Improving Care for Chronic Kidney Disease and Kidney Failure

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Improving Care for Chronic Kidney Disease and
Kidney Failure

• Lesley Stevens MD MS
• MassPro Liaison Meeting
• February 8, 2007

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Why Kidney?

• A sample of calls we receive
• Is this the . department?
• Neurology
• Urology
• Allergy
• Phrenology
• Necrology

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Chronic Kidney Disease is a Public Health Problem

• CKD is common
• 11 of US adults
• Higher prevalence in patients with CVD risk
  factors
• CKD is harmful
• Increased risk for CVD
• Complications of decreased kidney function
• Progression to kidney failure
• We have treatment

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Practice Model for Detection, Evaluation and
Management in CKD
At increased risk
Kidneydamage and Mild ? GFR
Kidneydamage and Normal or ? GFR
Severe? GFR
Kidneyfailure
Moderate ? GFR
Stage 1 Stage 2 Stage
3 Stage 4 Stage 5
GFR 90 60
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Kidney Specialist
Primary care physician
Other health care providers
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Outline

• Kidney Failure
• Chronic kidney disease
• Definition
• Outcomes
• CKD Clinical Action Plan
• Detect CKD
• Prevent progression of CKD
• Diagnosis and treat CVD
• Treat co-morbid conditions and complications
• Refer to nephrology

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Kidney Failure (ESRD) in the US
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Disparities in ESRD Incidence
Incident ESRD patients rates by age adjusted for
gender race, rates by race ethnicity 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.
USRDS 2006
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General Population
General Population
Transplant
Transplant
Dialysis
Dialysis
USRDS 2006
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Stages in Progression of Chronic Kidney Disease
and Therapeutic Strategies
Complications
CKDdeath
Normal
Increasedrisk
Kidneyfailure
Damage
? GFR
Screening for CKDrisk factors diabeteshyperten
sion age gt60family history US ethnic minorities
CKD riskreductionScreening forCKD
Diagnosis treatmentTreat comorbidconditions
Slow progression
EstimateprogressionTreatcomplicationsPrepare
forreplacement
Replacementby dialysis transplant
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NKF K/DOQI Definition of Chronic Kidney Disease

• Structural or functional abnormalities of the
  kidneys for gt3 months, as manifested by either
• 1. GFR lt60 ml/min/1.73 m2, with or without kidney
  damage
• 2. Kidney damage, with or without decreased GFR,
  as defined by
• pathologic abnormalities
• markers of kidney damage
• urinary abnormalities (proteinuria)
• blood abnormalities (renal tubular syndromes)
• imaging abnormalities
• kidney transplantation

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Normal GFR
Wesson Human Physiology of the Kidney 1969
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Prevalence of CKD and Estimated Number of Adults
with CKD in the US (NHANES 99-00)
Based on NHANES 19992000 prevalence and
200,948,641 adults age 20 years and older in 2000
census. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by
dialysis, and assuming 70,000 additional patients
not on dialysis. GFR estimated from serum
creatinine using MDRD Study equation based on
age, gender, race and calibration for serum
creatinine. For Stage 1 and 2, kidney damage
estimated by spot albumin-to-creatinine ratio ?17
mg/g in men or ?25 mg/g in women in two
measurements.
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New ICD-9-CM Codes

• Revise 585 Chronic renal failure Chronic kidney
  disease (CKD)
• New code 585.1 Chronic kidney disease, Stage 1
• New code 585.2 Chronic kidney disease, Stage 2
  (mild)
• New code 585.3 Chronic kidney disease, Stage 3
  (moderate)
• New code 585.4 Chronic kidney disease, Stage 4
  (severe)
• New code 585.5 Chronic kidney disease, Stage 5
• New code 585.6 End stage renal disease
• New code 585.9 Chronic kidney disease,
  unspecified
• Chronic renal disease
• Chronic renal failure NOS
• Chronic renal insufficiency
• Add Use additional code to identify kidney
  transplant status, if applicable (V42.0)

