Goal - Objective Educate nephrology community about new Pre-ESRD classes and current pilot programs in the greater Houston...
At the end of this presentation the reader will be able to answer <ul><li>Why Kidney Education is important in Chronic Kid...
Chronic Kidney Disease in the US <ul><li>Over 20 Million Americans have some degree of renal insufficiency….1 in 8 people....
CKD EDUCATION <ul><li>Knowledge is Power…for us and our patients.  To educate patients is the highest form of care we can ...
 
Projection for ESRD Population USRDS ADR 2008
Incidence by Race 2008
African Americans Develop ESRD at a Younger Age
New Conditions of Coverage <ul><li>ESRD Medicare Reform </li></ul><ul><ul><li>Medicare Improvements for Patients and Provi...
Why Educate? <ul><li>Why…Educate?  And When?  The earlier the better….Start education by stage 2 or 3 to have the biggest ...
What is community-based education? <ul><li>Patient education program that includes: </li></ul><ul><ul><li>Multidisciplinar...
<ul><li>Find a comfortable location and time. </li></ul>
Location <ul><li>The course does not need to be held in Maui, although it would be nice. A church down the street with a l...
What is Community-Based Education? Multidisciplinary Coaching  <ul><ul><li>Multidisciplinary coaching program </li></ul></...
Multidisciplinary education <ul><li>Multidisciplinary  coaching program can make a difference. </li></ul><ul><li>A nurse, ...
Benefits of early intervention and education <ul><li>Delay or prevent the worsening of cardiovascular disease, hypertensio...
Tools Provided <ul><li>An initial postcard and quarterly e-newsletters </li></ul><ul><li>Valuable tools from a well-regard...
TOOLS FOR BETTER CARE
Health Diary <ul><li>Resource for the patients </li></ul><ul><li>Patient information </li></ul><ul><li>Healthcare phone nu...
The health diary <ul><li>Both the patients and the doctors really like this diary. </li></ul><ul><li>Not only is it a grea...
What stage am I? <ul><li>Stage 1 – GFR ≥ 90 cc/min/1.73m 2 </li></ul><ul><ul><li>Kidney Damage with normal or high GFR </l...
Glomerular filtration rate <ul><li>The serum creatinine by itself is a very POOR way to assess kidney disease. </li></ul><...
Assessment of kidney disease <ul><li>Learning how well the kidney is functioning is important not only in screening and di...
You have heard about Cystatin C <ul><li>Serum creatinine has a drawback in the measurement of glomerular filtration rate (...
Clinical evaluation of patients at increased risk for CKD <ul><li>All Patients </li></ul><ul><li>Measurement of blood pres...
Stage-Specific Education <ul><li>Taking Control of Kidney Disease </li></ul><ul><li>Living with Stage 3 and Early Stage 4 ...
Treatment of CKD <ul><li>Treat the underlying disease </li></ul><ul><li>Treat associated problems </li></ul><ul><li>Slowin...
 
Definition of Chronic Kidney Disease <ul><li>Chronic kidney disease is defined as either kidney damage or GFR < 60 cc/min/...
Clinical Practice Guidelines for Management of Hypertension in CKD Type of Kidney Disease Blood Pressure Target  (mm Hg) P...
Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD
Stages 1 and 2: Preventing Heart Disease in CKD <ul><li>Traditional cv risk factors  </li></ul><ul><li>Non traditional ris...
How Can You Protect Yourself Against Heart Disease And High Blood Pressure? <ul><li>Get regular medical checkups </li></ul...
 
Traditional Risk Factors <ul><li>Smoking </li></ul><ul><li>Cholesterol </li></ul><ul><li>Obesity </li></ul><ul><li>Family ...
Non Traditional Risk Factors <ul><li>Inflammation </li></ul><ul><li>Mineral-bone disorder </li></ul><ul><li>Anemia </li></ul>
ACEs and ARBs <ul><li>These drugs are critical to care starting in Stage 1 and 2 </li></ul><ul><li>ACES and ARBs have a co...
Blood Pressure Is Poorly Controlled in Patients With CKD
Inflammation <ul><li>Associated with CKD </li></ul><ul><li>Atherosclerosis </li></ul><ul><li>Vascular calcification </li><...
Exercise And Kidney Care <ul><li>Talk to your doctor about starting an exercise program that’s right for you. </li></ul><u...
Watch meds and therapies <ul><li>Avoid Metformin in Stage 3 and beyond </li></ul><ul><li>Contrast media –  </li></ul><ul><...
Diet <ul><li>Sodium - 100 mmoles </li></ul><ul><li>Lipids - pre dialysis </li></ul><ul><li>Carbohydrates - Diabetes </li><...
Nutritional Tips For Healthy Kidneys <ul><li>In order to help maintain healthy kidneys it is important to eat properly </l...
Stage 3 – Medical Focus <ul><li>CKD MBD – Metabolic bone disease </li></ul><ul><li>Acidosis - Bicarbonate </li></ul><ul><l...
Stage 3 <ul><li>a. Cardiovascular  risks and therapy –  stay the course </li></ul><ul><li>b. Preparation:   1. Anemia   2....
Preparation <ul><li>Anemia </li></ul><ul><li>Acidosis </li></ul><ul><li>Blood pressure - ACES & ARBS </li></ul><ul><li>Inf...
Anemia in CKD <ul><li>Anemia management with EPO since 1990s -  </li></ul><ul><li>Keep Hct < 42  </li></ul><ul><ul><li>N E...
EPO RBC RBC PRECURSOR
Acidosis <ul><li>Increased protein catabolism of amino acids </li></ul><ul><li>Inhibition of protein synthesis can cause a...
Albumin Synthesis <ul><li>Chronic acidosis impairs albumin synthesis and causes negative nitrogen balance </li></ul><ul><u...
Metabolic Acidosis <ul><li>The kidney has a major responsibility to eliminate and buffer acids. In renal failure these aci...
Benefits of anemia correction <ul><li>Improved work and aerobic capacity </li></ul><ul><li>Reduced cardiovascular complica...
Vascular Calcification <ul><li>Kidney damage causes decreased phosphorus excretion. This stimulates phosphotonins to incre...
Chronic Kidney Disease  And Mineral Bone Disorder <ul><li>Too much phosphorus and </li></ul><ul><li>Damaged kidneys do not...
How to Protect Against  CKD MBD? <ul><li>Vitamin D level </li></ul><ul><li>Parathyroid hormone level </li></ul><ul><li>Erg...
What Effect Can Chronic Kidney Disease Have On The Body? <ul><li>Heart disease </li></ul><ul><li>High blood pressure </li>...
Recommendations <ul><li>Inflammation - Dental hygiene, fiber in early stages, exercise, keep trim. If we develop a stomach...
PHOSPHORUS AND VITMIN D <ul><li>CKD-MBD - Avoid excess phosphorus in the diet and have vitamin D levels checked. If low, s...
Stage-Specific Education Making Healthy Choices    <ul><li>Preparing for dialysis for Stages 4 and 5  CKD  </li></ul><ul><...
Stage 4 and 5 CKD Class <ul><li>Making Healthy Choices  </li></ul><ul><li>Preparing for dialysis in later Stage 4 to early...
Modality Choice <ul><li>PD - 7% of population </li></ul><ul><ul><li>Preference values higher than for HD 74-69 </li></ul><...
Stage 4 – Medical focus <ul><li>Modalities – Incenter and Home Dialysis, Transplant or Conservative therapy </li></ul><ul>...
Stage 5 – but not yet on dialysis <ul><li>One-on-one modality options  </li></ul><ul><ul><li>Conservative treatment – Medi...
PD References – Early referral helps 1. Bass EB, Wills S, Fink NE, et al: How strong are patients' preferences in choices ...
Home Hemodialysis <ul><li>Short - 2 hour per day X 6 days per week </li></ul><ul><li>Long - Overnight X 6 </li></ul><ul><l...
Nocturnal Home Hemodialysis <ul><li>May be able to stop binders </li></ul><ul><li>May need supplemental phosphorus </li></...
Access Preparation <ul><li>Arteriovenous fistula - 1966  </li></ul><ul><li>Lasts many years </li></ul><ul><ul><li>Veins ar...
SAVE YOUR VEINS
Easy Education Referral Process <ul><li>Easy education referral process </li></ul><ul><ul><li>Identify patient </li></ul><...
How the program works <ul><li>The CKD community-based process begins and ends with the office team </li></ul><ul><li>First...
Communication is crucial <ul><li>Nephrologist receives a  letter from CKD educator  </li></ul><ul><ul><li>Indicates what c...
Follow-up <ul><li>We will provide a follow up letter for every patient that is educated, indicating which class the patien...
Summary of Stages <ul><li>Pre-ESRD patient education  does better when referred early to an education program. An educated...
CKD Education Benefits  <ul><li>Patients </li></ul>Physician <ul><li>Taxpayers </li></ul><ul><ul><li>Feel more engaged and...
