Longterm Practice Management of the Renal Transplant Patient

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Long-term Practice Management of the Renal
Transplant Patient
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Introduction

• Transplant centers are finding it difficult to
  accommodate the rapidly growing number of
  successfully transplanted patients
• Many renal transplant recipients are turning to
  their community nephrologist for optimal
  management
• Long-term practice management is necessary when
  dealing with the unique and complex set of
  medical care needs of the renal transplant patient

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Advantages Offered by the Community Nephrologist

• One-on-one office visits with patients
• Establishes close relationship with patient based
  on trust
• Patient feels safe knowing that the physician is
  familiar with his/her specific medical history
  and condition
• Board-certified internist
• Community nephrologist has been trained to deal
  with pre- and posttransplant comorbidities
• Able to provide successful long-term management
• Convenience
• Patients are more likely to make follow-up visits
  if the medical professional resides in their own
  neighborhood
• A community-based nephrology practice also
  reassures the patient that appropriate medical
  care is minutes, rather than hours, away

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Delivering Optimal Care to Renal Transplant
Patients

• Clinical
• working knowledge of immunosuppression
• cognizance of the complexities involved with
  posttransplant renal care
• facilitating community hospital and laboratory
• Clerical
• an efficient office tracking system
• experienced nurses

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Pretransplant Clinical Objectives

• Patients with chronic kidney disease should be
  evaluated to determine
• diagnosis (type of kidney disease)
• comorbid conditions (eg, hypertension, diabetes
  mellitus, hyperlipidemia, cardiovascular and
  peripheral vascular disease)
• severity, assessed by level of kidney function
• complications, related to level of kidney
  function
• risk for loss of kidney function
• risk for cardiovascular disease

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Pretransplant Clinical Objectives

• Treatment of chronic kidney disease should
  include
• specific therapy, based on diagnosis
• evaluation and management of comorbid conditions
• prevention and treatment of cardiovascular
  disease
• prevention and treatment of complications of
  decreased kidney function
• preparation for kidney failure/replacement
  therapy
• replacement of kidney function by dialysis and
  transplantation, if signs and symptoms of uremia
  present

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Pretransplant Clinical Objectives

• Review of medications performed at all visits
• dosage adjustment based on level of kidney
  function
• medications for comorbid conditions
• potentially adverse effects on kidney function or
  complications of chronic kidney disease
• drug interactions
• Self-management behaviors to incorporate into the
  treatment plan
• diet/nutrition
• healthy lifestyle (ie, no smoking, no drinking)
• exercise

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Posttransplant Clinical Objectives

• Accurate selection and adjustment of
  immunosuppression
• Continued monitoring of immunosuppressive therapy
  prevents the occurrence of adverse effects as
  well the development of posttransplant
  complications, such as
• metabolic disease
• gout
• infections
• malignancy
• osteoporosis
• pregnancy

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Posttransplant Checklist for Transferring Care of
Patient

• Donor type (living/cadaveric)
• HLA matching
• Donor/recipient serology
• Demographics (age, race, gender, state/territory)
• Warm ischemia time (minutes)
• Cold ischemia time (hours)
• Number of rejection episodes (timing, severity,
  resolution)
• Urinalysis or urinary protein/creatinine ratios
• Delayed graft function and duration

• Serum creatinine (1 month, 6 months, and 1 year
  post transplant)
• Glomerular filtration rate
• Lipid levels
• Hepatitis B and C status
• Cytomegalovirus status
• Pretransplant and 6-month posttransplant bone
  densitometry
• Immunosuppressive protocols and target levels
• Changes in therapy that can be expected (both
  immunosuppressives and other medications)

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Pivotal Role Between the Laboratory and
Transplant Center
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Follow-up Protocol
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Monitoring and Timing of Care
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Monitoring and Timing of Care
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Contacting the Transplant Center

• Contact the transplant center when clinical or
  laboratory profile changes occur or acute
  rejection is suspected
• any unexplained change in serum creatinine is
  noted
• suspicion of acute or chronic rejection
• unremitting febrile illness
• suspicion of malignancy
• Consult with the transplant center before making
  major adjustments in immunosuppressive
  medications, such as
• conversion of a calcineurin inhibitor
• addition of another immunosuppressant

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Contacting the Transplant Center

• All drug adjustments should be reported to the
  transplant center. Common medical conditions that
  require medications
• hypertension
• obesity
• diabetes
• hyperlipidemia

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Clerical ExpectationsOffice Staff

• Review your hiring process
• Offer competitive salaries
• Be creative with benefits
• Let employees offer input
• Show appreciation

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Clerical ExpectationsOffice Relations

• Illustrate that physician behavior and adherence
  to practice policies are just as important as
  clinical skills
• Boost the effectiveness of physician meetings
• Administer a work-style behavior assessment to
  understand each partners communication styles
  and needs
• Take a step back and evaluate deeper issues

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Clerical ExpectationsInformation Management

• Increase end-user access to database
• Standardize reports via the transplant center
• Assign information management duties to the
  transplant coordinator
• focuses on increasing efficiency and
  effectiveness of information management within
  the program
• develops data quality assurance system
• provides staff training on distribution of data
• Consider hiring additional support staff for
  transplant coordinators

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Financial Implications

• Understand insurance policies (dialysis versus
  transplant patient)
• Prepare claims using appropriate coding practices
• Secure appropriate payment for products (ie,
  reimbursement for immunosuppressive agents)

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Annual RevenueESRD Versus Transplant Patient
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Nephrology Code Reminders

• Renal disease is classified into categories
  580 through 593
• Both chronic renal failure and ESRD are coded as
  585, Chronic Renal Failure
• If both acute renal failure and hypertension are
  present, a code from category 584 is assigned for
  the acute renal failure with an additional code
  for hypertension
• Do not code symptoms if the underlying disease is
  established

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Nephrology Code Reminders

• Diabetic nephropathy is coded into diabetes with
  renal manifestation using 250.4x, with the
  appropriate fifth digit
• If a patient is admitted for dialysis to an
  outpatient facility, V56.0 or V56.8 should be
  used as the principal diagnosis
• Complications as a result of dialysis therapy are
  common and should be coded to the specific
  complication that occurs
• Suspected conditions
• not possible to code suspected conditions in
  ICD-9-CM
• conditions should be coded to their highest
  degree of certainty

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Pharmaceutical Companies Offering Patient
Assistance

• Fujisawa (Prograf tacrolimus)
• 1-800-477-6472
• Drug to office every 3 months reapply every 6
  months
• Novartis (Sandimmune cyclosporine, Neoral
  cyclosporine)
• 1-800-277-2254
• Drug to patient every 3 months
  reapply every 12 months
• Roche (CellCept mycophenolate mofetil)
• 1-800-772-5790
• Drug to office every 2 months reapply every 12
  months

• Wyeth (Rapamune sirolimus)
• 1-877-472-7268
• Applications to apply for assistance will be sent
  to the office if it is deemed that the patient
  meets the appropriate guidelines
• SangStat/Abbott (Gengraf cyclosporine)
• 510-789-4300

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Conclusion

• There are many benefits of long-term management
  at the community level
• The community nephrologist must address the
  medical issues that are preeminent in the
  successful long-term management of the transplant
  recipient
• clinical objectives
• clerical expectations
• financial implications