Transcript CKD - Foma District 2

Timely Referral in CKD
Primary Care and Nephrology as a
Team
Jamal Salameh, M.D.
An Epidemic of Kidney Disease
Prevalence CKD stages 1- 4
10% 1988-94
13% 1999-2004
Coresh, JAMA 298:2038, 2007
Stage 5: GFR <15
Stage 4: GFR 15–29
n=300,000
n=400,000
Stage 3: GFR 30–59
n=7,600,000
Stage 2: GFR 60–89*
n=5,300,000
n=5,900,000
Stage 1: GFR ≥90*
Total=20 million USA
Clinical Practice Guidelines for CKD Am J Kidney Dis. 2002;39(suppl 1):S17–S31.
GFR = glomerular filtration rate (mL/min/1.73 m2); *with kidney damage
Scope of Chronic Kidney Disease (CKD) in
the US
•
There are over 8 million people in the US
with advanced CKD
Stage 3 and 4 CKD
Stage 5 CKD
•
15-20 million people
500,000 people
There are over 360,000 patients currently
on Renal Replacement Therapy
• 110,000 patients start Renal Replacement
Therapy every year
• The cost of End Stage Renal Disease Care
(ESRD) to Medicare exceeds $40 Billion per
year
Screening
• Screening Should Include:
– Laboratory studies to include serum creatinine and
eGFR
– Urinalysis to determine the presence of proteinuria
– Imaging studies such as ultrasound
Screening recommendations are provided in KDOQI,
Guideline 1
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
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ADD-CKD Study
• Over half of primary care clinicians recognize
CKD diagnostic criteria yet only 12.1% of
people with CKD with CKD were diagnosed.
• 84.8 % of individuals with type -2 diabetes
had eGFR data in the past 15 months yet only
12.1% of people with CKD were diagnosed
Szczech LA, et al. PLoS One 9(11);
2014:e110535
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Improved CKD diagnosis driven by the
PC clinician…
• Studies demonstrate when a CKD diagnosis is
identified by the PC clinician:
– Significant improvements are shown in
• Increased urinary albumin testing
• Increased appropriate use of ACEi or ARB
• Avoidance of NSAIDs prescribing among patients with
low eGFR
• Appropriate nephrology consultation
• Improved patient quality of life
• Decreased healthcare costs
•
Improved Diagnosis
Improves Outcomes
NSAID prescribing
• There was significantly
decreased after the
implementation of eGFR
reporting, and there were
significant improvements
in estimated renal
function in patients who
stopped taking NSAIDs.
Hence eGFR reporting
may result in safer
prescribing.1
increased overall
mortality in the late
referral group as
compared with the early
referral group. The
duration of hospital stay,
at the time of initiation of
renal replacement
therapy, was greater in
the late referred group by
an average of 12 days.2
1. Wei, L., MacDonald, T.M., Jennings, C., Sheng, X., Flynn, R.W., & Murphy, M.J. (2013). Estimated GFR reporting is
associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function. Kidney In,
84(1), 174-8.
2. Chan, M.R., Dall, A.T., Fletcher, K.E., Lu, N., & Trivedi, H. (2007). Outcomes in patients with chronic kidney disease
referred late to nephrologists: a meta-analysis. Am J Med, 120(12), 1063-1070.
KDOQI CKD Definition
• eGFR < 60 ml/min/1.73 m2 for 3 months or longer
OR
• Spot urine albumin/creatinine ratio of >30 mg/g in 2 of 3
urine samples
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The Early NHANES III Study
Analysis of Prevalence of CKD by Stage
eGFR Range
Population
(1,000’s)
Population
(%)
Stage
Description
1
Kidney
damage with
normal or
increase GFR
≥ 90
5,900
3.3 %
2
Mildly
decreased
GFR
60-89
5,300
3.0 %
3
Moderately
decreased
GFR
30-59
7,600
4.3 %
4
Severely
decreased
GFR
15-29
400
0.2 %
5
Kidney Failure
< 15
300
0.1%
(ml/min/ 1.73 m2)
- Adapted from NHANES III (2000)
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The Scope of CKD
The Renal Continuum of Care
Primary Care
Physician
At Risk
Population
Diabetes
Hypertension
Obesity
CVD
Nephrologist
CKD
ESRD
500,000+ People
~375,000 Dialysis
26,000,000+ People
~125,000 Transplant
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Do CKD patients need special care?
