Transcript Advanced CKD Patient Management Toolkit Optimizing the

Optimizing the Care of Patients With
Advanced Chronic Kidney Disease
1
Overview
I.
Why is optimizing care of advanced chronic kidney
disease (CKD) patients important?
II. What’s involved in following the new advanced
CKD guidelines?
III. What practical approaches/tools can we use to ensure
guideline-based care?
2
I. Why Is Optimizing Care of Advanced
CKD Patients Important?
1. The number of patients with kidney failure is rising
350,000
Prevalent dialysis patients
(2003: 324,826)
300,000
250,000
200,000
Prevalent transplant patients
(2003: 128,131)
150,000
100,000
50,000
0
Incident dialysis patients
(2003: 100,499)
88
90
92
94
96
98
00
02
United States Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal
Disease in the United States, National Institutes of Health:67.
3
Adjusted Prevalent ESRD Rates: 2003*
1,580 + (1,835)
1,480 to <1,580
1,370 to <1,480
1,270 to <1,370
<1,270 (1,167)
*Per million population.
Point prevalent end-stage renal disease (ESRD) patients; Medical Evidence form data; by HSA; rates
adjusted for age, gender, & race.
United States Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal
Disease in the United States, National Institutes of Health:73.
4
I. Why Is Optimizing Care of Advanced
CKD Patients Important?
2. Advanced CKD involves multiple complex issues:
A. Anemia
B. Bone disease
C. Hypertension
D. Nutrition
E. Dyslipidemia
F. Counseling and rehabilitation
These 7
areas are
addressed
by the
RPA
guidelines
G. Preparation for renal replacement
Renal Physicians Association Clinical Practice Guideline #3: Appropriate Patient
Preparation for Renal Replacement Therapy, October 2002.
5
I. Why Is Optimizing Care of Advanced
CKD Patients Important?
Proportion Surviving Unadjusted
3. Intervention makes a difference
1.00
0.98
0.96
0.94
Hgb  13.0
0.92
12.0  Hgb  13.0
11.0  Hgb  12.0
0.90
10.0  Hgb  11.0
0.88
9.0  Hgb  10.0
0.86
Hgb  9.0
0.84
0.82
0.80
0
15 30 45 60 75 90 105 120 135 150 165 180
Follow-Up Time (days)
Ofsthun, N. Kidney Int. 2003;63(5):1908-14. Used with permission from
Kidney International.
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I. Why Is Optimizing Care of Advanced
CKD Patients Important?
3. Intervention makes a difference

Malnutrition at the start of dialysis is associated with
increased mortality
2.5
Relative Risk of Death
2.16
2.0
1.92
HD
1.79
1.66
PD
1.5
1.20
1.09
1.0
1.00 1.00
0.87
0.98
0.5
0.0
<2.5
2.5-3.0
3.0-3.5
Serum Albumin at Start of Dialysis (g/dL)
2,897 HD and 666 PD Patients who began dialysis in 1986-1987.
HD=hemodialysis; PD=peritoneal dialysis.
Port F. Kid Int. 1994;46:1731.
7
3.5-4.0
>4.0
3. Intervention Makes a Difference

8
Poor outcomes related to delayed referral of CKD patients
have been documented by numerous papers over the
last decade
Impact of Timing of Nephrology Referral and
Pre-ESRD Care on Mortality Risk Among New
ESRD Patients in the US
USRDS Dialysis M/M Study (N=2,264)
 57% had not seen a nephrologist 1 year prior to dialysis
 34% had permanent vascular access, 11% fistula; 25%
were using EPO
 32% had first nephrologist encounter 4 months prior (LR)


Late referrals had lower serum albumin and Hct (11% using
EPO), lower fraction with permanent vascular access/more
catheters
The 28% who saw a nephrologist at least twice in the year
prior to dialysis had a mortality benefit: RR=0.8
Stack AG. Am J Kid Dis. 2003;41:310-318.
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Impact of Timing of Nephrology Referral and
Pre-ESRD Care on Mortality Risk Among New
ESRD Patients in the US

Late nephrology referral






is a common problem,
is associated with suboptimal pre-ESRD care,
allows little time to manage complications of advanced CKD
and prepare for RRT,
is independently associated with greater death risk
More frequent pre-ESRD (CKD) care by nephrologist confers
increased survival benefit
Need exists for improved communication between
nephrologists and PCPs and ER to CKD clinics
Stack AG. Am J Kid Dis. 2003;41:310-318.
10
I. Why Is Optimizing Care of Advanced
CKD Patients Important?
4. Assessment makes a difference
 Majority
of patients start RRT without a permanent
vascular access

