ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue

ABIM Chronic Kidney Disease (CKD) PIM™
Practice Improvement Module
Measures Catalogue

Chronic Kidney Disease (CKD) Measures Catalogue
May 2011

TABLE OF CONTENTS

Introduction .............................................................................................................................................................. 3

Outcomes of Care ................................................................................................................................................... 5

Processes of Care

Patient Evaluation................................................................................................................................................. 8

Diagnostic Testing.............................................................................................................................................. 11

Treatment: Medication ....................................................................................................................................... 17

Treatment: Other................................................................................................................................................. 21

Preventive Care ................................................................................................................................................. 25

Coordination of Care ........................................................................................................................................ 26

End of Life Care ................................................................................................................................................ 28

Chronic Kidney Disease Measure Catalog May 2011 Page 2 of 28

Introduction

This catalogue provides information related to the American Board of Internal Medicine’s Chronic Kidney Disease (CKD)
Practice Improvement Module®. It is written in language that addresses the physician who might choose to complete this
module, and it details the specifics of the module. Included is information regarding:

• Purpose and structuring of the module
• Patient inclusion criteria
• Detailed description of the measures

This PIM examines the care you provide to your patients by addressing key processes and outcomes of chronic kidney disease care
based on recommendations of the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI), and
Kidney Disease: Improving Global Outcomes (KDIGO).
.

The PIM is divided into three parts, with multiple sections in each part.

Part 1 -Performance Data
Provide baseline data about your practice's current performance by:

• Reviewing your charts
• Assessing your practice systems

The 68 chart review measures are summarized below. ABIM requires a minimum of 25 chart reviews. The practice systems
assessment comprises questions covering various aspects of practice structure and protocols.

Patients can be included in this module if all of the following are true:

1. Patients are between the ages of 18 and 85 (inclusive);
2. Patient’s GFR is <30 mL/min/1.73 m2 for three months or longer;
3. Management decisions regarding their chronic kidney disease are made primarily by providers in the practice;
4. They have been patients in the practice for at least one year; AND
5. They have been seen by the practice within the past 12 months.


Patients should be excluded from this module if any of the following are true:

1. They are on dialysis or have received a kidney transplant
OR
2. They have late stage cancer, are currently receiving chemotherapy, or are in hospice.

Part 2 - Quality Improvement (QI) Plan
Develop a plan for improving one aspect of your practice after reviewing the analysis of your current performance data. The analysis
will include many aspects of care you provide to your patients. Ultimately, you will target only one of these to use in this quality
improvement (QI) cycle.

Part 3 - Remeasurement
Remeasure your performance data after you have implemented your QI plan to see if you achieved your goal. Then, you will reflect on
the process of developing and implementing a QI plan.

You may claim CME credit for completing this activity. The University of Pennsylvania School of Medicine designates this
educational activity for a maximum of 20 AMA PRA Category 1 Credit(s)TM.


CKD - OUTCOMES OF CARE

Clinical Outcomes

Measure Title Description Numerator Denominator Rationale

Most recent blood Patients in the sample Number of patients in the sample Number of patients Studies show that reducing blood pressure
pressure < 130/80 mm whose blood pressure whose blood pressure in the sample. in people with CKD reduces the rate of
Hg measurement at the most measurement at the most recent deterioration of their kidney function whether
recent visit was less than visit was less than 130/80 mm or not they have hypertension or diabetes.
130/80 mm Hg. Hg. Randomized controlled trials conclusively
demonstrate the benefit of lowering blood
pressure to <140 mm Hg systolic and <80
mm Hg diastolic in patients. Epidemiologic
studies show that the risk of CVD begins at
blood pressures of >115/75 mm Hg. Experts
have therefore agreed that <130/80 mm Hg
is a reasonable target for blood pressure
control in patients.
Hemoglobin >=10 g/dL in Patients in the sample not Number of patients in the sample Number of patients Multiple studies have shown that
patients not receiving an receiving an ESA whose not receiving an ESA whose in the sample. maintaining a hemoglobin >= 10 g/dL results
ESA and Hemoglobin 10 most recent Hemoglobin most recent Hemoglobin value in improvement in quality of life. Several
to 12 g/dL in patients value was greater than or was greater than or equal to 10 studies have shown a trend toward greater
receiving an ESA equal to 10 g/dL or patients g/dL or patients in the sample cardiovascular events in dialysis and
in the sample receiving an receiving an ESA whose most nondialysis patients assigned to Hgb targets
ESA whose most recent recent Hemoglobin value was greater than 13.0 g/dL.
Hemoglobin value was greater than or equal to 10 and
greater than or equal to 10 less than or equal to 12 g/dL.
and less than or equal to 12 Hemoglobin test must have been
g/dL. done within the specified
abstraction period (for patients
not receiving an ESA, it should
be within 12 months of the visit
date, with a three month grace
period; for patients receiving an
ESA, it should be within three
months of the visit date, with a
one month grace period).
Hemoglobin > 12g/dL at Patients in the sample Number of patients in the sample Number of patients Studies have shown that a hemoglobin
time of last ESA whose hemoglobin was > whose hemoglobin was > 12g/dL in the sample greater than 13g/dL is associated with
administration (Overuse) 12g/dL at time of last ESA at time of last ESA receiving ESA. increased mortality and frequency of
administration administration. cardiovascular events. The clinical
recommendation regarding Hgb levels for
CKD patients receiving ESA therapy is that


