Overview of Chronic Kidney Disease

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  • Diabetes is the most rapidly rising cause of ESRD, but the hypertension rate also continues to rise.
  • Possible specific changes: 1.Facilities and/or hospitals designate staff member responsible for vascular access CQI Assemble multi-disciplinary vascular access team in facility or hospital Investigate and track all non-AVF access placements and AVF failures 2. Primary care physicians use ESRD/CKD referral criteria to ensure timely referral to nephrologists Nephrologists document AVF plan for all patients expected to require renal replacement therapy Designated nephrology staff person educates family and patient to protect vessels 3. Nephrologist/skilled nurse performs evaluation and physical exam Nephrologist performs or refers patient for vessel mapping Nephrologist refers patient to surgeon for “AVF only” 4. Nephrologists refer to vascular access surgeons willing to meet specific standards and expectations Surgeons are evaluated on frequency, quality, and patency of access placements 5. Surgeons utilize current techniques for AVF placement including vein transposition Surgeons ensure mapping is performed if suitable vein not identified on physical exam Surgeons work with nephrologists to plan and place secondary AVF in AV graft. 6. Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion Dialysis facility staff and/or rounding nephrologists examining outflow vein of all graft patients (“sleeves up”) at least monthly Nephrologists refer to surgeon for placement of secondary AVF before failure of AV graft 7. Regardless of prior access (e.g. AV graft), nephrologists and surgeons evaluate all catheter patients as soon as possible for AVF Facility implements protocol to track patients for early removal of catheter 8. Facility uses best cannulators and best teaching tools to teach AVF cannulation to all facility staff Dialysis staff use specific protocols for initial dialysis treatments with new AVFs and assign the most skilled staff to such patients Facility offers option of self-cannulation to patients who are interested and able 9. Nephrologists and surgeons conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure/refer for intervention Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF Medical team adopts standard criteria for appropriate extent of intervention in existing access before placing new access 10. Routine facility staff in-servicing and education program in vascular access Continuing education for all care-givers including inservices by nephrologists, surgeons, and interventionalists Facilities educate patients to improve quality of care and outcomes (e.g. prepping puncture sites, applying pressure at needle sites, etc.) 11. Networks work with dialysis providers to give specific feedback to all decision-makers on incident and prevalent rates of AVF, AVG, and catheter use Review data monthly or quarterly in facility staff meetings
  • Overview of Chronic Kidney Disease

    1. 1. Overview of Chronic Kidney Disease and ESRD Gordon McLennan, MD
    2. 2. Conflicts & Acknowledgments <ul><li>Member, Board of Trustees, The Renal Network Inc. </li></ul><ul><li>Grant Support </li></ul><ul><ul><li>Boston Scientific Corporation </li></ul></ul><ul><ul><li>Omnisonics Medical Technologies </li></ul></ul><ul><ul><li>Cook, Inc. </li></ul></ul><ul><ul><li>W. L. Gore, Inc. </li></ul></ul><ul><ul><li>Arrow International </li></ul></ul>
    3. 3. Take Home Message <ul><li>CKD represents a much larger problem than ESRD </li></ul><ul><li>Use of calculated GFR to assess renal function will help us identify patients at risk for ESRD </li></ul><ul><li>It is incumbent on us to identify patients who can have fistulas placed at stage 3 & 4 CKD </li></ul>
    4. 4. Chronic Kidney Disease & ESRD <ul><li>ESRD (Renal Failure affects only about 400,000 Americans </li></ul><ul><li>Chronic Kidney Disease affects 8 Million </li></ul>
    5. 5. Chronic Kidney Disease <ul><li>Glomerular filtration rate (GFR) <60mL/min/1.73m 2 for > 3 months with or without kidney damage </li></ul><ul><ul><ul><ul><ul><li>OR </li></ul></ul></ul></ul></ul><ul><li>Kidney damage for > 3 months, with or without decreased GFR, manifested by either </li></ul><ul><ul><li>Pathologic abnormalities </li></ul></ul><ul><ul><li>Markers of kidney damage, eg, proteinuria </li></ul></ul><ul><li>Affects 11% of US popluation </li></ul>
    6. 6. CKD <ul><li>Stages 0-4 NHANES III 1988-1994 </li></ul><ul><li>Stage 5 USRDS 1998 </li></ul>11.2 20,000 > 90 At increase risk of CKD 0 0.1 300 <15 or dialysis Kidney Failure 5 0.2 400 15-29 severe ↓ GFR 4 4.3 7,600 30-59 moderate ↓ GFR 3 3.0 5,300 60-89 Kidney damage w/ mild ↓ GFR 2 3.3 5,900 > 90 Kidney damage w/ normal or ↑ GFR 1 % N (1000’s) mL/min/1.73 m 2 Prevalence GFR Description Stage
    7. 7. Co-morbidities of CKD <ul><li>50-500 x mortality </li></ul><ul><li>Predominant cause is CVD </li></ul>Foley RN, Parfrey PS, Sarnak MJ: Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 32:S112-S119, 1998 ( suppl 3)
    8. 8. Incidence of End Stage Renal Disease (ESRD) According to Primary Diagnosis USRDS. 2004. Available at: http:// www.usrds.org/atlas.htm .
