, I wonder if that will become a larger part of our treatment arsenal.”

Research at CHKD currently focuses on variants of the specific carbohydrate diet. While it is still too early to recommend the diet to all patients, the research is offering valuable insights on how to use diet alongside medications.

As researchers and physician develop more targeted medications, diets and surgeries for IBD, patients can expect to experience better quality of life and management of these conditions.

A Review of Opioid Prescription and Treatment Changes in 2017

By Bonnie P. Lane

With the declaration of a growing opioid crisis in Virginia, last year the Virginia Board of Medicine adopted regulations attempting to counteract the issue throughout the Commonwealth.

The regulations governing the prescribing of opioids and buprenorphine were initially enacted on March 15, 2017, with emergency regulations adopted on August 28, 2017, revising and replacing the March version. The August version replaced the term substance “abuse” with substance “misuse,” provided that pregnant women “may” be treated with buprenorphine mono-product, (as opposed to “shall”), and included a prohibition on the prescribing of buprenorphine mono-product in tablet form for chronic pain. Finally, with the treatment of addiction, “for patients who have a demonstrated intolerance to naloxone, such prescriptions for the mono-product shall not exceed 3% of the total prescriptions for buprenorphine written by the prescriber and the exception shall be clearly documented in the patient’s medical record” was added. The regulations do NOT apply to (1) the treatment of acute or chronic pain related to cancer or a patient in hospice or palliative care, (2) the treatment of acute or chronic pain during an inpatient hospital admission or in a nursing home or assisted living facility that uses a sole source pharmacy, or (3) a patient enrolled in a clinical trial as authorized by state or federal law.

Overall, these regulations apply to the evaluation and treatment of acute and chronic pain patients and to the prescribing of and treatment with buprenorphine for addiction treatment.  For both acute and chronic pain patients, non-opioid treatment must be considered prior to treatment with opioids, the PMP must be queried, and a history and physical examination must be conducted. For chronic pain patients, a mental status examination must also be conducted and documented, and the risks and benefits of opioid therapy must be discussed. Acute pain opioid prescription is limited to a seven day supply (fourteen days for treatment for a surgical procedure).  Opioid treatment for chronic pain patients must be reevaluated every three months and the rationale for continuation documented. Urine drug screen or serum medication levels must be conducted at the start of chronic pain management, at least every three months during the first year of treatment, and at least every six months thereafter. Buprenorphine without naloxone is restricted to pregnant patients or when converting patients from methadone or buprenorphine without naloxone to buprenorphine with naloxone for no longer than seven days. Additionally, practitioners engaged in office-based opioid addiction treatment with buprenorphine shall have obtained a SAMHSA waiver and the appropriate DEA registration.  As always, thorough and consistent documentation of evaluations and medical decisions related to opioid treatment is critical.

Looking forward, with a newly elected Governor and recent shake-up to the membership of the General Assembly, we can anticipate additional legislative changes. Several bills are currently proposed regarding the prescribing of opioids for treating pain and addiction. To read more on the proposed bills, please visit the “Crux of the Matter” blog on my firm’s website.

Reference: 18 VAC 85-21-10 et seq.

Bonnie P. Lane is an attorney at the Norfolk office of Goodman Allen Donnelly PLLC, and focuses her practice primarily on medical malpractice defense litigation and healthcare issues. www.goodmanallen.com