• CKD Prevalence is quite high
–
–
–
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A worldwide public health condition-20 million patients in US
Poor outcomes
High cost of care-a problem for Value Based Health Care
Warrants Strategic Interventions by a network of providers
• Morbidity and Mortality is high
– CKD Stage 3 (eGFR of 30-59)
• 1.1% risk of progression to ESRD
• 24.3% mortality risk before ESRD
– CKD stage 4 (eGFR of 15-29)
• 17.6% risk of progression to ESRD
• 45.7% mortality risk before ESRD
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Primary & Secondary Prevention for CKD
Patients
• The 2006 CDC expert panel on CKD identified 3 Prevention Strategies:
– Primary Prevention-aimed at preventing and treating CKD risk factors
– Secondary Prevention-begins with the diagnosis of CKD
• CKD stages 1 & 2 (eGFR >60) attention to guidelines for good
management of DM and HTN and CKD education
• CKD stage 3 (eGFR 30-59) attention to therapy for CKD related
complications such as anemia and hyperparathyroidism and CV disease
• CKD stage 4 (eGFR 15-29) preparation for Renal Replacement Therapy
with education about treatment choices and preparation for chronic
access AND Dealing with worsening problems above (anemia, fluid xs, K
level , etc…)
– Tertiary Prevention- adequate renal replacement therapy
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CKD Care: Co-morbidities and Complications
•
Establish CKD diagnosis and Details:
– Make a specific renal disease diagnosis if possible
– Determine the severity of CKD (know the eGFR)
– Identify co-morbidities
• Hypertension
• Diabetes
• Cardiovascular Disease
– Identify CKD Complications
• Anemia (know the Hgb)
• Secondary Hyperparathyroidism (know the Ca and Phos and PTH)
• Malnutrition (know the albumin)
• Metabolic Acidosis
• Fluid Overload
– Assess stability of Kidney Function and CKD Stage
Recommendations for further evaluation are outlined in KDOQI Guideline 2
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
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CKD and Cardiovascular disease
• Framingham Heart Study:
-Prevalence of CVD 18% in Males and 21% in Females with
CKD
-In Males Cr 1.5-3 and Females Cr 1.4-3
-Compared to 14% in M and 9% in F with Normal Serum
Creatinine levels
-CVD Mortality in CKD patients is More Likely than the
Development of ESRD (198 DIED, 10 ESRD)
-Timely Referral for Cardiovascular disease screening
decreases Morbidity and Mortality.
Benefits of Early Identification and Treatment
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Renal Function Preservation
Decline in Morbidity and Mortality
Decline in Number of Hospitalizations
Decline in Duration of Hospitalizations
Increase in Access placement
Appropriate Anemia Management
Improves Quality of Life
Renal Function Preservation
• In one study 726 patients newly referred to
Nephrology saw the rate of decline in GFR drop from
5.4 ml/min per year from the 5 years prior to 0.35
ml/min/year during the 5 years post referral
• The Protective Effect of Therapy has greatest impact
if initiated before Creatinine exceeds 1.5 to 2 mg/dl
or a GFR of < 60 ml/min per 1.73 m2
• If the patient has a GFR of 30 and still has more than
10 years to live then then ESRD is a distinct
possibility. Many different possibilities here.
Timely Referral to Nephrology
• 30-40% of referrals to nephrologists occur less than 120 days
prior to starting dialysis
• Referral to nephrology <4 months before starting dialysis is
considered a “Late Referral” by Medicare and other Payers
• Timely Referral to Nephrology creates the opportunity for
Modality Education, creation of a permanent dialysis access,
and management of CKD complications like Anemia,
Malnutrition, sHPT, Fluid overload, Metabolic Acidosis, etc…
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Timely Referral: Mortality
• In the CHOICE Study Late Referral is associated with an
increased RISK OF DEATH
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Timely Referral: Long-lasting benefits
• “Late Referral” patients have a 44% higher risk
of mortality in the first year of dialysis
compared to “Early Referral” patients
• These patients start Hemodialysis with a
catheter and poor nutritional status, fluid
overload, poorly controlled HTN and
significant anemia and endocrinopathy and
die of sepsis commonly
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Timing of Nephrologist Referral and AV Access
Use: CHOICE Study
• Cohort of 356 Dialysis patients in CHOICE
• Patients seeing Nephrologist at least 1 month prior to
start of dialysis 39% AVF/G vs 10%
• At 6 month mark on HD this effect as 74% vs 56%
• Patients referred w/in 1 month of dialysis had a median
of 202 days compared with 19 days of Catheter use for
patients referred > 12 months prior
•
Prospective Study of ESRD patients in Korea
• 1028 patients with ESRD comparing ER vs LR
• Survival was increased by 240 % (Hazard Ratio 2.4)
• Time to incident dialysis ER 62 mos vs 3 mos for LR
• Catheter use in 44% ER vs 52% LR
Timely Referral: Quality of Life
• Timely Referral improves Quality of Life in CKD
patients
– First dialysis is a planned event avoiding a “Crash” into Dialysis
– Dialysis Access is established
– Families and Patients are prepared
– Appropriate use of Erythropoeisis-Stimulating Agent (ESA) therapy for
treating anemia
– Modality of Dialysis can be tailored to the patient’s needs
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Timely Referral: Healthcare Costs
• Timely Referral  Lowers Healthcare Costs
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Reduced Hospitalizations
Improved management of co-morbidities
Reduced complications from cardiovascular disease
Delayed deterioration of residual renal function and the
need to start Renal Replacement Therapy
– Enhances patient choices for treatment modalities
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Improved Diagnosis
Improves Population Health
• CKD patients & their co-morbid
conditions drive significant
healthcare costs across the board.