Win – Win - Win <ul><li>CKD Education is a Win-Win-Win program.  It is provided to patients and the community at no cost o...
How Do You Participate? <ul><li>Establish CKD Education as part of your practice </li></ul><ul><li>Protocol: Educate all p...
How to work with a physician office <ul><li>Every physician practice operates differently.  The 3 biggest things to walk a...
Early CKD Education Benefit  Patient’s? <ul><li>What Houston CKD patients say about CKD Education: </li></ul><ul><ul><li>“...
Success Stories <ul><li>Patients need information and change can happen </li></ul><ul><ul><li>Pt went from stage 4 to stag...
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CKD Education

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  • Knowledge is Power…for us and our patients. To educate patients is the highest form of care we can give. It Empowers our patients to make changes big and small to improve their health and quality of life. It empowers them with control and information to feel more relaxed in an anxiety producing situation of CKD transition to ESRD.
  • Agenda for the meeting Introduction: Hello and good afternoon. I am pleased to be able to speak to you about something close to my heart. Education for patients with CKD. This pilot program of Empower thru DaVita has been a great experience for me and my fellow teammates. We have seen over 100 pts in 10 months of last year and are thrilled at the positive responses from the patients and physicians. Why is Kidney education important in CKD? And for ESRD? What is EMPOWER? How does EMPOWER benefit your patients, your patients health and your physicians practice? What do the patients say? How do you participate?
  • CKD is increasing In the US and the world. Over 20 million americans have some degree of renal insufficiency….That is 1 in 8 people. Another 20 million people are at risk of kidney disease. The two leading causes of CKD are hypertension and diabetes with 23% of all Americans having hypertension and 16 million Americans having diabetes. The number of people in America with these risk factors is steadily growing and therefore the CKD population will continue to grow. Hypertension and Diabetes are also independent risk factors for cardiovascular disease. These risk factors make the CKD population at a higher morbidity and mortality rate.
  • Some interesting data Projections from the USRDS in 2008 shows a projected increase of in End Stage Renal Patients from almost to 111 thousand in 2006 to 150 thousand in 2020. With this increasing population keeping us all busier: How is it best to educate them as now mandated by the New Conditions of coverage for education of CKD
  • Some differences noted by Race. The Incidence of ESRD by Race in 2004: The lowest being the white at a rate of 280 thousand per million in 2004 and the highest is the African American population with a rate almost 3 x that at 930 thousand per million. With the North Americian and Asian in the middle. What can we do to help those people with CKD?
  • Here we see the Age differences in the ESRD groups: With the African American and the North American are in younger at 59.9 and 57.6 years respectively. The latest onset is 67.1 in the Caucasian population. These are not “old” people. These are working members with jobs and families and lives. So we have a lot of “At risk” population in Houston and in the US.
  • Why…Educate? And When? The earlier the better….Start education by stage 2 or 3 to have the biggest impact. One reason is we must. The new cfc regulations are requiring pt education on kidney disease, treatment options, accesses. I don’t think this man had his “Save my vessels” class information or he would not allow anyone to stick him up and down both arms. Another reason: It is smart use of patients time and energy. Pts who use this information stay healthier longer and start dialysis in a better place both physically and mentally. If they come to us healthier – they start healthier in ESRD with better Outcomes, more choices and better quality of life. They make better choices: more open to dialysis options when starting dialysis not an emergency. When pt education is done ahead of starting dialysis Home dialysis is chosen more often.
  • Kidney Education and You is the CKD education arm of DaVita and EMPOWER is our education program. Our mission is to improve kidney health and awareness through community based education. Over the past 12 months we have revitalized the program . I have been part of the pilot and it has really been fun . Previously our efforts were spread across health fairs, professional conventions among several other venues. Today we are focused on education and are attention is centered around providing ongoing education to those identified with kidney disease under the care of a nephrologist to delay onset and improve transition to dialysis . The education program includes the following which will be discussed in detail on the next several slides . Multidisciplinary coaching program Stage-specific education Easy education referral process Follow-up
  • Yes I tried to get this location but my administrator said No . Our seach took a to a nice church down the street with a large conference room. I have always done Renal Treatment Options training and felt we would gain more patients in a non-medical location . And our participants have reinforced that concept. We have had close over 200 pts/family/friends attend our Empower Sessions. The patient feedback is so positive ….
  • We know that our multidisciplinary coaching program  EMPOWER can make a difference . We have a nurse, a dietitian and a social worker attend each class to present the information and answer questions. We are here to help your patients learn as much as they can about kidney health . Informed patients are less anxious and more equipped to effectively follow their treatment plan, preserve renal function and improve their quality of life . We can also help patients to identify the best treatment choice for their lifestyle and reinforce early fistula placement. Tools provided: An initial postcard and quarterly e- newsletter s are delivered to introduce the valuable tools that DaVita.com offers – GFR calculator and tracker, over 500 CKD recipies, DaVita Diet Helper, CKD videos and more. The health diary is a tool given to each CKD patient and is designed to help organize and track their health care. We recommend that patients utilize their Health Diary for all provider visits to maintain continuity of care.
  • Both the patients and the doctors really like this diary . Not only is it a great resource but It gives the patients a central location to keep their valuable health information. They just ask for copies and file it away. Then when they go to any health professional , they have it. Even with Hurricane Ike – picK it up and go. The doctors like it when they can see all the information . Best from pts is the questions to ask the doctor . Reminds them of the importance of the medication, BP or lab results.
  • This is the question most patients ask. We review kidney function and the stages of kidney disease. We review how this calculation works and that is based on both kidneys. We discuss that the stages are generally progressive but that patients can impact or slow the progression of kidney disease with diet, medications and healthy behaviors. Patients need to be informed and ask lots of questions of their health care team and physicians.
  • Now for the classes. We have 2 new stage specific presentations: Taking Control of Kidney Disease for Stages 3 and 4 is a “prevention” focused presentation which includes information on basic kidney function, diet, medication and managing co-morbid conditions. We feel the greatest impact for behaviors and life styles changes toward healthier choices can be made during stages 3 and early 4. Class Detail: Introduction What kidneys do – Kidneys filter the blood of waste and control fluid balance. They control the chemical balance of your blood and body for important functions like muscle and nerves. This directly impacts cardiac function. They produce hormones for the body erythropoietin for anemia, renin for blood pressure control and they activate a hormone called calcitriol for bone health. What causes kidney disease – Diabetes and hypertension are the leading causes of kidney disease. Ways to help take control of kidney disease and other diseases that are related to kidney disease – review both diabetes and hypertension. How it damages the kidneys and why it is so important to control these diseases now. We review ways to monitor self with daily bp or bs and recording for physicians review. Controlling your health through diet – Diet is reviewed for the following: Salt for swelling and blood pressure control, potassium for cardiac function, phosphoru s for bone and heart health, cholesterol and lipids for heart and vascular health, caloric and sugar/carbohydrate intake for good body weight and glucose control. The patients are given a general review as well as handouts and websites to look up more information regarding diet and food choices. The patients are encouraged to see a registered renal dietitian for a one on one consult for their specific needs. Common medicines for people with kidney disease – Renal Vitamins , Vitamin D and phosphorus control is a big topic for bone and cardiac health . Review impact of early intervention for SHPT on improved pt health. Pts are counseled to stay away from herbs and ask their doctor about over the counter meds before taking them. Preserving veins from repeated venipunctures is cautioned for patient with CKD because they may need their veins for future access for hemodialysis, such as fistulas or grafts. Pts are told to preserve their nondominant arm and start venipunctures in the hand only. Their lives may depend on having intact vessel for future access. Patients have died from lack of access sites for dialysis. How to stay active and continue working
  • Making Healthy Choices Preparing for dialysis in later Stage 4 to early Stage 5 Chronic Kidney Disease This is the longer class due to the number of questions we have from the patients and family members. We focus on maintaining the patients kidney health as long as possible but also educate the patients on the symptoms of uremia and the transition process to ESRD. Class detail: What kidneys do What causes kidney disease – Symptoms of Uremia – Nausea and vomiting, Taste changes, Swelling, SOB, Itching, Lack of concentration and memory issues. Preparing for dialysis – Preventing the “Crash and Burn” admission to dialysis. No one knows the exact moment but working with your doctor will help to get the time right for you. We can delay but not forever without it damaging your health due to malnutrition or heart or stroke. Managing your health through diet . Review diet changes at the end of stg 4, especially related to low protein, potassium, phosphorus, salt and fluid. What the stg 5 diet is for the different treatment modalities . Most of the pts enjoy knowing their diet will get more protein on ESRD than in stage 4. Control of DM and HTN – Protect your heart and vasculature as well as your kidney function never stops. Dialysis patients do not die from dialysis. They die from infection and Cardiac/Vascular disease due to DM and HTN. BP and BS – Heart healthy behaviors. Diet, Exercise, Stop smoking. We all know it …. Common medicines for people with kidney disease Phosphorus binders, Vitamen D, Renal Vitamen, Bicarbonate, EPO. Stay off magnesium, aluminum products. Call doctor for any new meds prescribed or OTC or from other doctors. Stay away from IV dye contrast. Access information and planning early with stg 4 – No to catheters – yes to fistula’s . Lots of info about best choice and get it now . Fistulas may take months to mature . Be sure to get vein mapping done prior to surgery for improved success with fistulas. You don’t take a trip without a map – you don’t want surgery without a map either. CVC catheters have more infections, clotting, hospitalizations and deaths. Be sure to remove CVC catheters as soon as possible . Getting a CVC catheter may be necessary for a short while for initial dialysis but getting your fistula now will shorten that time and may save your life. An in-depth look at all of your treatment choices : Peritoneal Dialysis (PD) Home Hemodialysis ( HHD) Hemodialysis ( HD) Nocturnal hemodialysis Self-Care hemodialysis Transplant Conservative treatment Choosing the right treatment for your lifestyle , especially if you want to continue working or have active life. Understanding Insurance – state and federal insurances and when to apply for secondary insurance especially if want transplant due to medication cost. We have saved patients money by assisting with insurance questions.