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Complications Related to CKD
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CKD and Other Chronic Conditions Cost Multiplier
Populations estimated from the 5 percent Medicare
sample, include patients surviving the entire
cohort year (1992, 2002) with Medicare as primary
payor, plus period prevalent ESRD patients for
1993 2003. Diagnoses determined from claims in
1992 2002. Patients with ESRD in the 5 percent
sample are excluded, as they are counted in the
ESRD population. Costs are for the second year of
the two-year period.
USRDS Annual Data Report 2005
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CKD Mortality Kaiser Permanente Northern
California
Cardiovascular Deaths
All Cause Mortality
Go A, et al. NEJM 2004
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Longitudinal Follow-up and Outcomes Among
Population With Chronic Kidney Disease in a Large
Managed Care Organization
Keith et al Arch Intern Med 2005
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Chronic Kidney Disease A Clinical Action Plan
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CKD Testing

• Serum creatinine to estimate the GFR
• Urine albumin testing

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Creatinine Generation

• Muscle mass
• Varies by age, sex, race, weight
• Diet
• Short and long term meat intake

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GFR Estimating Equations

• Cockcroft-Gault formula
• Ccr (ml/min) (140-age) x weight 0.85 if female
• 72 Scr
• MDRD Study equation
• GFR (ml/min/1.73 m2) 186 x (Scr)-1.154 x
  (age)-.203 x (0.742 if female) x (1.210 if
  African American)

All labs will be reporting GFR within a few
years On Line Calculator www.kidney.org
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Serum Creatinine vs. est. GFR

• A serum creatinine of 1.2 mg/dl represents
• eGFR 102 in an 18 year-old African American man
• eGFR 66 in a 57 year-old Caucasian man
• eGFR 59 in a 62 year-old African American woman
• eGFR 46 in a 76 year-old Caucasian woman

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At what level of creatinine does a 65-year-old
white woman have chronic kidney disease (CKD)?
77 of physicians said Creatinine gt 1.5 mg/dL
Creatinine 0.94 mg/dL when eGFR 60
mL/min/1.73 m2
Coresh, et al. J Am Soc Nephrol 200516180-188.
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Who should be Tested?

• Age gt 60
• African Americans, Native Americans, Hispanics
  and Asian Pacific Islanders
• Diabetics Hypertensives
• Individuals with known CVD
• Individuals with a family history of CKD

• Source NKF CKD Clinical Practice Guidelines

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Fewer than 20 with CKD know they have the
disease
Coresh, et al. J Am Soc Nephrol 200516180-188.
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Frequency of Testing of Serum Creatinine compared
to other analytes in 277,111 patients who had
blood work testing in Columbus, Ohio
Stevens LA et al. JASN 2005
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Probability of the assessment of 1
microalbuminuria or proteinuria tests within a
year, 2004Figure 1.8
general Medicare patients entering Medicare
before January 1, 2003, age 65 older, alive on
December 31, without a diagnosis of CKD during
2003. Patients enrolled in an HMO or with
Medicare as secondary payor or diagnosed with
ESRD during the year are excluded. EGHP patients
enrolled for the entire year 2003 in a
fee-for-service plan, age 5064, without a
diagnosis of CKD during 2003. Patients diagnosed
with ESRD before or during the year are excluded.
For both populations, diabetes hypertension are
defined in 2003. Patients censored at end of the
plan end of 2004 Medicare patients also
censored at death. All tests tracked in 2004.
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Even High-risk PatientsKidney Disease Rarely
Documented
Discharge Documentation of Kidney
AbnormalitiesDetected During Hospitalization
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DM
HTN
13
11
10
10
8
0
Proteinuria gt1
S. Cr. gt 1.5 mg/dl
McClellan WM et al. AJKD 1997
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Treatments to Slow the Progression of Chronic
Kidney Disease in Adults
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ESRD incidence leveling off?
Incident ESRD patients adjusted for age, gender,
race.
USRDS 2006
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Change in Incidence of ESRD Effect of better
blood pressure or ACEI? Adjusted incident rates
of ESRD due to diabetes
illi
illi
lla
lla
Incident ESRD patients, adjusted for gender.
USRDS Annual Report 2005
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Interventions to Delay Progression Boston-area
chart audit
Kausz JASN 2001 12 1501-7
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Continuation of ACEI/ARBs by New CKD Patients
incident CKD patients, 20002004 combined, from
the Medstat database, 19992004.
USRDS 2006
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CVD Diagnosis in CKD
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CVD Risk Factor Management in CKD
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Reasons for Referral to Nephrologist