Permanent access placed or attempted before start of ESRD?
Unsure
7.9%
No
43.9%
Yes
48.2%
USRDS 1996 Annual Data Report. National Institutes of Health, National Institutes of
Diabetes and Digestive and Kidney Diseases. Bethesda, MD, 1996.
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I. Why Is Optimizing Care of Advanced
CKD Patients Important?
4. Assessment makes a difference (cont’d)
 BP less than 130/80
 Use antihypertensive agent
 Attention to nutrition
 Treatment of anemia
 Treatment of hyperphosphatemia
 Treatment of hyperlipidemia and other CV risk factors
 Referring patients to a nephrologist for an early opinion
 Proactive permanent vascular AV fistula
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I. Why Is Optimizing Care of Advanced
CKD Patients Important?
5. Early treatment makes a difference
Brenner BM, et al. N Engl J Med. 2001;345:861-869.
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II. What’s Involved in Following the
New Advanced CKD Guidelines?
1. Identify patients with advanced CKD
2. Plan: Develop and communicate a management plan
3. Manage: Provide ongoing monitoring and treatment
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II. What’s Involved in Following the
New Advanced CKD Guidelines?
1. Identify patients with advanced CKD
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
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15
Measure serum creatinine in patients at high risk for
CKD (eg, diabetes, hypertension, elderly, cardiovascular
disease, other)
Calculate GFR
Flag patients with low GFR (eg, on problem list)
II. What’s Involved in Following the
New Advanced CKD Guidelines?
2. Plan: Develop and communicate a management plan


16
Select patient goals within the 7 guideline areas
Decide who is responsible for each aspect of advanced CKD
care (nephrologist vs non-nephrologist)

In general

For each patient
II. What’s Involved in Following the
New Advanced CKD Guidelines?
3. Manage: Provide ongoing monitoring and treatment

Order and track laboratory tests

Adjust therapy based on targets

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Educate patients appropriate to their disease stage,
capabilities, and preferences
III. What Practical Approaches/Tools
Can We Use?
Physician tools
1. Identify
Identification tools
2. Plan and communicate
Communication and
reminder tools
Education resources
CKD classes
Management tools
Diary
3. Manage
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Patient tools
III. What Practical Approaches/Tools
Can We Use?

Identification tools
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19
CKD Identification and Action Plan (card and poster)
GFR calculator (slide-rule, resources for calculations on
Palm/hand-held PC device/Web sites)
Chart stickers
Chronic Kidney Disease:
Identification and Action Plan
Stage
Description
GFR/
(mL/min)*
Action
Increased risk for CKD
90
 Screen for CKD risk factors‡
1
Kidney damage§ with
normal or increased GFR
90




2
Kidney damage with mildly
decreased GFR
60-89
• Adjust medication doses
• Minimum yearly assessment of rate of GFR
decline
3
Moderately decreased GFR
30-59
• Minimum biyearly GFR assessment
• Screen for complications every 3 months
and treat if present
4
Severely decreased GFR
5
Kidney failure
15-29
15
Diagnosis of cause of CKD and treat
Screen and treat progression risk factors||
Treat comorbid conditions
Screen and treat cardiovascular risk factors
• Refer for preparation for renal
replacement therapy
• See RPA clinical practice guidelines at
www.renalmd.org
Management
Responsibility†
Many can be managed
primarily by PCP; nephrology
consult helpful for diagnosis
of cause of CKD and
treatment plan
Consider periodic consultation
or co-management with
nephrologist, especially in
patients with complications
or progression
Regular follow-up by
nephrologist recommended
• Begin replacement if uremic
Adapted from Am J Kid Dis. National Kidney Foundation, [K/DOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification and Stratification, S17-S31, ©2002, with permission from National
Kidney Foundation.]
*GFR is preferred over creatinine alone for assessing kidney function.
†This is the view of the RPA.
‡,§,See next slide for list.
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CKD Identification
CKD Risk Factors
•
•
•
•
•
•
•
Hypertension
Diabetes
Age 60
Family history of CKD
Nephrotoxic drug exposure, including NSAIDs
Cardiovascular disease
History of acute renal failure
•
•
•
•
•
Autoimmune disease
Urologic disorders
Systemic infection
Cancer
Ethnic minority
Indicators of Kidney Damage
•
•
•
•
•
•
Proteinuria
Hematuria
Other urine sediment abnormalities
Structural (imaging) abnormalities
GFR 60 mL/min*
Other abnormal blood tests†
*GFR is preferred over creatinine alone for assessing kidney function.
†See “Potential Complications” in CKD: Identification and Action Plan.
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GFR Calculator
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III. What Practical Approaches/Tools Can
We Use?