Clinical Outcomes

Hgb levels should generally be in the range
of 11.0 to 12.0 g/dL. Additionally, these
patients should also have their Hgb level
checked at least monthly. The initial ESA
dose and the ESA dose adjustments should
be determined by the patient’s Hgb level, the
target Hgb level, the observed rate of
increase in Hgb level, and clinical
circumstances.
Serum phosphorus in Patients in the sample Number of patients in the sample Number of patients A number of different observational studies
normal range (3.0-5.5 whose most recent serum whose most recent serum in the sample. in dialysis patients have demonstrated an
mg/dL), tested within six phosphorus was in normal phosphorus was in normal range association between elevated serum
months of visit range (3.0-5.5 mg/dL). (3.0-5.5 mg/dL). Phosphorus phosphorus and mortality, cardiovascular
measurement must have been events, and hospitalization. The relative risk
done within the specified of mortality increased with serum
abstraction period (within six phosphorus levels >6.5 mg/dL. Serum
months of the visit date, with a phosphorus levels <2.5 mg/dL may be
one month grace period). associated with abnormalities in bone
mineralization such as osteomalacia. Serum
phosphorus should be checked at least
annually in patients with eGFR < 45
ml/min/1.73 m2 and at least every six
months if abnormal.
Serum bicarbonate < 20 Patients in the sample Number of patients in the sample Number of patients Low serum bicarbonate levels have been
mEq/L, tested within six whose most recent serum whose most recent serum in the sample. associated with changes in bone
months of visit bicarbonate measurement bicarbonate measurement was < histomorphometry among populations with
was < 20 mEq/L. 20 mEq/L. Serum bicarbonate differing glomerular filtration rates (GFRs).
measurement must have been Patients with CKD are susceptible to
done within the specified developing acidosis. Acidosis may cause
abstraction period (within six increased risk for bone disease as well as
months of the visit date, with a multiple other complications (i.e.,
one month grace period). cardiovascular disease and malnutrition). It
is presumed that correction of serum
bicarbonate leads to prevention of bone
disease and preservation of bone buffering.


Clinical Outcomes

Serum LDL cholesterol Patients in the sample Number of patients in the sample Number of patients Continuing evidence shows that lowering
<100 mg/dL, tested within whose most recent LDL whose most recent LDL in the sample. LDL in patients with CKD may retard the
12 months of visit cholesterol level was <100 cholesterol level was <100 progression of kidney disease. It has been
mg/dL. mg/dL. LDL measurement must recommended that the levels of LDL be
have been done within the measured every year.
specified abstraction period
(within 12 months of the visit
period).
Serum HDL cholesterol Patients in the sample Number of patients in the sample Number of patients Strong epidemiological evidence links low
>= 40 mg/dL for men; >= whose most recent HDL whose most recent HDL in the sample. levels of serum HDL cholesterol to
50 mg/dL for women, cholesterol level was >= 40 cholesterol level was >= 40 increased CHD morbidity and mortality.
tested within 12 months mg/dL for men and >= 50 mg/dL for men and >= 50 mg/dL Epidemiological studies consistently show
of visit mg/dL for women. for women. HDL measurement low HDL cholesterol to be an independent
must have been done within the risk factor for CHD. A low HDL level
specified abstraction period correlates with the presence of other
(within 12 months of the visit atherogenic factors. Prospective studies
date, with a three month grace have shown that a high HDL cholesterol is
period). associated with reduced risk for CHD.
Serum triglycerides < 150 Patients in the sample Number of patients in the sample Number of patients Many prospective epidemiological studies
mg/dL, tested within 12 whose most recent whose most recent triglyceride in the sample. have reported a positive relationship
months of visit triglyceride level was <150 level was <150 mg/dL. between serum triglyceride levels and
mg/dL. Triglyceride measurement must incidence of CHD. Elevated triglycerides are
have been done within the widely recognized as a marker for increased
specified abstraction period risk for CHD.
(within 12 months of the visit
period).
Hemoglobin A1C > 9.0% Patients in the sample with Number of patients in the Number of patients Although aggressive control of glucose to
(poor control), tested diabetes whose most recent sample with diabetes whose in the sample with near normal levels may not be appropriate
within six months of visit A1C level was greater than most recent A1C level was diabetes. for all patients, including those who are frail,
9.0%, reflecting poor greater than 9.0%, OR who did have a history of severe hypoglycemia, or
glucose control. In this not have A1C measurement who have longstanding and severe
measure, lower percentages done or documented during the cardiovascular disease, most experts agree
are better. specified abstraction period that all patients can benefit from glucose
(within six months of the visit control that lowers A1C to < 9%, a level
date, with a one month grace above which patients are at high risk for
period). complications related to hyperglycemia.