• HHS goal to have 85% of all
Medicare fee-for-service payments
tied to quality or value by 2016, and
90% by 2018.
Burwell, S. Setting Value-Based Payment Goals – HHS Efforts to Improve U.S. Health Care. New England Journal of
Medicine. (2015);DOI:10. 1056/NEJMp1500445
Benefits of Timely Referral in CKD Care
• Slower progression to ESRD
• Increased functional status
• Decreased Morbidity and Mortality from fewer
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Hospitalizations
CVD events
Urgent Care & Emergency Visits
Medication Management complications
• Decreased costs from fewer urgent complications
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Benefits of Timely Referral in Preparation for
Renal Replacement Therapy
• Patient Education and Preparation associated with Timely
Referral are critical for:
– Timely vascular access placement
– Reduced use of dialysis catheters
– Modality Choice for Patients
• Home Therapies
– Peritoneal Dialysis
– Home Hemodialysis
• Transplantation
• In-Center Hemodialysis
• Palliative or End of Life Care
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Coordinated Roles in the care of the CKD Patient
• Primary Care Provider
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Early identification of CKD patients
Focused & Structured evaluation and management
Referral and co-management with nephrologist
Co-Management of Co-Morbid Diseases
• Nephrologist and the Renal Care Team
– Focused assistance in management of co-morbidities
•
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Diabetes, Hypertension, Cardiovascular disease
Anemia, Mineral Metabolism, Nutrition & Volume management
Vascular Access Preparation & Management
Education on ESRD treatment options & modality selection
– Co-management of Medications, Family and Social Issues of Renal Disease
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Rethinking the CKD Clinic
•
Second Tier components of CKD Care
1. Protocols and tools for Anemia, Mineral
Metabolism and Nutrition Management (sharing
best practices)
2. Communication tools for Co-management of Comorbidities (DM, HTN, CVD)
3. Communication tools for exchanging Problem
Lists, Medication Lists and Plan of Care with all
Providers
4. Best Resources allocations based on Best
Practices
CKD Care: PCP & Nephrology Team
• Various Descriptors of the PCP / Nephrology Team
Relationship in CKD care
– “Joint Care” between PCP and Nephrology Team
– “Co-Management” as shared care with defined roles between PCP
and Nephrology Team
– “Combicare” as care from an informed PCP working with support from
the Nephrology team
– “Right Care” denoting jointly working together to provide the Right
Care for the CKD patient
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Treatment Options/Kidney Smart
• This multidisciplinary education improves patient and family
understanding of CKD and treatment options including
transplantation and dialysis
• Treatment Options education has been proven to increase the
percentage of patients who chose Home Therapies and who
start dialysis with a permanent access
• Treatment Options education may best be provided by a
variety of encounters including clinic encounters &
Nephrology Practice Educational programs
• CKD Coordinated Care should track and coordinate all
Treatment Options Education encounters for every
appropriate patient
Timely Referral Decision Making
• Timely Referral Guidance:
– Rapidly decreasing renal function REFER
– Abnormal eGFR AND proteinuria or glucose/casts/cellularity not a uti
 REFER
– Proteinuria  REFER
– eGFR ≤ 60 ml/min/ 1.73 m2  REFER
– Uncontrolled Hypertension Present  REFER
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“Improving the way care is
delivered is central to our reform
efforts. We have put into place
policies to encourage greater
integration within practice sites,
greater coordination among
providers, and greater attention
to population health.” - HHS
Burwell, S. Setting Value-Based Payment Goals – HHS Efforts to Improve U.S. Health Care. New England Journal of
Medicine. (2015);DOI:10. 1056/NEJMp1500445
Jamal Salameh, M.D.
First Coast Nephrology
904 744 4448