Communication and reminder tools
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23
Awareness Letter from nephrologist to referring physician
Referring Physician Faxback Form
Post-Consult Letter
< FAX HEADER >
Date: __________________
From: ________________________________
To: ____________________
Fax # ________________________________
Fax # __________________
Phone # ______________________________
Phone # ________________
______________________________________________________________________________________________________________
TO BE COMPLETED BY NEPHROLOGIST
Dear Doctor ____________________
Thank you for referring your patient, ________________________, for nephrology consult. Your patient has been given an appointment on
___/___/___. If this time frame is not what you consider best, please let me know.
The following results may be helpful to have in hand — if available, please fax to my office prior to the consult visit.
- CBC
- Serum Creatinine (if available, prior results as well as current)
- Electrolytes, bicarbonate, urea, calcium, phosphorus, glucose, albumin, lipids
- Urine analysis
- Renal ultrasound
Thanks again. I look forward to seeing your patient.
_________________________________________
_____________________________________________________________________________________________________________________
< FAX HEADER >
Date: __________________
From: ________________________________
To: ____________________
Fax # ________________________________
Fax # __________________
Phone # ______________________________
Phone # _________________
TO BE COMPLETED BY REFERRING PHYSICIAN (attach med list and labs if applicable)
- Please find attached requested labs/information
- Purpose of referral:
- For opinion only
- To develop a co-management plan
- For comprehensive management
Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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Dear Dr. :
Thank you for asking me to assist in the care of your patient __________________________ who was seen in my
office on ___ /___ /___ for evaluation of chronic kidney disease (CKD). S/he has a serum creatinine of ______ mg
%, with an estimated GFR of ______ ml/min/1.73m2 (Stage 1 / 2 / 3 / 4 / 5 CKD).
The major issues that need to be addressed at this stage are: establishing the cause of the CKD, optimizing BP, lipid,
and diabetes management, evaluation and treatment of anemia, calcium, phosphorous, and metabolic derangements,
avoidance of nephrotoxic agents, attention to nutrition, education about renal replacement therapy options, and
referral for vascular access when appropriate. I anticipate that over the next year, I will need to see your patient every
___ months. We will be reminding your patient to avoid venipunctures in either arm, but especially the nondominant
arm. The best place for blood drawing is the dorsum of either hand, if possible.
I ordered certain studies at my visit with him/her and will forward the results to you as they become available. I plan
to focus my attention on achieving BP goal (<130/80), managing renal-related bone disease and anemia, and ongoing
review of medications/doses that may need adjustment in advanced CKD. We will also arrange for nutritional
counseling, education on modalities of renal replacement therapy, and referral for vascular access at an appropriate
time. If you would prefer to primarily manage any of the above areas of care, please let me know, and
we can agree on appropriate goals.
I will send a letter or copy of office note after each office visit. The patient’s next appointment is ___ /___ /___. If
you have any questions or concerns, please do not hesitate to contact me. The best way to reach me is by
telephone ( ___ - ___ - ___ ) /beeper/mobile ( ___- ___-___ ).
Sincerely yours,
_____________________________________
Date:______________________
III. What Practical Approaches/Tools Can
We Use?