CKD - PROCESSES OF CARE

Patient Evaluation


Height Patients in the sample with Number of patients in the sample Number of patients It is recommended that the physical
height documented. who have height documented. in the sample. examination should include the height,
weight and body mass index. Accurate
measurements of height and weight are
important to determine signs of malnutrition.

Weight from most recent Patients in the sample with Number of patients in the sample Number of patients It is recommended that the physical
office visit documented weight documented from who have weight documented in the sample. examination should include the height,
most recent office visit. from most recent office visit. weight and body mass index. Accurate
measurements of height and weight are
important to determine signs of malnutrition.
Additionally, increased weight may indicate
volume overload.
Weight from last three Patients in the sample with Number of patients in the sample Number of patients Serial weights are important in assessing
visits documented weight documented at each with weight documented at each in the sample, both volume status and adequacy of
of the last three office visits. of the last three office visits. excluding patients nutrition. Weight should be documented at
who have had less every visit.
than three office
visits.
Blood pressure Patients in the sample Number of patients in the Number of patients Recent research has shown that during
measured at most recent whose blood pressure sample whose blood pressure in the sample. office visits, approximately 20% to 30% of
visit (systolic / diastolic) was (systolic/diastolic) was CKD patients do not have their blood
measured at the most recent measured at the most recent pressure measured. Patients with CKD
visit. visit. should have their blood pressure measured
at each office visit so that changes can be
identified and treatment initiated as soon as
it is necessary. Blood pressure control is
important in slowing the progression of
chronic kidney disease. By slowing the
progression of the disease, quality of life is


Patient Evaluation

improved for the patient, and it results in a
longer period of time before a patient
requires renal replacement therapy.
Blood pressure Patients in the sample Number of patients in the sample Number of patients Recent research has shown that during
measured at last three whose blood pressure whose blood pressure in the sample, office visits, approximately 20% to 30% of
office visits (systolic/diastolic) was (systolic/diastolic) was measured excluding patients CKD patients do not have their blood
measured at the last three at the last three office visits. who have had less pressure measured. Patients with CKD
office visits. than three office should have their blood pressure measured
visits. at each office visit so that changes can be
identified and treatment initiated as soon as
it is necessary. Blood pressure control is
important in slowing the progression of
chronic kidney disease. By slowing the
progression of the disease, quality of life is
improved for the patient, and it results in a
longer period of time before a patient
requires renal replacement therapy.
Most recent blood Patients in the sample with Number of patients in the sample Number of patients Patients with CKD should have their blood
pressure >=130/80 mm most recent blood pressure with most recent blood pressure in the sample pressure measured at each office visit so
Hg with documented measurement >= 130/80 measurement >= 130/80 mm Hg whose most recent that changes can be identified and treatment
blood pressure mm Hg who were reported who were reported as having a blood pressure initiated as soon as it is necessary. Blood
management plan of care as having a documented documented blood pressure measurement was pressure control is important in slowing the
blood pressure management management plan of care. >= 130/80 mm Hg, progression of chronic kidney disease.
plan of care. regardless the date Patients with chronic kidney disease should
of the blood have a target blood pressure of <130/80.
pressure Treatment of high blood pressure in CKD
measurement. should include identification of target blood
pressure levels, nonpharmacologic therapy,
and specific antihypertensive agents for the
prevention of progression of kidney disease
and development of cardiovascular disease.
CKD diagnosis Patients in the sample with a Number of patients in the sample Number of patients Identification and diagnosis of CKD is
documented chart documentation of who were reported as having in the sample. important to optimize clinical management
current diagnosis of CKD. current diagnosis of CKD recommendations for this complex patient
documented. population. All individuals with GFR < 60
mL/min/1.73 m2 for three months are
classified as having chronic kidney disease,
irrespective of the presence or absence of
kidney damage.