• GFR lt30 mL/min/1.73 m2
• Unable to carry out CKD Action Plan
• Undetermined cause
• Spot urine protein/creatinine ratio gt500 mg/g
• High risk for progression
• Difficult to manage complications
• GFR decline without adequate explanation
• Hyperkalemia (gt5.5 mEq/l)
• Resistant hypertension (gt130/80 mm Hg)
• Age lt18 (pediatric nephrologist)

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Referral to Nephrologists
Kinchen et al. Ann Intern Med 2002 137 479-486
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In-Center Hemodialysis Should Not Be the Default
First Choice

• Peritoneal dialysis
• Home hemodialysis
• conventional 3x/week
• daily short hemodialysis
• nocturnal hemodialysis

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Home Hemodialysis Seattle, 1964
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Home Hemodialysis 2007
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Fistula First
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Vascular Access 1992-2004
illi
illi
lla
lla
Period prevalent hemodialysis patients. Data from
Part B claims. Some patients may have more than
one access at a given point in time.
USRDS 2006
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Influenza vaccinations 1993-2003
illi
illi
lla
lla
ESRD patients initiating therapy at least 90 days
before September 1 of each year alive on
December 31 vaccinations tracked between
September 1 December 31 of each year. 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.
USRDS 2006
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Pneumococcal vaccinations 2000-2004
illi
illi
lla
lla
ESRD patients initiating therapy at least 90 days
before the start of the period alive on the
periods last day vaccinations tracked during
entire period. 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.
USRDS 2006
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How Might You Improve CKD Care?

• 1. Raise Awareness
• Medical record correct classification
• Patients, their families and friends
• Clinicians
• Make sure educational materials are readily
  available

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How Might You Improve CKD Care?

• 1. Raise Awareness
• 2. Help with Education
• Who is at risk
• Benefits of continued ACE inhibitor/ARB use and
  of lower blood pressure targets
• CKD is a risk factor for CVD, and need aggressive
  risk factor modification
• Consider kidney replacement options early
• Living donor transplant the first choice, for
  some even in 70s
• Home hemodialysis peritoneal dialysis the
  second choice
• early AVF creation important

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How Might You Improve CKD Care?

• 1. Raise Awareness
• 2. Help with Education
• 3. Coordinate
• Screening of high-risk groups
• Nephrologist and dietician referrals
• Prior authorization erythropoietin, vitamin D
  analogs, ACE inhibitors, ARBs
• Access creation arranging early appointments
• Transportation and reminders
• Immunizations
• Medication follow-up

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Take-Home Messages

• Chronic kidney disease is a public health problem
• outcomes include loss of kidney function and
  cardiovascular disease
• Clinical assessment from laboratory tests
• spot albumin/creatinine ratio to assess kidney
  damage
• serum creatinine to estimate GFR
• You can help improve outcomes
• Facilitate clinical action plan based on stages
  of severity
• Physician, patient, and public education

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You have the Power to Prevent Kidney Disease
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www.nkdep.nih.gov
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New Elderly ESRD Patients Many Diagnoses in
Preceding 2 Years
New ESRD patients aged 75 USRDS 2006
illi
illi
lla
lla
incident ESRD patients age 75 older.
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Frequent Admissions Just Before ESRD
illi
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lla
lla
incident ESRD patients age 67 older, with a
first ESRD service date between January 1, 2003,
June 30, 2004, with Medicare as primary
payor. Data by year include incident patients
from July 1, 1998, to June 30, 1999 (labeled
19981999) from July 1, 2003, to June 30, 2004
(labeled 20032004). Data are unadjusted.
USRDS 2006
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Healthy People 2010 Targets for ESRD Levels
Achieved
USRDS 2006
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Boulware E et al. Am J Kidney Dis 2006 48192-204