Management tools



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Management Flow Sheet to be inserted in patient chart
(also serves as a reminder and as a data repository for
performance measurement)
Algorithms for clinical issues (eg, anemia management,
hypertension management)
Patient diary to be filled in by patient/family and brought
to all doctor visits
ADVANCED CKD PATIENT MANAGEMENT FLOW SHEET
Patient Name:
Action/Measure
(Area of Guidance)
Target
Minimum
Frequency
Serum
Creatinine/GFR
Decrease
rate of GFR
decline
Depends on
stage, rate of
change, and
clinical factors
Hemoglobin
11–12 g/dL
Every
3 months
Bicarbonate
>22 mmol/L
Every
3 months
Phosphorus
<4.5 mg/dL
Every
3 months
(Anemia)
(Bone disease)
(Bone disease)
Low phosphorus diet prescribed
Phosphate binder prescribed
Calcium
8.5–10.5
mg/dL
Every
3 months
iPTH
Not >100
pg/mL or
1.5xnormal
Every
3 months if Ca
or PO4
abnormal
(Bone disease)
(Bone disease)
25(OH)
Vitamin D
>30 ng/mL
(Bone disease)
Blood pressure
(Hypertension)
130/80
mmHg
If iPTH
abnormal
Every
3 months
ACEI or ARB dose increased or new
agent prescribed
Body Weight
(Nutrition)
Albumin
(Nutrition)
LDL
(Lipid)
Unintentional
Weight loss
<5%
Every
3 months
>4.0 g/dL
by BCG
assay, or
>3.7 g/dL by
BCP assay
Every
3 months
<100 mg/dL
3 months
following a
change in
status, then
annually
RRT modality discussion (Timing)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Algorithm for Management of Anemia1
Check Hb every 3 months
Patient is anemic? *
Perform complete workup for anemia
including iron studies
Yes
No
Iron deficiency**
identified?
Yes
Iron Therapy
No
Patient remains
anemic? *
Prescribe EPO/analogue
and check BP at every
dose
1RPA
Yes
CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy.
*Anemia = <12 g/dL for women, <13 g/dL for men
**Iron deficiency = TSAT < 20% or ferritin < 100 mcg/mL
28
No
Algorithm for Management of
Hypertension1
Check blood pressure at every office visit
(at least every 3 months)
BP 130/80
BP 130/80
Advise therapeutic life style changes*
On ACEI or ARB?
No
Add ACEI or ARB
Yes
Intensify antihypertensive therapy1
* Therapeutic lifestyle changes (TLC) include weight reduction, the DASH diet, salt restriction, physical activity, and moderation of
alcohol.(JNC-VII)
1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy
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Algorithm for Management of
Bone Disease1
Measure calcium, phosphorus and iPTH levels
All normal
iPTH level high* and phosphorus
level normal or high
Check calcium and
phosphorus levels at least
every 3 months
iPTH level normal and Phosphorus
level high**
Low phosphorus diet
Measure 25 (OH) vit D
Normal
Low***
Low phosphorus diet
Prescribe vit D2 and low phosphorus diet
Re-check phosphorus levels after 1 month
Phosphorus level high
Phosphorus level normal
Prescribe phosphate
binder
Repeat iPTH levels in 3 months
iPTH level still high
iPTH levels normal
Prescribe 1,25 vitamin D analogue
Check calcium, phosphorus and
iPTH levels at least every 3 months
30
*High iPTH level: >100 pg/mL or >1.5 times the upper limit of normal for each assay used
**High Phosphorus level: 4.5 mg/dL
***Decreased 25 (OH) vitamin D: 30 ng/mL
NB: Caution should be used with vitamin D analogue when serum calcium is in the upper range of normal.
1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy
Algorithm for Management of Nutrition1
Monitor body weight and serum
albumin every 3 months
Is there evidence of
malnutrition*?
No
Evaluate for causes of
malnutrition
Non-advanced CKD related
cause identified?
No
(advanced CKD related malnutrition)
Offer nutritional assessment and counseling**
by qualified personnel
Yes
Is the malnutrition
corrected?
Offer diet assessment and
nutritional counseling
Yes
No
Initiate renal replacement
therapy if GFR  20mL/min
* Malnutrition = Unintentional decrease in body weight by more than 5% OR decrease in serum albumin (4.0 g/dL for Bromo-CresolGreen or 3.7g/dL for Bromo-Cresol-Purple) or decrease from baseline by 0.3 g/dL with either assay
** Dietary recommendations include energy intake 30-35 kcal/kg body weight/day, and protein intake  0.6 g/kg body weight/day
1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy
31
Algorithm for Management of
Dyslipidemias1
Monitor for dyslipidemia at
presentation, 3 months after change in
status and annually thereafter. Measure
triglycerides, LDL, HDL, total
cholesterol
Patient has
dyslipidemia?
Evaluate for secondary causes
(comorbidities* and medications**)
Yes
No
Secondary cause*
identified?
No
Yes
Treat dyslipidemia***
Manage secondary cause
* Comorbidities = hypothyroidism, diabetes mellitus/hyperglycemia, nephrotic syndrome, alcohol excess, chronic liver disease
** Medications = beta-blockers, diuretics, corticosteroids, calcineurin inhibitors (especially cyclosporin), sirolimus, oral
contraceptives,
anticonvulsants, antiretroviral therapy
*** Suggested target levels = LDL 100 mg/dL, non-HDL cholesterol 130 mg/dL, fasting triglycerides 500 mg/dL
1 RPA CPG #3: Appropriate Patient Preparation for Renal Replacement Therapy
32
How to Use These Pieces to Optimize
Advanced CKD Care in Individual Practices


33
Guide to Tool Selection
Assessment and Evaluation tools: measure performance
before and after process changes
Putting the Pieces Together