  • Treatment Choices One-on-one education for those who are interested in more information about modalities An in-depth look at all treatment choices Conservative treatment Transplant Home therapies Peritoneal Dialysis (PD) Home Hemodialysis (HHD) In-center therapies Hemodialysis (HD) Nocturnal hemodialysis Self-Care hemodialysis
  • The EMPOWER process begins and ends with you. First, you will need to identify patients who are Stage 3, 4 and 5 that need CKD education. Next, refer those patients for education by completing and faxing the EMPOWER referral form (show form). We will notify your patients, enroll them in a class and call to remind them of class approximately 1 week prior. The day of class, your patients will complete an attendance form and evaluate the class. This data will be recorded at the call center. The recorded data allows us to provide you with information affecting your patients and practice. We can extract the number of your patients who have attended a class, which class they have attended, their stage of CKD, access preparation for dialysis, type of access, modality choice just to name a few of the components. Ultimately, our goal help patients to take control of their CKD and, if dialysis is needed, that they begin dialysis healthier and prepared.
  • Note to presenter
  • Abecassis M, Bartlett ST, Collins AJ, et al. Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference. Clin J Am Soc Nephrol. 2008;3(2):471-80. 2. Agrawal V, Ghosh AK, Barnes MA, McCullough PA. Awareness and Knowledge of Clinical Practice Guidelines for CKD Among Internal Medicine Residents: A National Online Survey. Am J Kidney Dis. 2008;52(6):1061-9. 3. Babos K, Lawless G, McClellan W. The ABCDEs of CKD: a simple approach to early detection and management. South Med J. 2008;101(10):1001-6. 4. Brouwer DJ. Optimizing vascular access: a team perspective using the National Kidney Foundation-Dialysis Outcomes Quality Initiative Guidelines. Adv Ren Replace Ther. 1999;6(1):93-6. 5. Buccianti G, Baragetti I, Alberghini E, Furiani S, Musacchio N. [Early therapeutic education in chronic renal disease: a new approach.]. G Ital Nefrol. 2005;22(2):134-9. 6. Buettner K, Fadem SZ. The internet as a tool for the renal community. Adv Chronic Kidney Dis. 2008;15(1):73-82. 7. Caruso JF, Coday MA. The combined acute effects of massage, rest periods, and body part elevation on resistance exercise performance. J Strength Cond Res. 2008;22(2):575-82. 8. Carver M, Carder J, Hartwell L, Arjomand M. Management of mineral and bone disorders in patients on dialysis: a team approach to improving outcomes. Nephrol Nurs J. 2008;35(3):265-70. 9. Chandrasekharan L, Ramlan G, Harnett P, Almond MK, Worrall S. PHOS GRAPH a novel tool in hyperphosphataemia management in haemodialysis patients. J Hum Nutr Diet. 2008;21(4):384-385. 10. Coresh J, Byrd-Holt D, Astor BC, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol. 2005;16(1):180-8. 11. Curtin RB, Walters BA, Schatell D, Pennell P, Wise M, Klicko K. Self-efficacy and self-management behaviors in patients with chronic kidney disease. Adv Chronic Kidney Dis. 2008;15(2):191-205. 12. Fischer D, Cline K, Plone MA, Dillon M, Burke SK, Blair AT. Results of a randomized crossover study comparing once-daily and thrice-daily sevelamer dosing. Am J Kidney Dis. 2006;48(3):437-44. 13. Gilmore J. KDOQI clinical practice guidelines and clinical practice recommendations--2006 updates. Nephrol Nurs J. 2006;33(5):487-8. 14. Horl WH. A need for an individualized approach to end-stage renal disease patients. Nephrol Dial Transplant. 2002;17 Suppl 6:17-21. 15. Jenkins K, Thomas N, McIntyre N. Understanding chronic kidney disease 2: referral. Nurs Times. 2007;103(42):28-9. 16. Jones ER. Unification of the voice of nephrology stakeholders. Adv Chronic Kidney Dis. 2008;15(1):15-8. 17. Keith D, Ashby VB, Port FK, Leichtman AB. Insurance type and minority status associated with large disparities in prelisting dialysis among candidates for kidney transplantation. Clin J Am Soc Nephrol. 2008;3(2):463-70. 18. Key SM. Optimizing dialysis modality choices around the world: a review of literature concerning the role of enhanced early pre-ESRD education in choice of renal replacement therapy modality. Nephrol Nurs J. 2008;35(4):387-94; quiz 395. 19. Kottgen A, Selvin E, Stevens LA, Levey AS, Van Lente F, Coresh J. Serum cystatin C in the United States: the Third National Health and Nutrition Examination Survey (NHANES III). Am J Kidney Dis. 2008;51(3):385-94. 20. Leal S, Soto M. Chronic kidney disease risk reduction in a Hispanic population through pharmacist-based disease-state management. Adv Chronic Kidney Dis. 2008;15(2):162-7. 21. Lenz O, Fornoni A. Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey. BMC Med. 2006;4:30. 22. Lenz O, Mekala DP, Patel DV, Fornoni A, Metz D, Roth D. Barriers to successful care for chronic kidney disease. BMC Nephrol. 2005;6:11. 23. Lenz O, Sadhu S, Fornoni A, Asif A. Overutilization of central venous catheters in incident hemodialysis patients: reasons and potential resolution strategies. Semin Dial. 2006;19(6):543-50. 24. Levin A, Lewis M, Mortiboy P, et al. Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis. 1997;29(4):533-40. 25. Lou-Meda R. ESRD in Guatemala and a model for preventive strategies: outlook of the Guatemalan Foundation for Children with Kidney Diseases. Ren Fail. 2006;28(8):689-91. 26. Marchant K. Diabetes and chronic kidney disease: a complex combination. Br J Nurs. 2008;17(6):356-61. 27. McCarley P. The KDOQI clinical practice guidelines and clinical practice recommendations for treating anemia in patients with chronic kidney disease: implications for nurses. Nephrol Nurs J. 2006;33(4):423-6, 445; quiz 427-8. 28. Moinuddin I, Leehey DJ. A comparison of aerobic exercise and resistance training in patients with and without chronic kidney disease. Adv Chronic Kidney Dis. 2008;15(1):83-96. 29. Narva AS. Reducing the burden of chronic kidney disease among American Indians. Adv Chronic Kidney Dis. 2008;15(2):168-73. 30. Obialo CI, Ofili EO, Quarshie A, Martin PC. Ultralate referral and presentation for renal replacement therapy: socioeconomic implications. Am J Kidney Dis. 2005;46(5):881-6. 31. Obrador GT, Pereira BJ. Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis. 1998;31(3):398-417. 32. Pazin-Filho A, Kottgen A, Bertoni AG, et al. HbA(1c) as a risk factor for heart failure in persons with diabetes: the Atherosclerosis Risk in Communities (ARIC) study. Diabetologia. 2008;51(12):2197-204. 33. Ravani P, Marinangeli G, Stacchiotti L, Malberti F. Structured pre-dialysis programs: more than just timely referral? J Nephrol. 2003;16(6):862-9. 34. Rothberg MB, Kehoe ED, Courtemanche AL, et al. Recognition and management of chronic kidney disease in an elderly ambulatory population. J Gen Intern Med. 2008;23(8):1125-30. 35. Russell TA. Diabetic nephropathy in patients with type 1 diabetes mellitus. Nephrol Nurs J. 2006;33(1):15-28; quiz 29-30. 36. Sinsky CA, Foreman-Hoffman V, Cram P. The impact of expressions of treatment efficacy and out-of-pocket expenses on patient and physician interest in osteoporosis treatment: implications for pay-for-performance programs. J Gen Intern Med. 2008;23(2):164-8. 37. Spergel LM, Ravani P, Asif A, Roy-Chaudhury P, Besarab A. Autogenous arteriovenous fistula options. J Nephrol. 2007;20(3):288-98. 38. Spry L. Building the chronic kidney disease management team. Adv Chronic Kidney Dis. 2008;15(1):29-36. 39. Triolo G, Savoldi S. [When to start dialysis. The predialysis patient.]. G Ital Nefrol. 2008;25 Suppl 41:S9-12, discussion S13-20. 40. Van Ravesteijn H, Hageraats E, Rethans JJ. Training of the gynaecological examination in The Netherlands. Med Teach. 2007;29(4):e93-9. 41. Vargas RB, Jones L, Terry C, et al. Community-partnered approaches to enhance chronic kidney disease awareness, prevention, and early intervention. Adv Chronic Kidney Dis. 2008;15(2):153-61. 42. Weiner DE, Tighiouart H, Elsayed EF, Griffith JL, Salem DN, Levey AS. Uric acid and incident kidney disease in the community. J Am Soc Nephrol. 2008;19(6):1204-11. 43. Wintz R, Rosenthal B, Fadem SZ. The Physician Quality Reporting Initiative: a practical approach to implementing quality reporting. Adv Chronic Kidney Dis. 2008;15(1):56-63. 44. Zhang AH, Zhong H, Tang W, et al. Establishing a renal management clinic in China: initiative, challenges, and opportunities. Int Urol Nephrol. 2008;40(4):1053-8.