Patient Evaluation

CKD stage documented Patients in the sample with a Number of patients in the sample Number of patients Staging of CKD may facilitate the application
chart documentation of who were reported as having in the sample. of clinical practice guidelines (CPG), clinical
current stage of CKD. stage of CKD documented. performance measures, and quality
improvement efforts to the evaluation and
management of CKD.

Medications reviewed at Patients in the sample who Number of patients in the sample Number of patients A number of drugs can be associated with
most recent office visit were reported as having who were reported as having in the sample. chronic kidney damage, so a thorough
current medications current medications reviewed at review of the medication list (including
reviewed at most recent most recent office visit. prescribed medications, over-the-counter
office visit. medications, “nontraditional” medications,
vitamins and supplements, herbs, and drugs
of abuse) is vital. Severe kidney impairment
may alter volume of distribution and protein
binding, prompting dosage adjustments. In
patients with CKD, medications that are
renally excreted may require a lower initial
dose or an increase in the interval between
doses.


Diagnostic Testing


eGFR assessment, Patients in the sample who were Number of patients in the sample Number of patients Estimated glomerular filtration rate
within six months of reported as having eGFR who were reported as having in the sample. (eGFR) has become the “gold
visit assessment during the six month eGFR assessment during the six standard” test for the measurement
period prior to the visit date, with month period prior to the visit of kidney function. A variety of
a one month grace period. date, with a one month grace different prediction equations have
period. been developed including the
MDRD (4- and 6-variable) and
Cockroft-Gault Formulas. While
estimates of eGFR may be
unreliable at the extremes of age,
muscle mass and weight, and at
eGFR levels above 60
ml/min/1.73m2, eGFR is reasonably
accurate measure of true GFR in
most patients with moderate or
more severe CKD.

UPC ratio or UACR, Patients in the sample who had Number of patients in the sample Number of patients Protein excretion in the urine is an
tested within six months testing for UPC ratio or UACR who had testing for UPC ratio or in the sample. indicator of abnormal kidney
of visit done during the six month period UACR done during the six month function and should be assessed in
prior to the visit date, with a one period prior to the visit date, with all patients with CKD. Proteinuria is
month grace period. a one month grace period. not only a marker of kidney
damage, it is also a guide to the
differential diagnosis, prognosis,
and therapy of chronic kidney
disease.

Hemoglobin, tested as Patients in the sample not Number of patients in the sample Number of patients Observational studies show that (in
per guidelines receiving ESA who were not receiving ESA who were in the sample. the absence of ESA therapy) the
reported as having hemoglobin reported as having hemoglobin natural history of anemia in patients
testing done during the 12 month testing done during the 12 month with CKD is a gradual decline in
period prior to the visit date, with period prior to the visit date, with Hgb levels over time. The
a three month grace period, OR a three month grace period, OR recommendation is that patients be
patients in the sample receiving patients in the sample receiving evaluated at least annually.
ESA who were reported as ESA who were reported as Hemoglobin is the preferred test for
having hemoglobin testing done having hemoglobin testing done evaluation of anemia. A complete
during the three month period during the three month period blood count can help determine
prior to the visit date, with a one prior to the visit date, with a one whether anemia is present, how
month grace period. month grace period. severe the anemia is and whether
the patient would benefit from
treatment. Patients receiving an


