Liaison Meeting ESRD Presentation


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  • ESRD patients: 1% of the Medicare population, but 6% of the payments Kidney failure care 2002: $ 25.2 billion Lost patient income: ~ $2- 4 billion/year
  • Age standardized rate of death
  • These are populations that I am sure are served in many community health centers
  • The study also recognised that admission notes rarely documented the presence or absence of a history of renal disease. Only 2 of 16 (12.5%) hypertensive and 4 of 51 (7.8%) diabetic patients with 1 + or greater proteinuria had abnormal renal function mentioned in their discharge summaries. Similarly, of the 35 hypertensive patients with a serum creatinine of 1.5 mg/dl or greater, the discharge summaries of only 4 (11.4%) noted abnormal renal function. Only 4 of 41 (9.8%) diabetic patients with a serum creatinine of 1.5 mg/dl or greater had the evidence for abnormal renal function recorded at discharge. Additionally, the charts of the patients with abnormal renal function tests showed neither awareness of the disorder nor plans for further evaluation of the possible underlying disease.
  • There is actually moderately strong evidence to support the recommendation for referral of individuals with advanced CKD in stage 4 to a nephrologist. This suggests that there is sub-optimal CKD care that drives the early ESRD Spike in costs. Further studies have shown that late referral to a nephrologist is associated with worse outcomes. Here is data on cumulative mortality from the CHOICE cohort which was a national prospective cohort study in the USA, in which 1041 patients starting dialysis from 1995 to 1998 were followed. Patients were divided into three groups depending on the time between their first visit to a nephrologist and the onset of dialysis: < 4 months, 4-12 months, and > 12 months. These findings of a graded relationship between time of referral to nephrology and survival on dialysis has been confirmed by several other studies. Currently, about one third of individuals are referred < 4 months before the start of dialysis, causing a threefold increase in the risk of death during the first months of dialysis. What exactly is the activity of the nephrologist that causes the positive effects on survival? It appears that avoiding emergency dialysis or a non-elective start of dialysis is a major benefit of early referral. Other probable causes are related to the management of CKD complications.
  • Liaison Meeting ESRD Presentation

    1. 1. Improving Care for Chronic Kidney Disease and Kidney Failure Lesley Stevens MD MS MassPro Liaison Meeting February 8, 2007
    2. 2. Why K idney? <ul><li>A sample of calls we receive: </li></ul><ul><li>Is this the …. department? </li></ul><ul><li>Neurology </li></ul><ul><li>Urology </li></ul><ul><li>Allergy </li></ul><ul><li>Phrenology </li></ul><ul><li>Necrology </li></ul>
    3. 3. Chronic Kidney Disease is a Public Health Problem <ul><li>CKD is common </li></ul><ul><ul><li>11% of US adults </li></ul></ul><ul><ul><li>Higher prevalence in patients with CVD risk factors </li></ul></ul><ul><li>CKD is harmful </li></ul><ul><ul><li>Increased risk for CVD </li></ul></ul><ul><ul><li>Complications of decreased kidney function </li></ul></ul><ul><ul><li>Progression to kidney failure </li></ul></ul><ul><li>We have treatment </li></ul>
    4. 4. Kidney damage and Normal or  GFR Kidney damage and Mild  GFR Severe  GFR Kidney failure Moderate  GFR Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Other health care providers GFR 90 60 30 15 Practice Model for Detection, Evaluation and Management in CKD At increased risk Kidney Specialist Primary care physician
    5. 5. Outline <ul><li>Kidney Failure </li></ul><ul><li>Chronic kidney disease </li></ul><ul><ul><li>Definition </li></ul></ul><ul><ul><li>Outcomes </li></ul></ul><ul><li>CKD: Clinical Action Plan </li></ul><ul><ul><li>Detect CKD </li></ul></ul><ul><ul><li>Prevent progression of CKD </li></ul></ul><ul><ul><li>Diagnosis and treat CVD </li></ul></ul><ul><ul><li>Treat co-morbid conditions and complications </li></ul></ul><ul><ul><li>Refer to nephrology </li></ul></ul>
    6. 6. Kidney Failure (ESRD) in the US Lung Cancer Kidney Failure Colon Cancer Breast Cancer Prostate Cancer 57 99 42 32 Kidney Failure Compared to Cancer Deaths in the U.S. in 2000* (in Thousands) 157 *SEER, 2003 Male Female Black White 0.01 100 10 1 0.1 Annual mortality 25–34 45–54 65–74  85 35–44 55–64 75–84 Dialysis Age (years) General population
    7. 7. Disparities in ESRD Incidence Incident ESRD patients; rates by age adjusted for gender & race, rates by race & ethnicity adjusted for age & gender. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity. USRDS 2006
    8. 8. General Population Transplant Dialysis USRDS 2006 General Population Transplant Dialysis
    9. 9. Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies CKD death Complications Screening for CKD risk factors: diabetes hypertension age >60 family history US ethnic minorities CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant Normal Increased risk Kidney failure Damage  GFR
    10. 10. NKF K/DOQI Definition of Chronic Kidney Disease <ul><li>Structural or functional abnormalities of the kidneys for > 3 months, as manifested by either: </li></ul><ul><li>1. GFR <60 ml/min/1.73 m 2 , with or without kidney damage </li></ul><ul><li>2. Kidney damage, with or without decreased GFR, as defined by </li></ul><ul><ul><ul><li>pathologic abnormalities </li></ul></ul></ul><ul><ul><ul><li>markers of kidney damage </li></ul></ul></ul><ul><ul><ul><ul><li>urinary abnormalities (proteinuria) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>blood abnormalities (renal tubular syndromes) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>imaging abnormalities </li></ul></ul></ul></ul><ul><ul><ul><li>kidney transplantation </li></ul></ul></ul>
    11. 12. Normal GFR Wesson Human Physiology of the Kidney 1969
    12. 13. Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 99-00) *Based on NHANES 1999–2000 prevalence and 200,948,641 adults age 20 years and older in 2000 census. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio  17 mg/g in men or  25 mg/g in women in two measurements. % N (1000s) 0.1 391 < 15 or Dialysis Kidney Failure 5 0.1 300 15-29 Severe  GFR 4 3.7 7,400 30-59 Moderate  GFR 3 2.8 5,700 60-89 Kidney Damage with Mild  GFR 2 2.8 5,600  90 Kidney Damage with Normal or  GFR 1 Prevalence* GFR (ml/min/1.73 m 2 Description Stage
    13. 14. New ICD-9-CM Codes <ul><li>Revise 585 Chronic renal failure Chronic kidney disease (CKD) </li></ul><ul><li>New code 585.1 Chronic kidney disease, Stage 1 </li></ul><ul><li>New code 585.2 Chronic kidney disease, Stage 2 (mild) </li></ul><ul><li>New code 585.3 Chronic kidney disease, Stage 3 (moderate) </li></ul><ul><li>New code 585.4 Chronic kidney disease, Stage 4 (severe) </li></ul><ul><li>New code 585.5 Chronic kidney disease, Stage 5 </li></ul><ul><li>New code 585.6 End stage renal disease </li></ul><ul><li>New code 585.9 Chronic kidney disease, unspecified </li></ul><ul><li>Chronic renal disease </li></ul><ul><li>Chronic renal failure NOS </li></ul><ul><li>Chronic renal insufficiency </li></ul><ul><li>Add Use additional code to identify kidney transplant status, if applicable (V42.0) </li></ul>
    14. 15. Complications Related to CKD
    15. 16. USRDS Annual Data Report 2005 CKD and Other Chronic Conditions: Cost Multiplier Populations estimated from the 5 percent Medicare sample, & include patients surviving the entire cohort year (1992, 2002) with Medicare as primary payor, plus period prevalent ESRD patients for 1993 & 2003. Diagnoses determined from claims in 1992 & 2002. Patients with ESRD in the 5 percent sample are excluded, as they are counted in the ESRD population. Costs are for the second year of the two-year period.
    16. 17. CKD Mortality: Kaiser Permanente Northern California Go A, et al . NEJM 2004 All Cause Mortality Cardiovascular Deaths
    17. 18. Longitudinal Follow-up and Outcomes Among Population With Chronic Kidney Disease in a Large Managed Care Organization Keith et al Arch Intern Med 2005 6.6 10.3 16.2 14.9 Disenrolled 45.7 24.3 19.5 10.2 Death 2.3 0.2 0.2 0.01 Received Tx 17.6 1.1 0.9 0.06 Initiated Dialysis 27.8 64.2 63.3 74.8 None of above Events (%) 37.6 51.1 49.8 53.9 FU (months) 73.6 71.6 60.8 61.4 Age (years) 777 11378 1741 14202 N Stage 4 Stage 3 Stage 2 GFR 60-89, No U prot
    18. 19. Chronic Kidney Disease: A Clinical Action Plan Replacement, if Uremia Present <15 or Dialysis Kidney Failure 5 Preparation for Kidney Replacement Therapy 15-29 Severe  GFR 4 Evaluating and Treating Complications 30-59 Moderate  GFR 3 Estimating Progression 60-89 Kidney Damage with Mild  GFR 2 Diagnosis and Treatment, Treatment of Comorbid Conditions, Slowing Progression, CVD Risk Reduction > 90 Kidney Damage with Normal or  GFR 1 Screening, CKD Risk Reduction >60 (CKD Risk Factors) At Increased Risk Action† GFR (ml/min/1.73 m 2 ) Description Stage
    19. 20. CKD Testing <ul><li>Serum creatinine to estimate the GFR </li></ul><ul><li>Urine albumin testing </li></ul>
    20. 21. Creatinine Generation <ul><li>Muscle mass </li></ul><ul><li>Varies by age, sex, race, weight </li></ul><ul><li>Diet </li></ul><ul><li>Short and long term meat intake </li></ul>
    21. 22. GFR Estimating Equations <ul><li>Cockcroft-Gault formula </li></ul><ul><li>C cr (ml/min) = (140-age) x weight *0.85 if female </li></ul><ul><li>72 S cr </li></ul><ul><li>MDRD Study equation </li></ul><ul><li>GFR (ml/min/1.73 m 2 ) = 186 x (S cr ) -1.154 x (age) -.203 x (0.742 if female) x (1.210 if African American) </li></ul>All labs will be reporting GFR within a few years On Line Calculator:
    22. 23. Serum Creatinine vs. est. GFR <ul><li>A serum creatinine of 1.2 mg/dl represents: </li></ul><ul><ul><li>eGFR 102 in an 18 year-old African American man </li></ul></ul><ul><ul><li>eGFR 66 in a 57 year-old Caucasian man </li></ul></ul><ul><ul><li>eGFR 59 in a 62 year-old African American woman </li></ul></ul><ul><ul><li>eGFR 46 in a 76 year-old Caucasian woman </li></ul></ul>
    23. 24. At what level of creatinine does a 65-year-old white woman have chronic kidney disease (CKD)? 77% of physicians said: Creatinine > 1.5 mg/dL Creatinine = 0.94 mg/dL when eGFR = 60 mL/min/1.73 m 2 Coresh, et al. J Am Soc Nephrol 2005;16:180-188. Actual eGFR at this creatinine = 37 mL/min/1.73m 2
    24. 25. Who should be Tested? <ul><li>Age > 60 </li></ul><ul><li>African Americans, Native Americans, Hispanics and Asian & Pacific Islanders </li></ul><ul><li>Diabetics & Hypertensives </li></ul><ul><li>Individuals with known CVD </li></ul><ul><li>Individuals with a family history of CKD </li></ul>Source: NKF CKD Clinical Practice Guidelines
    25. 26. Fewer than 20% with CKD know they have the disease Coresh, et al. J Am Soc Nephrol 2005;16:180-188. 2.9 % 17.9 % 50 % 40 % 30 % 20 % 10 % 0 % Female Male Told They Have Weak or Failing Kidneys, %
    26. 27. Frequency of Testing of Serum Creatinine compared to other analytes in 277,111 patients who had blood work testing in Columbus, Ohio Stevens LA et al. JASN 2005
    27. 28. Probability of the assessment of 1+ microalbuminuria or proteinuria tests within a year, 2004 Figure 1.8 general Medicare: patients entering Medicare before January 1, 2003, age 65 & older, alive on December 31, & without a diagnosis of CKD during 2003. Patients enrolled in an HMO or with Medicare as secondary payor or diagnosed with ESRD during the year are excluded. EGHP: patients enrolled for the entire year 2003 in a fee-for-service plan, age 50–64, & without a diagnosis of CKD during 2003. Patients diagnosed with ESRD before or during the year are excluded. For both populations, diabetes & hypertension are defined in 2003. Patients censored at end of the plan & end of 2004; Medicare patients also censored at death. All tests tracked in 2004.
    28. 29. Even High-risk Patients’ Kidney Disease Rarely Documented 8% 10% 13% 11% 0% 10% 20% Proteinuria >1+ S. Cr. > 1.5 mg/dl Discharge Documentation of Kidney Abnormalities Detected During Hospitalization DM HTN McClellan WM et al. AJKD 1997
    29. 30. Treatments to Slow the Progression of Chronic Kidney Disease in Adults
    30. 31. ESRD incidence: leveling off? Incident ESRD patients; adjusted for age, gender, & race. USRDS 2006
    31. 32. Change in Incidence of ESRD: Effect of better blood pressure or ACEI? Adjusted incident rates of ESRD due to diabetes lla illi lla illi Incident ESRD patients, adjusted for gender. USRDS Annual Report 2005
    32. 33. Interventions to Delay Progression: Boston-area chart audit Kausz JASN 2001: 12 1501-7
    33. 34. Continuation of ACEI/ARBs by New CKD Patients incident CKD patients, 2000–2004 combined, from the Medstat database, 1999–2004. USRDS 2006
    34. 35. CVD Diagnosis in CKD ECF fluid overload in kidney failure or nephrotic syndrome; absence of ECF fluid overload in dialysis patients Heart Failure Retained CK MB and troponins; false negative inducible-perfusion scans (balanced ischemia); increased risk of acute kidney injury from contrast studies Ischemia Additional diagnostic considerations in CKD Condition
    35. 36. CVD Risk Factor Management in CKD Erythropoietin stimulating proteins; iron Anemia LDL <100, reduce dose of fibrates, increased risk of side effects from combination therapy Dyslipidemia Glipizide preferred, avoid metformin Diabetes BP goal <130/80; ACEI or ARB if proteinuria; increased frequency of monitoring Hypertension Additional therapeutic considerations in CKD Risk Factor
    36. 37. Reasons for Referral to Nephrologist <ul><li>GFR <30 mL/min/1.73 m 2 </li></ul><ul><li>Unable to carry out CKD Action Plan </li></ul><ul><ul><li>Undetermined cause </li></ul></ul><ul><ul><li>Spot urine protein/creatinine ratio >500 mg/g </li></ul></ul><ul><ul><li>High risk for progression </li></ul></ul><ul><ul><li>Difficult to manage complications </li></ul></ul><ul><ul><li>GFR decline without adequate explanation </li></ul></ul><ul><ul><li>Hyperkalemia (>5.5 mEq/l) </li></ul></ul><ul><ul><li>Resistant hypertension (>130/80 mm Hg) </li></ul></ul><ul><ul><li>Age <18 (pediatric nephrologist) </li></ul></ul>
    37. 38. Referral to Nephrologists Kinchen et al. Ann Intern Med 2002; 137: 479-486
    38. 39. In-Center Hemodialysis Should Not Be the Default First Choice <ul><li>Peritoneal dialysis </li></ul><ul><li>Home hemodialysis </li></ul><ul><ul><li>conventional 3x/week </li></ul></ul><ul><ul><li>daily short hemodialysis </li></ul></ul><ul><ul><li>nocturnal hemodialysis </li></ul></ul>
    39. 40. Home Hemodialysis: Seattle, 1964
    40. 41. Home Hemodialysis 2007
    41. 42. Fistula First
    42. 43. Vascular Access 1992-2004 lla illi lla illi Period prevalent hemodialysis patients. Data from Part B claims. Some patients may have more than one access at a given point in time. USRDS 2006
    43. 44. Influenza vaccinations 1993-2003 lla illi lla illi ESRD patients initiating therapy at least 90 days before September 1 of each year & alive on December 31; vaccinations tracked between September 1 & December 31 of each year. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity. USRDS 2006
    44. 45. Pneumococcal vaccinations 2000-2004 lla illi lla illi ESRD patients initiating therapy at least 90 days before the start of the period & alive on the period’s last day; vaccinations tracked during entire period. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity. USRDS 2006
    45. 46. How Might You Improve CKD Care? <ul><li>1. Raise Awareness </li></ul><ul><ul><li>Medical record: correct classification </li></ul></ul><ul><ul><li>Patients, their families and friends </li></ul></ul><ul><ul><li>Clinicians </li></ul></ul><ul><ul><li>Make sure educational materials are readily available </li></ul></ul>
    46. 47. How Might You Improve CKD Care? <ul><li>1. Raise Awareness </li></ul><ul><li>2. Help with Education </li></ul><ul><ul><li>Who is at risk </li></ul></ul><ul><ul><li>Benefits of continued ACE inhibitor/ARB use and of lower blood pressure targets </li></ul></ul><ul><ul><li>CKD is a risk factor for CVD, and need aggressive risk factor modification </li></ul></ul><ul><ul><li>Consider kidney replacement options early </li></ul></ul><ul><ul><ul><li>Living donor transplant the first choice, for some even in 70s </li></ul></ul></ul><ul><ul><ul><li>Home hemodialysis & peritoneal dialysis the second choice </li></ul></ul></ul><ul><ul><ul><li>early AVF creation important </li></ul></ul></ul>
    47. 48. How Might You Improve CKD Care? <ul><li>1. Raise Awareness </li></ul><ul><li>2. Help with Education </li></ul><ul><li>3. Coordinate </li></ul><ul><ul><li>Screening of high-risk groups </li></ul></ul><ul><ul><li>Nephrologist and dietician referrals </li></ul></ul><ul><ul><li>Prior authorization: erythropoietin, vitamin D analogs, ACE inhibitors, ARBs </li></ul></ul><ul><ul><li>Access creation: arranging early appointments </li></ul></ul><ul><ul><li>Transportation and reminders </li></ul></ul><ul><ul><li>Immunizations </li></ul></ul><ul><ul><li>Medication follow-up </li></ul></ul>
    48. 49. Take-Home Messages <ul><li>Chronic kidney disease is a public health problem </li></ul><ul><ul><li>outcomes include loss of kidney function and cardiovascular disease </li></ul></ul><ul><li>Clinical assessment from laboratory tests </li></ul><ul><ul><li>spot albumin/creatinine ratio to assess kidney damage </li></ul></ul><ul><ul><li>serum creatinine to estimate GFR </li></ul></ul><ul><li>You can help improve outcomes </li></ul><ul><ul><li>Facilitate clinical action plan based on stages of severity </li></ul></ul><ul><ul><li>Physician, patient, and public education </li></ul></ul>
    49. 50. You have the Power to Prevent Kidney Disease
    50. 52.
    51. 53. New Elderly ESRD Patients: Many Diagnoses in Preceding 2 Years lla illi lla illi incident ESRD patients age 75 & older. New ESRD patients aged 75+ USRDS 2006
    52. 54. Frequent Admissions Just Before ESRD lla illi lla illi incident ESRD patients age 67 & older, with a first ESRD service date between January 1, 2003, & June 30, 2004, & with Medicare as primary payor. Data by year include incident patients from July 1, 1998, to June 30, 1999 (labeled 1998–1999) & from July 1, 2003, to June 30, 2004 (labeled 2003–2004). Data are unadjusted. USRDS 2006
    53. 55. Healthy People 2010 Targets for ESRD & Levels Achieved USRDS 2006
    54. 56. Boulware E et al. Am J Kidney Dis 2006; 48:192-204