  • Transcript of "CKD Education"

    1. 2. Goal - Objective Educate nephrology community about new Pre-ESRD classes and current pilot programs in the greater Houston area
    2. 3. At the end of this presentation the reader will be able to answer <ul><li>Why Kidney Education is important in Chronic Kidney Disease or CKD </li></ul><ul><li>What is a community-based education program </li></ul><ul><li>What information is included in CKD education program </li></ul><ul><li>How does early CKD education program benefit patient outcomes and the physician’s practice </li></ul><ul><li>What patients say about early CKD education </li></ul><ul><li>How one can participate or set up a program </li></ul>
    3. 4. Chronic Kidney Disease in the US <ul><li>Over 20 Million Americans have some degree of renal insufficiency….1 in 8 people. </li></ul><ul><li>20 million others are at risk </li></ul><ul><li>Hypertension & Diabetes are the leading causes of kidney failure </li></ul><ul><ul><li>23% of all Americans have hypertension </li></ul></ul><ul><ul><li>16 million Americans have diabetes </li></ul></ul><ul><li>Both are independent risk factors for cardiovascular disease </li></ul>
    4. 5. CKD EDUCATION <ul><li>Knowledge is Power…for us and our patients. To educate patients is the highest form of care we can give. It empowers our patients to make changes big and small to improve their health and quality of life. It empowers them with control and information to feel more relaxed in an anxiety producing situation of CKD transition to ESRD. </li></ul>
    5. 7. Projection for ESRD Population USRDS ADR 2008
    6. 8. Incidence by Race 2008
    7. 9. African Americans Develop ESRD at a Younger Age
    8. 10. New Conditions of Coverage <ul><li>ESRD Medicare Reform </li></ul><ul><ul><li>Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 – MIPPA) </li></ul></ul><ul><ul><li>CKD education is recognized by CMS </li></ul></ul><ul><ul><li>Reimbursement to nephrologists who provide chronic kidney disease education </li></ul></ul><ul><li>Physicians Must Educate CKD Patients on: </li></ul><ul><ul><li>Kidney disease </li></ul></ul><ul><ul><li>Access choices and issues </li></ul></ul><ul><ul><li>ESRD Treatment options </li></ul></ul><ul><li>Physician performance is based on </li></ul><ul><ul><li>Influenze vaccine </li></ul></ul><ul><ul><li>Blood Pressure control </li></ul></ul><ul><ul><li>Referral for an AV fistula </li></ul></ul><ul><ul><li>Laboratory values – Ca, PO 4 , PTH, Lipid profile </li></ul></ul><ul><li>*Best physicians educate on much more. </li></ul>
    9. 11. Why Educate? <ul><li>Why…Educate? And When? The earlier the better….Start education by stage 2 or 3 to have the biggest impact. </li></ul><ul><li>One reason is we must. The new cfc regulations are requiring pt education on kidney disease, treatment options, accesses. I don’t think this man had his “Save my vessels” class information or he would not allow anyone to stick him up and down both arms. </li></ul><ul><li>Another reason: It is smart use of patients time and energy. Pts who use this information stay healthier longer and start dialysis in a better place both physically and mentally. If they come to us healthier – they start healthier in ESRD with better Outcomes, more choices and better quality of life. </li></ul><ul><li>They make better choices: more open to dialysis options when starting dialysis not an emergency. When pt education is done ahead of starting dialysis Home dialysis is chosen more often. </li></ul>
    10. 12. What is community-based education? <ul><li>Patient education program that includes: </li></ul><ul><ul><li>Multidisciplinary coaching program </li></ul></ul><ul><ul><li>Stage-specific education </li></ul></ul><ul><ul><li>Easy education referral process </li></ul></ul><ul><ul><li>Follow-up with patients and physicians </li></ul></ul><ul><ul><li>Sessions are free for patients and guests </li></ul></ul>
    11. 13. <ul><li>Find a comfortable location and time. </li></ul>
    12. 14. Location <ul><li>The course does not need to be held in Maui, although it would be nice. A church down the street with a large conference room works fine. </li></ul><ul><li>Experience with renal treatment options training reveaed we would gain more patients in a non-medical location . </li></ul><ul><li>And our participants have reinforced that concept. </li></ul><ul><li>The Houston Community-based CKD program sponsored by DaVita, known as EMPOWER, has had nearly 200 pts/family/friends </li></ul><ul><li>The patient feedback is very positive </li></ul>
    13. 15. What is Community-Based Education? Multidisciplinary Coaching <ul><ul><li>Multidisciplinary coaching program </li></ul></ul><ul><ul><ul><li>Inform patients about their kidney health </li></ul></ul></ul><ul><ul><ul><li>Improve quality of life </li></ul></ul></ul><ul><ul><ul><li>Preserve renal function </li></ul></ul></ul><ul><ul><ul><li>Help patients identify the best treatment choice for their lifestyle </li></ul></ul></ul><ul><ul><ul><li>Tools to organize and track their health care </li></ul></ul></ul><ul><ul><ul><li>Health Diary </li></ul></ul></ul>
    14. 16. Multidisciplinary education <ul><li>Multidisciplinary coaching program can make a difference. </li></ul><ul><li>A nurse, a dietitian and a social worker attend each class to present the information and answer questions. </li></ul><ul><li>The goal is help patients learn as much as they can about kidney health. </li></ul><ul><li>Informed patients are less anxious and more equipped to effectively follow their treatment plan, preserve renal function and improve their quality of life. </li></ul><ul><li>CKD education helps patients to identify the best treatment choice for their lifestyle and reinforce early fistula placement. </li></ul>
    15. 17. Benefits of early intervention and education <ul><li>Delay or prevent the worsening of cardiovascular disease, hypertension and diabetes </li></ul><ul><li>Delay or prevent the progression to chronic kidney disease </li></ul><ul><li>Improve outcomes if kidney replacement therapy ever becomes necessary </li></ul><ul><li>Psychologically prepare one for kidney disease </li></ul><ul><li>Reduce health care costs </li></ul><ul><li>Keep people employed and out of the hospital </li></ul>
    16. 18. Tools Provided <ul><li>An initial postcard and quarterly e-newsletters </li></ul><ul><li>Valuable tools from a well-regarded website, http://davita.com </li></ul><ul><ul><li>GFR calculator and tracker </li></ul></ul><ul><ul><li>500 CKD recipes </li></ul></ul><ul><ul><li>DaVita Diet Helper </li></ul></ul><ul><ul><li>CKD videos </li></ul></ul><ul><ul><li>More. </li></ul></ul><ul><li>The health diary is a tool given to each CKD patient and is designed to help organize and track their health care. We recommend that patients utilize their Health Diary for all provider visits to maintain continuity of care. </li></ul>
    17. 19. TOOLS FOR BETTER CARE
    18. 20. Health Diary <ul><li>Resource for the patients </li></ul><ul><li>Patient information </li></ul><ul><li>Healthcare phone numbers </li></ul><ul><li>History and Physical </li></ul><ul><li>Medication list </li></ul><ul><li>Lab work </li></ul><ul><li>Diabetes and Hypertension </li></ul><ul><li>Glossary </li></ul>
    19. 21. The health diary <ul><li>Both the patients and the doctors really like this diary. </li></ul><ul><li>Not only is it a great resource but it gives the patients a central location to keep their valuable health information. </li></ul><ul><li>They just ask for copies and file it away. </li></ul><ul><li>When they go to any health professional, they have it. </li></ul><ul><li>Even with Hurricane Ike – pick it up and go. </li></ul><ul><li>The doctors like it when they can see all the information. </li></ul><ul><li>Best from patients is the questions to ask the doctor. </li></ul><ul><li>Reminds them of the importance of the medication, BP or lab results. </li></ul>
    20. 22. What stage am I? <ul><li>Stage 1 – GFR ≥ 90 cc/min/1.73m 2 </li></ul><ul><ul><li>Kidney Damage with normal or high GFR </li></ul></ul><ul><li>Stage 2 – GFR – 60 to 89 cc/min/1.73m 2 </li></ul><ul><ul><li>Kidney Damage with mildly decreased GFR </li></ul></ul><ul><li>Stage 3 – GFR – 30 to 59 cc/min/1.73m 2 </li></ul><ul><ul><li>Moderate decreased GFR </li></ul></ul><ul><li>Stage 4 – GFR – 15 to 29 cc/min/1.73m 2 </li></ul><ul><ul><li>Severely decreased GFR </li></ul></ul><ul><li>Stage 5 – GFR - < 15 cc/min/1.73m 2 </li></ul><ul><ul><li>Kidney failure </li></ul></ul>NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease This is the question most patients ask. We review kidney function and the stages of kidney disease. We review how this calculation works and that is based on both kidneys. We discuss that the stages are generally progressive but that patients can impact or slow the progression of kidney disease with diet, medications and healthy behaviors. Patients need to be informed and ask lots of questions of their health care team and physicians .