Diagnostic Testing


ESA should have their hemoglobin
level checked at least monthly.
Documented plan of Patients in the sample receiving Number of patients in the sample Number of patients Studies have shown that a
care to reduce an ESA and with the most recent receiving an ESA and with the in the sample hemoglobin greater than 13 g/dL is
hemoglobin in patients Hemoglobin value greater than most recent Hemoglobin value receiving an ESA associated with increased mortality
receiving an ESA and or equal to 13g/dL who were greater than or equal to 13g/dL and with the most and frequency of cardiovascular
with Hemoglobin reported as having a who were reported as having a recent Hemoglobin events. The clinical
>=13g/dL documented plan of care to documented plan of care to value greater than or recommendation regarding Hgb
reduce hemoglobin. reduce hemoglobin. equal to 13g/dL. . levels for CKD patients receiving
ESA therapy is that Hgb levels
should generally be in the range of
11.0 to 12.0 g/dL. Additionally,
these patients should also have
their Hgb level checked at least
monthly. The initial ESA dose and
the ESA dose adjustments should
be determined by the patient’s Hgb
level, the target Hgb level, the
observed rate of increase in Hgb
level, and clinical circumstances.
Serum ferritin, tested Patients in the sample receiving Number of patients in the sample Number of patients Serum ferritin level is the only
per guidelines an ESA who were reported as receiving an ESA who were in the sample with available blood marker of storage
having serum ferritin testing done reported as having serum ferritin anemia. Anemia is iron. It is recommended that
during the six month period prior testing done during the six month defined as a hemoglobin, ferritin, and TSAT be
to the visit date, with a one period prior to the visit date, with documented tested together because the
month grace period, OR patients a one month grace period, OR diagnose of anemia, combination provides important
in the sample with anemia who patients in the sample with or if their most recent insight into external iron balance
were not receiving an ESA and anemia who were not receiving hemoglobin is < 13 and internal iron distribution. Iron
who were reported as having an ESA and who were reported g/dL for men and < status tests provide reasonable
serum ferritin testing done during as having serum ferritin testing 12 g/dL for women, markers to detect iron deficiencies.
the 12 month period prior to the done during the 12 month period or hemoglobin has
visit date, with a three month prior to the visit date, with a three been <10 g/dL in the
grace period. month grace period. last 12 months.


Diagnostic Testing

Tsat, tested as per Patients in the sample receiving Number of patients in the sample Number of patients TSAT is a measure of the adequacy
guidelines an ESA who were reported as receiving an ESA who were in the sample with of iron supply for erythropoiesis. It
having Tsat testing done during reported as having Tsat testing anemia. Anemia is is recommended that hemoglobin,
the six month period prior to the done during the six month period defined as a ferritin, and TSAT be tested
visit date, with a one month prior to the visit date, with a one documented together because the combination
grace period, OR patients in the month grace period, OR patients diagnose of anemia, provides important insight into
sample with anemia who were in the sample with anemia who or if their most recent external iron balance and internal
not receiving an ESA and who were not receiving an ESA and hemoglobin is < 13 iron distribution. Iron status tests
were reported as having Tsat who were reported as having g/dL for men and < provide reasonable markers to
testing done during the 12 month Tsat testing done during the 12 12 g/dL for women, detect iron deficiencies.
period prior to the visit date, with month period prior to the visit or hemoglobin has
a three month grace period. date, with a three month grace been <10 g/dL in the
period. last 12 months.
Hemoglobin A1C, Patients in the sample with Number of patients in the sample Number of patients Studies have repeatedly shown that
tested within six months diabetes who had A1C testing with diabetes who had A1C in the sample with out-of-control diabetes results in
of visit done during the six month period testing done during the six month diabetes. complications from the disease.
prior to the visit date, with a one period prior to the visit date, with Hemoglobin A1C is thought to
month grace period. a one month grace period. reflect average glycemia over
several months, and has strong
predictive value for diabetes
complications. Patients with stable
glycemia well within target may do
well with testing only twice per year,
while unstable or highly intensively
managed patients (e.g., pregnant
type 1 women) may need testing
more frequently.
Serum calcium, tested Patients in the sample who had Number of patients in the sample Number of patients As kidney function declines, there is
within six months of visit serum calcium testing done who had serum calcium testing in the sample. a progressive deterioration in
during the six month period prior done during the six month period mineral homeostasis, with a
to the visit date, with a one prior to the visit date, with a one disruption of normal serum and
month grace period. month grace period. tissue concentrations of phosphorus
and calcium. The laboratory
diagnosis of CKD–MBD includes the
use of laboratory testing of serum
PTH, calcium, and phosphorus.
Serum phosphorus, calcium, and
intact PTH should be checked at
least annually in patients with eGFR
< 45 ml/min/1.73 m2 and at least
every six months if abnormal.


Diagnostic Testing

Serum phosphorus, Patients in the sample who had Number of patients in the sample Number of patients As kidney function declines, there is
tested within six months serum phosphorus testing done who had serum phosphorus in the sample. a progressive deterioration in
of visit during the six month period prior testing done during the six month mineral homeostasis, with a
to the visit date, with a one period prior to the visit date, with disruption of normal serum and
month grace period. a one month grace period. tissue concentrations of phosphorus
and calcium. The laboratory
diagnosis of CKD–MBD includes the
use of laboratory testing of serum
PTH, calcium, and phosphorus.
Serum phosphorus, calcium, and
intact PTH should be checked at
least annually in patients with eGFR
< 45 ml/min/1.73 m2 and at least
every six months if abnormal.
Serum bicarbonate, Patients in the sample who had Number of patients in the sample Number of patients
tested within six months serum bicarbonate testing done who had serum bicarbonate in the sample. Patients with CKD are susceptible
of visit during the six-month period prior testing done during the six-month to developing acidosis. Acidosis
to the visit date, with a one- period prior to the visit date, with may cause increased risk for bone
month grace period. a one-month grace period. disease as well as multiple other
complications (i.e., cardiovascular
disease and malnutrition). Since
the serum bicarbonate level can
fluctuate over days or weeks,
frequent monitoring is warranted.