Tool Selection Guide

34
A guide that helps a busy physician select the set of tools that
are applicable to his/her practice and interests
Putting the Pieces Together: Using the
“Guide to Tool Selection”



35
Tools for non-nephrology practices identifying advanced
CKD patients
Tools for non-nephrology practices managing advanced
CKD patients
Tools for nephrology practices
Recommended Tools for Non-nephrology
Practices Identifying Advanced CKD Patients
Purpose
Name of Tool
Page No.
Assessment Tool: Patient Identification
17
Evaluation Tool: Patient Identification
110
CKD Identification and Action Plan Card
74
CKD Identification and Action Plan Poster
75
GFR Calculator
76
CKD Chart Flags/Stickers
81
Nephrology CPT Codes
96
eDrugsRenal
97
Assess practice performance
Identify CKD patients
Improve patient management
36
Recommended Tools for Non-nephrology
Practices Managing Advanced CKD Patients
Purpose
Name of Tool
Page No.
Assessment Tool: Patient Identification
17
Evaluation Tool: Patient Identification
110
CKD Identification and Action Plan Card
74
CKD Identification and Action Plan Poster
75
GFR Calculator
76
Assess practice performance
Identify CKD patients
37
Recommended Tools for Non-nephrology
Practices Managing Advanced CKD
Patients (continued)
Purpose
Improve patient management
38
Name of Tool
Page No.
CKD Chart Flags/Stickers
81
Advanced CKD Management Flow Sheet
86
Advanced CKD Algorithms
90
Nephrology CPT Codes
96
eDrugsRenal
97
Putting the Pieces Together

Assessment and evaluation tools


39
Serve two functions:

Identify problem areas (Assessment tool)

Evaluate the impact of implementation (Evaluation tool)
Provide detailed instructions on performing a quick practice
assessment (before and after implementing guideline) for
two groups:

Physicians referring advanced CKD patients

Physicians managing advanced CKD patients
Summary

Optimizing care of advanced CKD patients is important:



40
The number of patients is rising
Involves multiple complex issues
Improving care makes a difference
Summary (cont’d)

What is involved in following the new RPA advanced
CKD guidelines:



41
Identify patients with advanced CKD
Develop and communicate a management plan
Manage: Provide ongoing monitoring and treatment
Summary (cont’d)

This toolkit suggests a practical approach to implementing
evidence-based best practices* for optimizing care of
advanced CKD patients
*Renal Physicians Association Clinical Practice Guideline #3, Appropriate Patient
Preparation for Renal Replacement Therapy, October 2002.
42
Additional slides
43
Prevalent Counts and Adjusted ESRD Rates
by Race
Counts
Rates
5,000
Rate Per Million Population
Number of Patients (in thousands)
500
400
300
200
100
0
4,000
3,000
2,000
1,000
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
White
Black
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Native American
Asian
All
Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age & gender.
United States Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal Disease
in the United States, National Institutes of Health: 73.
44
Prevalent Counts and Adjusted ESRD Rates
by Ethnicity
Rates
60
2,500
Hispanic/All
40
Hispanic/Mexican
20
Hispanic/Non-Mexican
Rate Per Million Population
Number of Patients (in thousands)
Counts
Hispanic
2,000
All
1,500
Non-Hispanic
1,000
0
1996 1997 1998 1999 2000 2001 2002 2003
1996 1997 1998 1999 2000 2001 2002 2003
Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age & gender. For Hispanic
patients we present data beginning in 1996, the first full year after the April 1995 introduction of the
revised Medical Evidence form, which contains more specific questions on race & ethnicity.
United States Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal Disease
in the United States, National Institutes of Health: 73.
45
Prevalent Counts and Adjusted ESRD
Rates by Primary Diagnosis
Counts
600
Rate Per Million Population
Number of Patients (in thousands)
200
150
100
50
0
Rates
500
400
300
200
100
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Diabetes
Glomerulonephritis
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Hypertension
Cystic Kidney
Point prevalent ESRD patients; Medical Evidence form data; rates adjusted for age, gender, & race.
United States Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal
Disease in the United States, National Institutes of Health: 73.
46
I. Why Is Optimizing Care of Advanced
CKD Patients Important?
1. The number of patients with kidney failure is rising
700
Number of Patients (in thousands)
661,330
600
500
400
Prevalence
300
372,407
172,667
200
98,953
100
Incidence
0
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
United States Renal Data System 2000 Annual Data Report: Atlas of End-Stage Renal
Disease in the United States, National Institutes of Health:S41.
47
2008
2010