    21. 23. Glomerular filtration rate <ul><li>The serum creatinine by itself is a very POOR way to assess kidney disease. </li></ul><ul><li>It does not take into account variation in muscle mass, nutritional status or body habitus </li></ul><ul><li>GFR measures how well your kidneys filter waste products, which tells your doctor how well your kidneys are working. </li></ul><ul><li>In 2002, the National Kidney Foundation began recommending the use of GFR instead of just serum creatinine for a more accurate measurement of kidney function. </li></ul><ul><li>GFR is calculated from your blood creatinine, age, race and gender. </li></ul>From AAKP Healthline, 2009 – Stephen Z. Fadem
    22. 24. Assessment of kidney disease <ul><li>Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD), but in following its progress. </li></ul><ul><li>Although there are various ways to do this, the simplest is the MDRD GFR (glomerular filtration rate) which can be calculated using a patient’s age, race, gender and a laboratory test, known as the serum creatinine. The muscles are in a constant state of being broken down and being repaired. </li></ul><ul><li>The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day. </li></ul><ul><li>While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors mentioned above necessary. </li></ul><ul><li>This equation was derived from a large study published in 1994 that looked at how the modification of dietary protein would affect renal disease – hence Modification of Diet in Renal Disease (MDRD). </li></ul><ul><li>This study required a very accurate measurement of kidney function. The investigators noticed the mathematical relationships between the accurately measured GFR, age, race, creatinine and gender, and derived the MDRD study equations still in use today. </li></ul><ul><li>It is also referred to as the eGFR. This GFR is used to determine what stage of kidney disease one has, stages 1 and 2 being very mild, with GFRs above 60 ml/min. </li></ul><ul><li>When the GFR is greater than 60, other markers of kidney function such as an abnormal urine or abnormal ultrasound are necessary for making the diagnosis. When the GFR is less than 60 for greater than three months, it indicates the presence of CKD. </li></ul><ul><li>Once the GFR is calculated, and repeated in 3 months we also need to look at other markers of Kidney disease. While this is necessary if the GFR is > 60, we also recommend testing for markers strongly in everyone since it helps us reverse the reversible and get a better diagnosis. Markers include the renal ultrasound and the urinalysis. </li></ul><ul><li>Although the calculation involves some complicated math tricks, it was programmed for the Internet shortly after it was discovered, and is on the Web at www.mdrd.com. </li></ul><ul><li>The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators. </li></ul><ul><li>Many laboratories routinely report the MDRD GFR along with the serum creatinine value. As more and more laboratories standardize their serum creatinine measurements to the National Institute of Standards, the equation will change slightly, but that change is also programmed and available at www.mdrd.com. </li></ul><ul><li>When using the program, simply key in your serum creatinine, age, race and gender and your GFR value will appear. The site will also calculate your kidney disease stage. It is important that you personally keep track of your serum creatinine and GFR values. </li></ul>From AAKP Healthline, 2009 – Stephen Z. Fadem
    23. 25. You have heard about Cystatin C <ul><li>Serum creatinine has a drawback in the measurement of glomerular filtration rate (GFR) in that it may vary according to muscle mass. </li></ul><ul><li>Cystatin C is a 13 kilodalton protein that is filtered by the glomerulus and reabsorbed and metabolized by tubular cells. The amount that is excreted into the urine is negligible. Its production is very steady, and not dependent on muscle mass. </li></ul><ul><li>It has been proposed as an alternate marker for estimating GFR by Dr. Joe Coresh. </li></ul><ul><li>An elevated serum cystatin C level may indicate a worse cardiovascular risk in patients with the metabolic syndrome. (18456039) . </li></ul><ul><li>The literature is emerging, and showing that it has benefit as a marker. Here are two formulae that might be useful in demonstrating the relationships between serum creatinine and serum cystatin C </li></ul><ul><li>The serum cystatin C calculation is found at http://touchcalc.com </li></ul><ul><li>Joe Coresh recommends averaging the Cystatin C and the MDRD GFR </li></ul>
    24. 26. Clinical evaluation of patients at increased risk for CKD <ul><li>All Patients </li></ul><ul><li>Measurement of blood pressure </li></ul><ul><li>Serum creatinine to estimate GFR </li></ul><ul><li>Protein to creatinine or albumin to creatinine ratio in first AM or random untimed spot urine specimen </li></ul><ul><li>Examination of the urine sediment or dipstick for red blood cells and white blood cells </li></ul>
    25. 27. Stage-Specific Education <ul><li>Taking Control of Kidney Disease </li></ul><ul><li>Living with Stage 3 and Early Stage 4 CKD Focus on preserving renal function </li></ul><ul><ul><li>Normal Kidney functions / Kidney Disease </li></ul></ul><ul><ul><li>Control of co-morbidities / Diabetes / HTN </li></ul></ul><ul><ul><li>Diet and medication </li></ul></ul><ul><ul><li>Heart healthy behaviors </li></ul></ul><ul><ul><li>Preserving veins </li></ul></ul><ul><ul><li>Insurance questions </li></ul></ul><ul><ul><li>Questions to ask physician </li></ul></ul>
    26. 28. Treatment of CKD <ul><li>Treat the underlying disease </li></ul><ul><li>Treat associated problems </li></ul><ul><li>Slowing the loss of kidney function </li></ul><ul><li>Prevent heart disease </li></ul><ul><li>Reduce complications </li></ul><ul><li>Preparation for dialysis/transplantation </li></ul><ul><li>Kidney transplant or dialysis </li></ul>NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
    27. 30. Definition of Chronic Kidney Disease <ul><li>Chronic kidney disease is defined as either kidney damage or GFR < 60 cc/min/1.73m 2 for ≥ 3 months. </li></ul><ul><li>Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging </li></ul>NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
    28. 31. Clinical Practice Guidelines for Management of Hypertension in CKD Type of Kidney Disease Blood Pressure Target (mm Hg) Preferred Agents for CKD, with or without Hypertension Other Agents to Reduce CVD Risk and Reach Blood Pressure Target Diabetic Kidney Disease <130/80 ACE inhibitor or ARB Diuretic preferred, then BB or CCB Nondiabetic Kidney Disease with Urine Total Protein-to-Creatinine Ratio  200 mg/g Nondiabetic Kidney Disease with Spot Urine Total Protein-to-Creatinine ratio <200 mg/g None preferred Diuretic preferred, then ACE inhibitor, ARB, BB or CCB Kidney Disease in Kidney Transplant Recipient CCB, diuretic, BB, ACE inhibitor, ARB
    29. 32. Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD
    30. 33. Stages 1 and 2: Preventing Heart Disease in CKD <ul><li>Traditional cv risk factors </li></ul><ul><li>Non traditional risk factors </li></ul>
    31. 34. How Can You Protect Yourself Against Heart Disease And High Blood Pressure? <ul><li>Get regular medical checkups </li></ul><ul><li>Control your blood pressure </li></ul><ul><li>Monitor your blood pressure weekly </li></ul><ul><li>Check your cholesterol regularly – watch saturated fats and fructose </li></ul><ul><li>Watch your diet - SALT </li></ul><ul><li>Regular doctor visits </li></ul><ul><li>Blood pressure - 130/80 </li></ul><ul><li>It make take several medications </li></ul><ul><li>Don’t smoke </li></ul><ul><li>If you choose to drink, do so in moderation </li></ul><ul><li>Exercise regularly </li></ul><ul><li>Manage stress </li></ul>
    32. 36. Traditional Risk Factors <ul><li>Smoking </li></ul><ul><li>Cholesterol </li></ul><ul><li>Obesity </li></ul><ul><li>Family History </li></ul>
    33. 37. Non Traditional Risk Factors <ul><li>Inflammation </li></ul><ul><li>Mineral-bone disorder </li></ul><ul><li>Anemia </li></ul>
    34. 38. ACEs and ARBs <ul><li>These drugs are critical to care starting in Stage 1 and 2 </li></ul><ul><li>ACES and ARBs have a compound effect on blocking the renin-angiotensin system. </li></ul><ul><li>The goal is to lower the blood pressure to 120 mm Hg and to titrate proteinuria. </li></ul><ul><li>Contraindications include allergy and bilateral renal artery stenosis </li></ul><ul><li>Potassium levels should be monitored closely when patients are on ACES or ARBS </li></ul><ul><li>(Beta blockers, NSAIDS, ACES and ARBS can raise serum potassium) </li></ul>
    35. 39. Blood Pressure Is Poorly Controlled in Patients With CKD
    36. 40. Inflammation <ul><li>Associated with CKD </li></ul><ul><li>Atherosclerosis </li></ul><ul><li>Vascular calcification </li></ul><ul><li>Statins not helpful in CKD5 </li></ul><ul><li>CRP not diagnostic </li></ul><ul><li>MIA </li></ul>
    37. 41. Exercise And Kidney Care <ul><li>Talk to your doctor about starting an exercise program that’s right for you. </li></ul><ul><li>Exercise can help you improve physical functioning and emotional well-being, increase physical stamina, improve blood pressure and reduce the risk of heart disease, lower cholesterol, help you sleep better and control body weight. </li></ul><ul><li>Incorporating consistent aerobic exercise, even taking a 20-minute walk, can help especially if your CKD is a result of hypertension or diabetes. </li></ul>
    38. 42. Watch meds and therapies <ul><li>Avoid Metformin in Stage 3 and beyond </li></ul><ul><li>Contrast media – </li></ul><ul><ul><li>Nephrogenic sclerosing fibrosis may occur with an MRI due to galadinium contrast – so procedure should be done without this contrast agent </li></ul></ul><ul><ul><li>Iodine can be nephrotoxic – and patients should be well hydrated pre procedure </li></ul></ul><ul><li>NSAIDS should not be given to kidney patients </li></ul>Here are some examples:
    39. 43. Diet <ul><li>Sodium - 100 mmoles </li></ul><ul><li>Lipids - pre dialysis </li></ul><ul><li>Carbohydrates - Diabetes </li></ul><ul><li>Proteins - MDRD Trial </li></ul><ul><li>Potassium - watch because of ARBs and ACE inhibitors </li></ul>
    40. 44. Nutritional Tips For Healthy Kidneys <ul><li>In order to help maintain healthy kidneys it is important to eat properly </li></ul><ul><li>Keep track of daily calories </li></ul><ul><li>Limit total fat </li></ul><ul><li>Watch high fructose corn syrup </li></ul><ul><li>Watch excess proteins and phosphorus - Monitor the amount of protein eaten </li></ul><ul><li>You may need to watch potassium - Learn about potassium </li></ul><ul><li>Your dietitian can help you with recipes that fit your needs </li></ul><ul><li>Control salt intake </li></ul><ul><li>Take care of your bones – exercise and take vitamin D </li></ul><ul><li>Be sure to get enough iron </li></ul><ul><li>Watch fluid intake </li></ul><ul><li>Understand your nutritional plan </li></ul>
    41. 45. Stage 3 – Medical Focus <ul><li>CKD MBD – Metabolic bone disease </li></ul><ul><li>Acidosis - Bicarbonate </li></ul><ul><li>Anemia – Erythropoietin </li></ul><ul><li>Class reinforces </li></ul><ul><li>bone and </li></ul><ul><li>heart healthy diet. </li></ul>
    42. 46. Stage 3 <ul><li>a. Cardiovascular risks and therapy – stay the course </li></ul><ul><li>b. Preparation: 1. Anemia 2. Acidosis 3. Blood pressure/ACEs and ARBS 4. Inflammation 5. Diet 6. Modality choice 7. Access preparation </li></ul><ul><li>c. Modalities of therapy </li></ul>
    43. 47. Preparation <ul><li>Anemia </li></ul><ul><li>Acidosis </li></ul><ul><li>Blood pressure - ACES & ARBS </li></ul><ul><li>Inflammation </li></ul><ul><li>Diet </li></ul><ul><li>Modality Choice </li></ul><ul><li>Access Preparation </li></ul>
    44. 48. Anemia in CKD <ul><li>Anemia management with EPO since 1990s - </li></ul><ul><li>Keep Hct < 42 </li></ul><ul><ul><li>N Eng J Med 339:584-90, 1998 </li></ul></ul><ul><li>Keep hgb 10 - 12 </li></ul><ul><ul><li>CHOIR </li></ul></ul><ul><ul><ul><li>N Eng J Med 355:2071-2084, 2006. </li></ul></ul></ul><ul><ul><ul><li>34% worse when hgb target is 13.5 than 11.2 </li></ul></ul></ul><ul><ul><li>CREATE </li></ul></ul><ul><ul><ul><li>N Eng J Med 355:2084-2098, 2006 </li></ul></ul></ul><ul><ul><ul><li>22% worse when hgb is 13-15 than 10.5-11.5 </li></ul></ul></ul><ul><li>Check Iron levels and correct first </li></ul><ul><li>EPO can be given in the office - monitor blood work </li></ul>
    45. 49. EPO RBC RBC PRECURSOR
    46. 50. Acidosis <ul><li>Increased protein catabolism of amino acids </li></ul><ul><li>Inhibition of protein synthesis can cause a low albumin </li></ul><ul><li>Accelerates renal osteodystrophy </li></ul><ul><li>Modulates vitamin D and parathyroid hormone levels </li></ul><ul><li>Evokes insulin resistance </li></ul>
    47. 51. Albumin Synthesis <ul><li>Chronic acidosis impairs albumin synthesis and causes negative nitrogen balance </li></ul><ul><ul><li>JCI 95:35-45, 1995 </li></ul></ul><ul><li>Albumin - major marker for nutrition </li></ul><ul><li>Low serum albumin - risk factor for poor dialysis outcome </li></ul><ul><li>It is advisable not to restrict dietary protein once the serum albumin level starts to fall </li></ul>
    48. 52. Metabolic Acidosis <ul><li>The kidney has a major responsibility to eliminate and buffer acids. In renal failure these acids accumulate. </li></ul><ul><li>When the clearance falls below 25 cc per minute, the accumulated acids cause loss of appetite. Protein stores and albumin fall, and muscle is broken down and used as a nutrient. </li></ul><ul><li>It is not clear whether correction of acidosis with bicarbonate solution is helpful, but there is consensus that as renal function deteriorates and albumin falls, the diet needs to be adjusted, and if that does not work, dialysis is needed to correct the acidosis. </li></ul>REGENERATES BUFFER SECRETES ACIDS
    49. 53. Benefits of anemia correction <ul><li>Improved work and aerobic capacity </li></ul><ul><li>Reduced cardiovascular complications </li></ul><ul><li>Reduced hospitalizations </li></ul><ul><li>Decreased mortality </li></ul><ul><li>Improved quality of life </li></ul><ul><li>Improved cognition </li></ul><ul><li>Improved sexual function </li></ul>Besarab. Am J Kidney Dis. 2000;36 (suppl 3):S13. Fink. Am J Kidney Dis. 2001;37:348. Kausz. Am J Kidney Dis . 2000;36(suppl 3):S39.
    50. 54. Vascular Calcification <ul><li>Kidney damage causes decreased phosphorus excretion. This stimulates phosphotonins to increase phosphorus excretion. </li></ul><ul><li>Phosphotonins and kidney damage decrease the activation of vitamin D </li></ul><ul><li>This weakens muscles, decreasing bone strength. </li></ul><ul><li>This decreases the calcium depositing in bone, and along with phosphorus – leads to changes in blood vessel cells </li></ul><ul><li>Calcium deposits in blood vessels </li></ul><ul><li>Inflammation and Hyperlipidemia (metabolic syndrome) make this worse </li></ul><ul><li>High fructose corn syrup makes metabolic syndrome works </li></ul>DIET IS IMPORTANT!!!