Serum potassium, Patients in the sample who had Number of patients in the sample Number of patients Disorders of potassium homeostasis
tested within six months serum potassium testing done who had serum potassium in the sample. (both high and low potassium
of visit during the six month period prior testing done during the six month levels) may result in preventable
to the visit date, with a one period prior to the visit date, with morbidity and mortality. Potassium
month grace period. a one month grace period. levels should be checked
periodically in patients with kidney
disease.


Diagnostic Testing

Serum intact PTH, Patients in the sample who had Number of patients in the sample Number of patients Renal osteodystrophy is a complex
tested within 12 months serum intact PTH testing done who had serum intact PTH in the sample. and multifaceted disease process
of visit during the 12 month period prior testing done during the 12 month that begins early in the course of
to the visit date, with a three period prior to the visit date, with chronic kidney disease (CKD) and is
month grace period. a three month grace period. a major, long-term complication
associated with high rates of
morbidity. Experimental and clinical
research has shown an increased
risk for hyperparathyroidism (HPTH)
with hypocalcemia and
hyperphosphatemia that often
accompanies CKD. HPTH reflected
by high immunoreactive parathyroid
hormone (iPTH) levels may exist in
the face of normal serum calcium
and phosphorus. Serum
phosphorus, calcium, and intact
PTH should be checked at least
annually in patients with eGFR < 45
ml/min/1.73 m2 and at least every
six months if abnormal.
Serum 25- Patients in the sample who had Number of patients in the sample Number of patients Beginning in CKD stage 3, the
hydroxyvitamin D serum 25-hydroxyvitamin D who had serum 25- in the sample. ability of the kidneys to
(calcidiol), tested within (calcidiol) testing done during the hydroxyvitamin D (calcidiol) appropriately excrete a phosphate
12 months of visit 12 month period prior to the visit testing done during the 12 month load is diminished. This leads to an
date, with a three month grace period prior to the visit date, with impairment in the conversion of
period. a three month grace period. 25(OH)D to 1,25(OH)2D reducing
intestinal calcium absorption and
increasing PTH. Vitamin D
deficiency and insufficiency may
have a role in the pathogenesis of
secondary hyperparathyroidism
(HPT). Studies have shown that
there is an association of low
25(OH)D levels with mortality.
Serum LDL cholesterol Patients in the sample who had Number of patients in the sample Number of patients Continuing evidence shows that
tested within 12 months LDL cholesterol testing done who had LDL cholesterol testing in the sample. lowering LDL in patients with CKD
of visit during the 12-month period prior done during the specified may retard the progression of
to the visit date, with a three abstraction period (within 12 kidney disease. It has been
month grace period. months of the visit date, with a recommended that the levels of LDL


Diagnostic Testing

three month grace period). be measured every year. It has
been recommended that all patients
with CKD should be evaluated for
dyslipidemias annually. The
assessment of dyslipidemias should
include a complete fasting lipid
profile with total cholesterol, low-
density lipoprotein (LDL), high-
density lipoprotein (HDL), and
triglycerides.
Serum HDL cholesterol Patients in the sample who had Number of patients in the sample Number of patients It has been recommended that all
tested within 12 months HDL cholesterol testing done who had HDL cholesterol testing in the sample. patients with CKD should be
of visit during the 12-month period prior done during the specified evaluated for dyslipidemias
to the visit date, with a three abstraction period (within 12 annually. The assessment of
month grace period. months of the visit date, with a dyslipidemias should include a
three month grace period). complete fasting lipid profile with
total cholesterol, low-density
lipoprotein (LDL), high-density
lipoprotein (HDL), and triglycerides.
Serum triglycerides Patients in the sample who had Number of patients in the sample Number of patients It has been recommended that all
tested within 12 months triglyceride testing done during who had triglyceride testing done in the sample. patients with CKD should be
of visit the 12-month period prior to the during the specified abstraction evaluated for dyslipidemias
visit date, with a three month period (within 12 months of the annually. The assessment of
grace period. visit date, with a three month dyslipidemias should include a
grace period). complete fasting lipid profile with
total cholesterol, low-density
lipoprotein (LDL), high-density
lipoprotein (HDL), and triglycerides.


