3. Patient Demographics
Age Population %
< 71 years old 52.2%
71-80 years old 31.0%
81-90 years old 16.8%
Primary causes of CKD among this population:
- Diabetes
- HTN
- Multiple comorbidities
4. Background
Pts with compromised renal function are at
greater risk for:
Elevated phosphorus levels, decreased vitamin
D levels, decreased calcium absorption and
increased PTH levels.
Abnormal mineral metabolism and bone
dysfunction which contributes to significant
Cardiovascular disease
Significant bone loss and blood vessel
calcification
Bone fractures, breaks, chronic back and leg
pain
5. Background
Adults receiving chronic hemodialysis
exhibit higher mortality rates compared to
the age matched general public, with
cardiovascular disease being the most
common cause of death
Cardiovascular disease has been linked
to mineral imbalances which results in
coronary calcification
6. Background
Normal functioning kidneys remove
excess phosphorus levels in the blood
70% of dietary phosphorus is excreted in
the urine
Dialysis pts are required to take a
phosphorus binder with every meal
Pts are also asked to eat a diet low in
phosphorus in addition to taking oral
binders
7. Project AIM
To increase the target threshold for
phosphorus compliance from the current
quarterly average of 49.1% to the >61.2%
issued by the Centers for Medicare &
Medicaid Services (CMS), by December
of 2015 among our Chronic Hemodialysis
population.
8. Dialysis Department
Dashboard
Quality Measures Target % Hemodialysis unit
Adequacy
KT/V >1.2
97.6% 97.9%
Anemia
Hgb 10-11 g/dL
%<10 g/dL
<12% 27.1%
Corrected Ca
<10.2 mg/L
94.8% 92.1%
Phosphorus 3.5-5.5
mg/L
61.2% 49.1%
Albumin >4 g/dL 42.1% 8.9%
9. Review of Literature 1
Srivahs, P., Goldstein, S., Krishnamurthy, R., & Silverstein, D.
(2014).High Serum phosphorus and FGF 23 levels are associated
with progression of coronary calcification. Pediatric Nephrology,
(29), 103-109. doi:10.1007/s00467-2575
1 year longitudinal study of 16 pediatric patients
receiving chronic Hemodialysis, was conducted to
evaluate the progression of coronary calcifications in
pediatric hemodialysis patients.
Study concluded that coronary calcifications were
progressive in pediatric patients receiving dialysis
and that increased phosphorus was associated with
this progression.
10. Literature Review 1
Limitations to this study:
Small sample size
The study used a one year time span for
follow up
11. Literature Review 2
Kramer, H., Berns, J., Choi, M., Martin, K., & Rocco, M. (2014). 25-
Hydroxyvitamin D Testing and Supplementation in CKD:
An NKF-KDOQI Controversies Report. AM J Kidney Dis, 64(4),
499-509.
12. Challenges
Dietary and medication non-adherence
Patient financial concerns (food and
medication)
Lack of education/family support
Cultural backgrounds
Staff availability for reeducate
13. Planned Interventions
Individualized counseling for the patient and
family by Hemodialysis Interdisciplinary Team
Display posters in patient waiting room to
enhance knowledge and provide education
Monthly news letter issues by unit social worker
Phosphorus and dietary compliance
discussions during patient support groups
Individualized patient meetings with dietician
Enroll patient into plan of care
15. References
Srivahs, P., Goldstein, S., Krishnamurthy, R., & Silverstein, D. (2014). High
Serum
phosphorus and FGF 23 levels are associated with progression of
coronary calcification. Pediatric Nephrology, (29), 103-109. doi:
10.1007/s00467-2575-8
Editor's Notes
Coronary calcifications are associated with elevated serum phosphorus levels, the use of calcuim containing po4 binders, elevated ca levels and alterations in parathyroid hormone levels.
Cardiovascular risk factors such as mineral imbalance and coronary calcifications are associate with and contribute significantly to the the hgh cardiovascular mortality in the ESRD populations. Cardiovascular calcifications are highly prevalent, 51-93% in adults receiving mantenance dialysis.
Many factors are linked with coronary calcifications with elevated serum phosphorus being among them.
70% of dietary phosphorus is excreted in the urine, you can probobly guess why this is a problem for pts with CKD as their ability to produce urine is compromised through the kidney.
The intestinal po4 binders are effective in lowering intestinal phospours absorption levels and allows the excess po4 to be excreted through the GI system.
Po4 restrictions are tricky for pts because everyting we eat contains phosphorus. It becomes very frustrating for many pts when trying to adhere to all of their dietary restrictions. It is a complete lifestyle change for not only them but also for their families and those preparing the meals.
Dialysis does remove some phosphorus but not enough to maintain levels within range without dietary restrictions and phos binders.
So what does that mean? We need to decrease these high phosphorus levels among our chronic hemodialysis population so we can increase the percentage that falls within the target threshold.
Phosphorus levels are drawn every other week and reports are generated monthly to keep track of reportable clinical outcomes.
This data is from June 2015. CMS guidelines state they want phosphorus levels to be maintained betwee 3.5-5.5mg/L
Currently the quarterly average is 49.1 % in hemodialysis and 38.5 % in Peritoneal dialysis are meeting the defined target, so we are still below our target goal.
This article came up during my search and I almost over looked it because of the pediatric component but a large part of my intervention for this specific initiative is going to be education, for both staff and patients. We have so many pts with multiple co morbidities, often times the phosphorus component is not of top priority in comparinson to uncontrolled DM and HTN. When mentioning the morbidity rates associated with coronaryt calcifications, a response I heard from a staff member was that these people have so much going on, I doubt it is the po4 that caused it. And with that single comment, the value of educating our pts on this particular subject could be lost. In order to spark interest in an old topic, I need new information and references. Being able to reference this article and say, even among pediatric pts who do not have years of an unfavorable lifestyle that attributed to various comorbidities and CKD, there is still data suggesting the elevated po4 levels are proven to cause Cardiovascular complications and loss of bone mineral density.
One year time span for f/u may not have been enough time to see correlating calcium changes, however, as the study indicated, pediatric pts do not remain on dialysis for long perioids of time like adults so longer f/u may have meant less patients to assess, further limiting the data.
Now going back to my phosphorus QI project, some potential challenges to reaching our goal for CMS guidelines include:
Poly pharmacy- many pts do not want to take another pill or do not have someone managing their medications properly.
Cultural backgrounds- eating larger meals during specific times of day would need additional phos binders along with freq snacking.
Staffing-less staff, higher acuity in addition to longer hours (12hr shifts). Closer tx times with a faster turnover, leaving little time to handle pt complications let alone thorough pt education, specifically for pts new to the hemodialysis setting and lifestyle.
Interdisciplinary team- Social worker, dietician, nephrologists, nurses
Posters-Dietician frequently has students who have done unit based projects, utilize this resource
News letter-New social worker to the unit, issues monthly news letter to pts and can feature phosphorus related articles
Support groups-discussion on diet and barriers to compliance. Have additional staff present to support discussion with social worker (nephrologist, dietician, nurse)