    51. 55. Chronic Kidney Disease And Mineral Bone Disorder <ul><li>Too much phosphorus and </li></ul><ul><li>Damaged kidneys do not produce enough vitamin D </li></ul><ul><li>Vitamin D helps maintain calcium levels which keep bones strong </li></ul><ul><li>Calcium may build up in blood vessels with CKD </li></ul><ul><li>Without enough vitamin D, you are more likely to have weak bones that may break easily </li></ul>
    52. 56. How to Protect Against CKD MBD? <ul><li>Vitamin D level </li></ul><ul><li>Parathyroid hormone level </li></ul><ul><li>Ergocalciferol over the counter </li></ul><ul><li>Vitamin D is probably for everyone –regargless of stage </li></ul><ul><li>At later stages you might need an active form of vitamin D </li></ul><ul><li>Exercise and diet management </li></ul><ul><li>The doctor may want to check for vascular calcification </li></ul>
    53. 57. What Effect Can Chronic Kidney Disease Have On The Body? <ul><li>Heart disease </li></ul><ul><li>High blood pressure </li></ul><ul><li>Vitamin D deficiency - bone and mineral disorder </li></ul><ul><li>Anemia </li></ul><ul><li>Malnutrition and low serum albumin </li></ul><ul><li>Acid buildup </li></ul>
    54. 58. Recommendations <ul><li>Inflammation - Dental hygiene, fiber in early stages, exercise, keep trim. If we develop a stomach illness like helicobacter, get it treated. Keep toenails trim. </li></ul><ul><li>Atherosclerosis - Check the serum cholesterol, LDL, VLDL, HDL - use diet, exercise, medications (statins, usually) to keep these numbers in the proper range </li></ul>
    55. 59. PHOSPHORUS AND VITMIN D <ul><li>CKD-MBD - Avoid excess phosphorus in the diet and have vitamin D levels checked. If low, start on ergocalciferol or cholecalciferol. Later, an active vitamin D like calcitriol, doxercalciferol or paricalcitol will be needed </li></ul><ul><li>Vascular calcification - As the disease progresses, restrict phosphorus and use a phosphate binder. </li></ul>
    56. 60. Stage-Specific Education Making Healthy Choices <ul><li>Preparing for dialysis for Stages 4 and 5 CKD </li></ul><ul><ul><li>Symptoms of Uremia </li></ul></ul><ul><ul><li>Controlled dialysis start </li></ul></ul><ul><ul><li>CKD and dialysis diet </li></ul></ul><ul><ul><li>Control of co-morbidities – DM/HTN </li></ul></ul><ul><ul><li>Medications – Call your Nephrologist </li></ul></ul><ul><ul><li>Access – No to catheters, Yes to fistulas – Vein Map </li></ul></ul><ul><ul><li>All treatment choices </li></ul></ul><ul><ul><li>Insurance issues </li></ul></ul>
    57. 61. Stage 4 and 5 CKD Class <ul><li>Making Healthy Choices </li></ul><ul><li>Preparing for dialysis in later Stage 4 to early Stage 5 Chronic Kidney Disease </li></ul><ul><li>This is the longer class due to the number of questions we have from the patients and family members. </li></ul><ul><li>We focus on maintaining the patients kidney health as long as possible but also educate the patients on the symptoms of uremia and the transition process to ESRD. </li></ul><ul><li>Class detail: </li></ul><ul><ul><li>What kidneys do </li></ul></ul><ul><ul><li>What causes kidney disease – Symptoms of Uremia – Nausea and vomiting, Taste changes, Swelling, SOB, Itching, Lack of concentration and memory issues. </li></ul></ul><ul><ul><li>Preparing for dialysis – Preventing the “Crash and Burn” admission to dialysis. No one knows the exact moment but working with your doctor will help to get the time right for you. We can delay but not forever without it damaging your health due to malnutrition or heart or stroke. </li></ul></ul><ul><ul><li>Managing your health through diet. Review diet changes at the end of stage4, especially related to low protein, potassium, phosphorus, salt and fluid. What the stage 5 diet is for the different treatment modalities. Most of the pts enjoy knowing their diet will get more protein on ESRD than in stage 4. </li></ul></ul><ul><ul><li>Control of DM and HTN – Protect your heart and vasculature as well as your kidney function never stops. Dialysis patients do not die from dialysis. They die from infection and Cardiac/Vascular disease due to DM and HTN. BP and BS – Heart healthy behaviors. Diet, Exercise, Stop smoking. We all know it …. </li></ul></ul><ul><ul><li>Common medicines for people with kidney disease Phosphorus binders, Vitamin D, Renal Vitamins, Bicarbonate, EPO. Stay off magnesium, aluminum products. Call doctor for any new meds prescribed or OTC or from other doctors. Stay away from IV dye contrast. </li></ul></ul><ul><ul><li>Access information and planning early with stage4 – No to catheters – yes to fistula’s. Lots of info about best choice and get it now. Fistulas may take months to mature. Be sure to get vein mapping done prior to surgery for improved success with fistulas. You don’t take a trip without a map – you don’t want surgery without a map either. CVC catheters have more infections, clotting, hospitalizations and deaths. Be sure to remove CVC catheters as soon as possible. Getting a CVC catheter may be necessary for a short while for initial dialysis but getting your fistula now will shorten that time and may save your life. </li></ul></ul><ul><ul><li>An in-depth look at all of treatment choices: </li></ul></ul><ul><ul><ul><li>Peritoneal Dialysis (PD) </li></ul></ul></ul><ul><ul><ul><li>Home Hemodialysis (HHD) </li></ul></ul></ul><ul><ul><ul><li>Hemodialysis (HD) </li></ul></ul></ul><ul><ul><ul><li>Nocturnal hemodialysis </li></ul></ul></ul><ul><ul><ul><li>Self-Care hemodialysis </li></ul></ul></ul><ul><ul><li>Transplant </li></ul></ul><ul><ul><li>Conservative treatment </li></ul></ul><ul><li>Choosing the right treatment for your lifestyle, especially if you want to continue working or have active life. </li></ul><ul><li>Understanding Insurance– state and federal insurances and when to apply for secondary insurance especially if want transplant due to medication cost. We have saved patients money by assisting with insurance questions. </li></ul>
    58. 62. Modality Choice <ul><li>PD - 7% of population </li></ul><ul><ul><li>Preference values higher than for HD 74-69 </li></ul></ul><ul><ul><li>Physicians in practice 11 years along more likely to refer to PD </li></ul></ul><ul><ul><li>More likely recommended to men, people with residual function, with weight less than 200 lb and the absence of diabetes </li></ul></ul><ul><li>Hong Kong </li></ul><ul><ul><li>Half the mortality </li></ul></ul><ul><ul><li>5 staff for 300 patients </li></ul></ul><ul><ul><li>Less mortality because residual function preservation </li></ul></ul><ul><ul><li>Loss of residual function is a cardiovascular risk factor </li></ul></ul>
    59. 63. Stage 4 – Medical focus <ul><li>Modalities – Incenter and Home Dialysis, Transplant or Conservative therapy </li></ul><ul><li>Referral for access – Vein mapping and surgery </li></ul><ul><li>Serum Albumin – Prevent malnutrition </li></ul><ul><li>Continue other therapies – ACE or ARB </li></ul><ul><li>Anemia – Erythropoietin therapy </li></ul>
    60. 64. Stage 5 – but not yet on dialysis <ul><li>One-on-one modality options </li></ul><ul><ul><li>Conservative treatment – Medical, diet management, Hospice Assistance </li></ul></ul><ul><ul><li>Transplant – refer early </li></ul></ul><ul><ul><li>Home therapies (Peritoneal, Home Hemodialysis) </li></ul></ul><ul><ul><li>In-center therapies (ICHD, Nocturnal, Self-Care) </li></ul></ul><ul><ul><li>Physicians focus - Therapy choice/transition </li></ul></ul>
    61. 65. PD References – Early referral helps 1. Bass EB, Wills S, Fink NE, et al: How strong are patients' preferences in choices between dialysis modalities and doses? Am J Kidney Dis 44:695-705, 2004 2. Winkelmayer WC, Glynn RJ, Levin R, et al: Late referral and modality choice in end-stage renal disease. Kidney Int 60:1547-1554, 2001 3. Lin C-L, Chuang F-R, Wu C-F, et al: Early referral as an independent predictor of clinical outcome in end-stage renal disease on hemodialysis and continuous ambulatory peritoneal dialysis. Ren Fail 26:531-537, 2004 4. Thamer M, Hwang W, Fink NE, et al: US nephrologists' recommendation of dialysis modality: results of a national survey. Am J Kidney Dis 36:1155-1165, 2000 5. Wang AY-M, Wang M, Woo J, et al: Inflammation, residual kidney function, and cardiac hypertrophy are interrelated and combine adversely to enhance mortality and cardiovascular death risk of peritoneal dialysis patients. J Am Soc Nephrol 15:2186-2194, 2004
    62. 66. Home Hemodialysis <ul><li>Short - 2 hour per day X 6 days per week </li></ul><ul><li>Long - Overnight X 6 </li></ul><ul><li>Prospective patients </li></ul><ul><ul><li>Visit during CKD </li></ul></ul><ul><ul><li>Logistics, location and type of equipment </li></ul></ul><ul><li>NxStage - 70 pounds </li></ul><ul><li>2008K@home (BabyK) </li></ul><ul><ul><li>May need plumbing and electrical </li></ul></ul><ul><li>Need ample storage </li></ul><ul><li>Need for vascular access </li></ul><ul><li>Need a partner </li></ul>
    63. 67. Nocturnal Home Hemodialysis <ul><li>May be able to stop binders </li></ul><ul><li>May need supplemental phosphorus </li></ul><ul><li>Less hypertensives </li></ul><ul><li>Less epo </li></ul><ul><li>Less fluid restriction </li></ul><ul><li>Nocturnal in-center for select patients </li></ul>