Treatment: Medication


ACE inhibitor or ARB Patients in the sample with Number of patients in the Number of patients in Numerous randomized, controlled
hypertension and proteinuria sample with hypertension and the sample with clinical trials have demonstrated that
who are currently receiving ACE proteinuria who are currently hypertension and the use of angiotensin converting
inhibitor or ARB. receiving ACE inhibitor or ARB. proteinuria (proteinuria is enzyme (ACE) inhibitors and
Proteinuria is defined as UACR defined as UACR > 300 angiotensin receptor blockers (ARBs)
> 300 mg/g or UPC ratio > 200 mg/g or UPC ratio > 200 as antihypertensive therapy is
mg/g. mg/g). effective, and may help slow the
progression of chronic kidney disease
(CKD). These drugs help control
hypertension and decrease
proteinuria. ACE inhibition has also
been shown to reduce mortality and
cardiovascular events in patients with
pre-existing coronary artery disease
and patients with diabetes mellitus
and at least one other coronary artery
disease risk factor. The mortality
benefit conferred by ACE inhibitors
may be greater for patients with
elevated serum creatinine compared
to those with normal renal function.
Patients with CKD are considered to
be in the highest category for cardiac
risk and are thus likely to derive
benefit from ACE inhibition. ARBs
have also been shown to reduce
progression of chronic kidney disease
in subjects with type II diabetes
mellitus.

Statin or other lipid- Patients in the sample who are Number of the patients in the Number of the patients Patients with CKD have increased
lowering drug potentially eligible for treatment sample who potentially eligible in the sample potentially coronary heart disease (CHD) risk
with a statin or other lipid- for treatment with a statin or eligible for treatment (greater than 20% per 10 years) and
lowering drug, and who are other lipid-lowering drug, and with a statin or other should be considered to be in the
currently receiving this therapy. who are currently receiving this lipid-lowering drug. highest risk category for
Patients were considered therapy. Patients were Patients were atherosclerotic cardiovascular disease
potentially eligible for treatment considered potentially eligible considered potentially (ACVD). Multiple clinical trials
with a statin or other lipid- for treatment with a statin or eligible for treatment demonstrated significant effects of
lowering drug if the chart other lipid-lowering drug if the with a statin or other pharmacologic (primarily statin)
documented that they had chart documented that they had lipid-lowering drug if the therapy on CVD outcomes in subjects
elevated LDL cholesterol or are elevated LDL cholesterol or are chart documented that with CHD and for primary CVD




on LDL-lowering medication, or on LDL-lowering medication, or they had elevated LDL prevention. A higher frequency of
if their most recent LDL if their most recent LDL cholesterol or are on adverse events has been reported
cholesterol was 100 mg/dL or cholesterol was 100 mg/dL or LDL-lowering with statin therapy in patients with
higher. higher. medication, or if their CKD so careful monitoring is
most recent LDL warranted. Lower statin doses may be
cholesterol was 100 necessary to reduce the risk of
mg/dL or higher. myopathy.
Aspirin Patients in the sample Number of patients in the Number of male patients One large meta-analysis and several
potentially eligible for sample potentially eligible for age 45 and over, and clinical trials demonstrate the efficacy
antiplatelet/anticoagulant antiplatelet/anticoagulant female patients age 55 of using aspirin as a preventive
therapy who are currently therapy who are currently and over in the sample, measure for cardiovascular events,
receiving this therapy. Patients receiving this therapy. Patients excluding patients who including stroke and myocardial
were considered potentially were considered potentially have medical infarction. The net benefit of aspirin
eligible if they were male eligible if they were male contraindications. depends on the initial risks for stroke
patients age 45 and over, or patients age 45 and over, or and gastrointestinal bleeding. Thus,
female patients age 55 and female patients age 55 and decisions about aspirin therapy should
over, excluding patients who over, excluding patients who consider the overall risk for stroke and
have medical contraindications have medical contraindications. gastrointestinal bleeding. The
optimum dose of aspirin for preventing
cardiovascular disease events is not
known. Primary prevention trials have
demonstrated benefits with various
regimens, including dosages of 75
and 100 mg/d and 100 and 325 mg
every other day. A dosage of
approximately 75 mg/d seems as
effective as higher dosages. The risk
for gastrointestinal bleeding may
increase with dose.