    9. 9. Co-Morbidities of the ESRD Population <ul><li>80% of dialysis patients who have an MI are dead within 3 years </li></ul>Herzog CA, Ma JZ, Collins AJ: Poor long-term survival after acute myocardial infarction among patients on long-term dialysis. N Engl J Med 339:799-805, 1998
    10. 10. Life Expectancy <ul><li>Patients Diagnosed with CKD ± DM Have a Greater Likelihood of Death than ESRD </li></ul><ul><li>First nephrologist visit at an outpatient clinic (n=20,363) </li></ul>Percent of patients (%) Status in the entry period 100 80 60 40 20 0 NDM/Non-CKD 90.33 8.27 83.75 12.40 68.24 20.42 11.34 60.73 21.60 17.58 DM/Non-CKD NDM/CKD DM/CKD n=11,698 3,637 2,884 2,144 No Events ESRD Death
    11. 11. CKD Principle #1 <ul><li>There are close to 20 million patients in the U.S. with CKD stages 1-5. There are perhaps another 20 million patients in the U.S. at risk for CKD </li></ul><ul><ul><li>Many of these patients are not under a physician’s care, so targeted screening of at-risk populations is cost-effective </li></ul></ul><ul><ul><li>For those patients under a physician’s care (usually a PCP), most of the CKD interventions can and should be delivered by the PCP </li></ul></ul><ul><ul><li>Early referral of a CKD patient to a nephrologist (when GFR <60 ml/min/1.73m 2 ) to provide strategic guidance is associated with improved outcomes </li></ul></ul>
    12. 12. GFR <ul><li>Serum Creatinine is not very predictive of renal function </li></ul><ul><li>GFR affected by age, gender, weight, & race </li></ul><ul><li>Formulas exist to estimate GFR that are more accurate than 24 hour urine collection </li></ul><ul><li>MDRD </li></ul><ul><ul><li>GFR (mL/min/1.73 m2) = 186 x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American) </li></ul></ul><ul><li>Crockroft-Gault </li></ul><ul><ul><li>    For men: CrCl = [(140 - Age) x Weight (kg)]/SCr x 72 </li></ul></ul><ul><ul><li>    For women: CrCl = ([(140 - Age) x Weight (kg)]/SCr x 72) x 0.85 </li></ul></ul>
    13. 13. GFR Lin J, Knight EL, Hogan ML, Singh AK: A Comparison of Prediction Equations for Estimating Glomerular Filtration Rate in Adults without Kidney Disease. J Am Soc Nephrol 14: 2573–2580, 2003
    14. 14. <ul><li>50 y/o AA Female referred from Family Practitioner for renal arteriography because of uncontrolled hypertension </li></ul><ul><li>Significant history: Type 2 DM & Hypertention </li></ul><ul><li>Serum Cr 1.4 </li></ul><ul><li>What would you do? </li></ul>
    15. 15. <ul><ul><li>MRA </li></ul></ul><ul><ul><li>Hydrate overnight </li></ul></ul><ul><ul><li>Bicarb </li></ul></ul><ul><ul><li>N-Acetyl Cystine </li></ul></ul><ul><ul><li>Use alternative contrast agents </li></ul></ul><ul><ul><li>Nothing special—Do arteriogram & limit contrast as much as possible </li></ul></ul>
    16. 16. Calculated MDRD GFR <ul><li>GFR (mL/min/1.73 m2) = 186 x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American) </li></ul><ul><li>GFR = 186 x 1.4 -1.154 x 50 -0.203 x 0.742 x 1.210 </li></ul>51
    17. 17. CKD Principle #2 <ul><li>Use of serum creatinine as a marker of kidney function grossly underestimates the presence and severity of CKD </li></ul><ul><ul><li>Formulas for GFR (MDRD) or creat. clearance (Cockcroft-Gault) are more sensitive, easy to use and do not require 24 hour urine collection </li></ul></ul><ul><ul><li>24 hour urine collection for creat. clearance is notoriously inaccurate </li></ul></ul><ul><ul><li>All labs should be encouraged to report renal function as GFR based on MDRD formula (age, gender and race) </li></ul></ul>
    18. 18. Optimal CKD Patient Care Early Detection of CRF Interventions that delay progression ACE inhibitors BP control Blood sugar control Protein restriction Prevention of uremic complications Malnutrition Anemia Osteodystrophy Acidosis Modification of comorbidity Cardiac disease Vascular disease Neuropathy (in diabetics) Retinopathy (in diabetics) Preparation for RRT Education Informed choice of RRT Timely access placement Timely initiation of dialysis
    19. 19. Assessment for Renal Replacement Therapy <ul><li>Transplant </li></ul><ul><li>Peritoneal Dialysis </li></ul><ul><li>Hemodialysis </li></ul><ul><ul><li>AVF </li></ul></ul><ul><ul><li>Graft </li></ul></ul><ul><ul><ul><li>Synthetic Material </li></ul></ul></ul><ul><ul><ul><li>Biological Material (Bovine Carotid Artery) </li></ul></ul></ul><ul><ul><li>Catheter </li></ul></ul>
    20. 20. Fistula First <ul><li>CMS, the ESRD Networks, the renal community, and IHI will work together to increase the likelihood that every eligible patient will receive the most optimal form of vascular access for that patient. In the majority of cases, this will be a fistula. </li></ul>
    21. 21. Incident Patients
    22. 22. Prevalent Patients
    23. 23. NVAII Goals <ul><li>By June 2006 </li></ul><ul><ul><li>40% prevalent fistulas </li></ul></ul><ul><ul><li>50% incident fistulas </li></ul></ul><ul><li>By June 2009 </li></ul><ul><ul><li>66% prevalent fistulas </li></ul></ul>
    24. 24. NVAII Change Concepts <ul><li>Routine CQI review of vascular access </li></ul><ul><li>Early referral to nephrologist </li></ul><ul><li>Early referral to surgeon for “AVF only” </li></ul><ul><li>Surgeon selection </li></ul><ul><li>Full range of appropriate surgical approaches </li></ul><ul><li>AVF placement in catheter patients </li></ul><ul><li>Cannulation training </li></ul><ul><li>Monitoring and surveillance </li></ul><ul><li>Continuing education: staff and patient </li></ul><ul><li>Secondary AVFs in AVG patients </li></ul><ul><li>Outcomes feedback </li></ul>
    25. 25. Algorithms <ul><li>Venography or ultrasound in all catheter & graft patients </li></ul><ul><ul><li>Look for conversions </li></ul></ul><ul><li>Algorithms to evaluate veins at Stage 3 & 4 </li></ul><ul><ul><li>Physical Exam </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Venography where needed </li></ul></ul>
    26. 26. AVF Types
    27. 27. Take Home Message <ul><li>CKD represents a much larger problem than ESRD </li></ul><ul><li>Use of calculated GFR to assess renal function will help us identify patients at risk for ESRD </li></ul><ul><li>It is incumbent on us to identify patients who can have fistulas placed at stage 3 & 4 CKD </li></ul>

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