    64. 68. Access Preparation <ul><li>Arteriovenous fistula - 1966 </li></ul><ul><li>Lasts many years </li></ul><ul><ul><li>Veins arterialize </li></ul></ul><ul><ul><li>Arteries expand </li></ul></ul><ul><ul><li>Capillaries and larger vessels absorb shock </li></ul></ul><ul><ul><li>Graft transmits shock and lasts only around 18 months </li></ul></ul>
    65. 69. SAVE YOUR VEINS
    66. 70. Easy Education Referral Process <ul><li>Easy education referral process </li></ul><ul><ul><li>Identify patient </li></ul></ul><ul><ul><li>Inform patient </li></ul></ul><ul><ul><li>Order education </li></ul></ul><ul><ul><li>Refer & Fax </li></ul></ul><ul><li>Empower Team </li></ul><ul><ul><li>Call patient </li></ul></ul><ul><ul><li>Schedule class </li></ul></ul>
    67. 71. How the program works <ul><li>The CKD community-based process begins and ends with the office team </li></ul><ul><li>First, the office will need to identify patients who are Stage 3, 4 and 5 that need CKD education. </li></ul><ul><li>Next, refer those patients for education by completing and faxing the referral form (show form). The patients are notified, enrolled in a class and called to remind them of class approximately 1 week prior. The day of class, patients will complete an attendance form and evaluate the class. This data will be recorded at the call center. </li></ul><ul><li>The recorded data allows the educators to provide the office with information affecting patients and practice. We can extract the number of your patients who have attended a class, which class they have attended, their stage of CKD, access preparation for dialysis, type of access, modality choice just to name a few of the components. </li></ul><ul><li>Ultimately, the goal is help patients to take control of their CKD and, if dialysis is needed, that they begin dialysis healthier and prepared. </li></ul>
    68. 72. Communication is crucial <ul><li>Nephrologist receives a letter from CKD educator </li></ul><ul><ul><li>Indicates what class patient attended </li></ul></ul><ul><ul><li>High lights “no shows” </li></ul></ul><ul><ul><li>Lists concerns and/or modality interests if expressed </li></ul></ul><ul><li>CKD patient receives a phone call from CKD educator & education materials </li></ul><ul><ul><li>Assess for additional teaching </li></ul></ul><ul><ul><li>Answer questions and provide resources </li></ul></ul><ul><ul><li>Initial postcard mailing & quarterly e-newsletters </li></ul></ul>
    69. 73. Follow-up <ul><li>We will provide a follow up letter for every patient that is educated, indicating which class the patient attended; what material was covered; any concerns they expressed and for late stage patients, their modality interest. </li></ul><ul><li>We maintain telephonic contact with your patients referred and educated to develop an understanding of their education needs and to help support them through additional classes and guidance to resources. As previously mentioned, an initial postcard and quarterly e-newsletter are delivered to introduce the valuable tools that a well known website, DaVita.com offers – GFR calculator and tracker, over 500 CKD recipies, DaVita Diet Helper, CKD videos and more. </li></ul><ul><li>All medical questions will be referred the physician. </li></ul>
    70. 74. Summary of Stages <ul><li>Pre-ESRD patient education does better when referred early to an education program. An educated patient will adhere better to the therapy that slows progression of disease </li></ul><ul><li>In the early stages, 1 and 2 – it is important to control for diabetes and blood pressure. Generally an ACE or an ARB is recommended </li></ul><ul><ul><li>Vitamin D management should start early in the course of disease </li></ul></ul><ul><ul><li>Some recommend restricting the use of process foods early </li></ul></ul><ul><ul><li>In addition to diet and blood pressure control with an ACE or ARB, control of glucose is valuable in diabetics </li></ul></ul><ul><li>By Stage 3 patients are starting to manifest signs of anemia, metabolic acidosis and early metabolic bone disease. </li></ul><ul><ul><li>They need to have laboratory studies – Ca, PO4, PTH, lipid profile </li></ul></ul><ul><li>By stage 4, the serum phosphorus is elevated. Vitamin D analogs may be necessary. Phosphorus control can be done with diet, but most likely at this stage will require a binder. </li></ul><ul><ul><li>Patients have other choices beside in center hemodialyssi. In stage 4 it is important to discuss options such as home hemodialysis and home peritoneal dialysis. Patients who have been educated are more likely to choose these modalities, and are more satisfied with them. </li></ul></ul><ul><ul><li>The patient should be evaluated early for a permanent vascular access, and depending upon the modality chosen, a fistula or peritoneal dialysis access placed. </li></ul></ul><ul><li>Pre-ESRD classes lead to a smoother transition into a dialysis (stage 5) regimen. </li></ul>
    71. 75. CKD Education Benefits <ul><li>Patients </li></ul>Physician <ul><li>Taxpayers </li></ul><ul><ul><li>Feel more engaged and in-control </li></ul></ul><ul><ul><li>Slow the progression of renal disease </li></ul></ul><ul><ul><li>Healthier on First Date of Dialysis </li></ul></ul><ul><ul><li>Free education to patients and community </li></ul></ul><ul><ul><li>Physician able to compliment own education </li></ul></ul><ul><ul><li>Saves physician time, resources and money </li></ul></ul><ul><ul><li>Patients learn of laws that protect them </li></ul></ul><ul><ul><li>Patients stay employed and insured </li></ul></ul><ul><ul><li>Decrease burden on Medicare </li></ul></ul>
    72. 76. Win – Win - Win <ul><li>CKD Education is a Win-Win-Win program. It is provided to patients and the community at no cost or obligation. </li></ul><ul><li>Patients who attend are empowered to take control of their kidney health. They are provided with the tools they need to preserve renal function. </li></ul><ul><li>Physicians are able to compliment their own excellent education, saving them time, resources and money. </li></ul><ul><li>Finally, by helping patient to understand the laws that protect them, we can help keep patients employed and maintain their insurance, thus decreasing the burden on Medicare. </li></ul>
    73. 77. How Do You Participate? <ul><li>Establish CKD Education as part of your practice </li></ul><ul><li>Protocol: Educate all patients Stages 3,4 and 5 </li></ul><ul><li>Process: </li></ul><ul><ul><li>Identify eligible patient during office visit </li></ul></ul><ul><ul><li>Patient communication (discussion and flyer) </li></ul></ul><ul><ul><li>Clinician orders education need using: </li></ul></ul><ul><ul><ul><li>Sticky note </li></ul></ul></ul><ul><ul><ul><li>Referral form </li></ul></ul></ul><ul><ul><li>Office staff completes and faxes referral form </li></ul></ul><ul><ul><li>CKD education team contacts patient and schedules class </li></ul></ul>
    74. 78. How to work with a physician office <ul><li>Every physician practice operates differently. The 3 biggest things to walk away from the meeting with are: </li></ul><ul><ul><li>The physicians commitment to refer their CKD pts (get granular as to are they willing to send Stage 3 pts as well as 4 and 5 or just 4 and 5 which is fine too) </li></ul></ul><ul><ul><li>A solid detailed process in writing on how the doctor is going to notify the administrative team of the order for education and how the administrative team is going to send the fax referral. If the Physicians are willing to set a &quot;protocol&quot; or &quot;standing order&quot; that states the admin staff is to refer all CKD pts (or all Stage 4/5 pts) that is great because it takes the step of the physicians remembering to refer for education out of the mix. </li></ul></ul><ul><li>An agreement on how often you and the administrative staff will touch base to make sure everything is good. </li></ul>
    75. 79. Early CKD Education Benefit Patient’s? <ul><li>What Houston CKD patients say about CKD Education: </li></ul><ul><ul><li>“ I wish I had this information sooner” </li></ul></ul><ul><ul><li>“ I will really study my lab values and check my diet” </li></ul></ul><ul><ul><li>“ I will talk to my doctor about my NSAID’s and decongestants” </li></ul></ul><ul><ul><li>“ The health diary is excellent. I really like the glossary” </li></ul></ul><ul><ul><li>“ As a family member, I think my father (patient) will feel more comfortable about the possibility of dialysis”. </li></ul></ul><ul><ul><li>Success Stories… </li></ul></ul>
    76. 80. Success Stories <ul><li>Patients need information and change can happen </li></ul><ul><ul><li>Pt went from stage 4 to stage 3 and thanked us for the class…. </li></ul></ul><ul><li>Office staff tell of a pt they were dreading to tell about time to start dialysis </li></ul><ul><ul><li>Pt said “It’s OK, I know about it”. The office nurse was amazed. </li></ul></ul><ul><li>Access placements before starting dialysis </li></ul><ul><ul><li>As they should be </li></ul></ul><ul><li>Insurances saved or supplemental insurance obtained before ESRD. </li></ul>
    77. 81. The End
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