Metformin (a marker of Number of patients in the Number of patients in the Number of patients in Metformin should not be given to
poor care) sample with diabetes who are sample with diabetes who are the sample with diabetic patients with CKD because it
currently receiving Metformin currently receiving Metformin diabetes. is cleared by the kidneys and may
therapy. It is a marker of poor therapy. It is a marker of poor build up with even modest impairment
care. care. of kidney function, putting patients at
risk of lactic acidosis.



ESA Patients in the sample Number of patients in the Number of patients in As kidney function declines, the
potentially eligible for treatment sample potentially eligible for the sample with likelihood of anemia associated with
with ESA who are currently treatment with ESA who are hemoglobin <10 g/dL EPO deficiency increases because the
receiving this therapy. Patients currently receiving this therapy. currently or in the last 12 diseased kidneys are unable to
were considered potentially Patients were considered months. produce sufficient quantities of EPO.
eligible for treatment with ESA if potentially eligible for treatment In patients with CKD not requiring
the chart documented that they with ESA if the chart dialysis, untreated anemia increases
had a hemoglobin <10 g/dL documented that they had a cardiovascular risk, hospitalization,
currently or in the last 12 hemoglobin <10 g/dL currently and all-cause mortality, and
months. or in the last 12 months. diminishes health-related quality of
life. Heightened risk for progression of
kidney failure has also been linked to
untreated anemia of CKD. ESA agents
will not work to their maximal potential
in patients with iron deficiency anemia.
Several interventional studies have
shown that treating anemia of CKD
with erythropoietic agents may reduce
or reverse cardiac complications and
retard the rate of CKD progression.
Iron supplements for Patients in the sample with iron Number of patients in the Number of patients in
patients with iron deficiency anemia who are sample with iron deficiency the sample with iron Anemia is common in patients with
deficiency anemia currently receiving iron anemia who are currently deficiency anemia. advanced CKD and can lead to a
supplements. receiving iron supplements. Anemia is defined as a variety of detrimental effects. In
Anemia is defined as a documented diagnose of addition to the direct effects of anemia
documented diagnose of anemia, or if their most on performance and ischemic
anemia, or if their most recent recent hemoglobin is < symptoms, it has also been suggested
hemoglobin is < 13 g/dL for 13 g/dL for men and < that mortality and major complications
men and < 12 g/dL for women, 12 g/dL for women, or during end-stage renal disease
or hemoglobin has been <10 hemoglobin has been (ESRD) are associated with anemia
g/dL in the last 12 months. Iron <10 g/dL in the last 12 that develops early in the course of
deficiency is defined as serum months. Iron deficiency CDK. Correcting anemia before the
ferritin < 100 ng/mL or Tsat < is defined as serum initiation of renal replacement therapy
20%. ferritin < 100 ng/mL or (RRT) may improve health outcomes.
Tsat < 20%.
Iron deficiency is treatable and failure
to replete iron stores may result in
resistance to erythropoietin.



Phosphate binders Patients in the sample who are Number of patients in the Number of patients in Treatment and prevention of bone
currently receiving phosphate sample who are currently the sample. disease in patients with CKD is
binders. receiving phosphate binders. directed at treating the elevated serum
phosphorus with phosphate binders
and dietary phosphate restriction, and
providing the active form of vitamin D
with a medication. Almost all patients
with CKD will require dietary
phosphorus restriction and/or
phosphate binders to maintain serum
phosphorus levels within the target
range. Several prospective
randomized, controlled trials have
shown that therapy is safe and
effective.
Alkalinization therapy Patients in the sample who are Number of patients in the Number of patients in Experimental studies in animals and
currently receiving alkalinization sample who are currently the sample. clinical studies in patients with CKD
therapy. receiving alkalinization therapy. have identified several potential
adverse consequences of acidosis,
including muscle wasting, induction of
a catabolic state, exacerbation of renal
osteodystrophy, and accelerating the
progression of kidney disease.
Correction of metabolic acidosis
lessens renal osteodystrophy and
improves protein metabolism.
Vitamin D supplement Patients in the sample who are Number of patients in the Number of patients in Vitamin D deficiency is a major
currently receiving Vitamin D sample who are currently the sample. complication in patients with CKD and
supplement. receiving Vitamin D facilitates the pathogenesis of
supplement. hyperparathyroidism. Several studies
have shown that administering active
vitamin D leads to significant reduction
in mortality in CKD patients. In all CKD
patients receiving vitamin D therapy,
continued surveillance is needed, and
hypercalcemia must be avoided.


ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue

ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue

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ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue