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-newsletters 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, phosphorus 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
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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. 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CHRONIC KIDNEY DISEASES
Goal - Objective
community about new Pre-
ESRD classes and current
pilot programs in the
greater Houston area
At the end of this presentation the
reader will be able to answer
• Why Kidney Education is important in Chronic Kidney
Disease or CKD
• What is a community-based education program
• What information is included in CKD education program
• How does early CKD education program benefit patient
outcomes and the physician’s practice
• What patients say about early CKD education
• How one can participate or set up a program
Chronic Kidney Disease in the US
• Over 20 Million Americans have some degree of renal
insufficiency….1 in 8 people.
• 20 million others are at risk
• Hypertension & Diabetes are the leading causes of
– 23% of all Americans have hypertension
– 16 million Americans have diabetes
• Both are independent risk factors for cardiovascular
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.
African Americans Develop ESRD at
a Younger Age
New Conditions of Coverage
• ESRD Medicare Reform
– Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 –
– CKD education is recognized by CMS
– Reimbursement to nephrologists who provide chronic kidney disease
• Physicians Must Educate CKD Patients on:
– Kidney disease
– Access choices and issues
– ESRD Treatment options
• Physician performance is based on
– Influenze vaccine
– Blood Pressure control
– Referral for an AV fistula
– Laboratory values – Ca, PO4, PTH, Lipid profile
*Best physicians educate on much more.
• 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.
What is community-based education?
• Patient education program that includes:
– Multidisciplinary coaching program
– Stage-specific education
– Easy education referral process
– Follow-up with patients and physicians
– Sessions are free for patients and guests
Location • 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.
• Experience with renal treatment
options training reveaed we would
gain more patients in a non-medical
• And our participants have reinforced
• The Houston Community-based CKD
program sponsored by DaVita, known
as EMPOWER, has had nearly 200
• The patient feedback is very positive
What is Community-Based Education?
• Inform patients about their
• Improve quality of life
• Preserve renal function
• Help patients identify the best
treatment choice for their
• Tools to organize and track their
• Health Diary
• Multidisciplinary coaching program can make a difference.
• A nurse, a dietitian and a social worker attend each class to present the
information and answer questions.
• The goal is help 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.
• CKD education helps patients to identify the best treatment choice for
their lifestyle and reinforce early fistula placement.
Benefits of early intervention and
• Delay or prevent the worsening of cardiovascular
disease, hypertension and diabetes
• Delay or prevent the progression to chronic
• Improve outcomes if kidney replacement therapy
ever becomes necessary
• Psychologically prepare one for kidney disease
• Reduce health care costs
• Keep people employed and out of the hospital
• An initial postcard and quarterly e-newsletters
• Valuable tools from a well-regarded website,
– GFR calculator and tracker
– 500 CKD recipes
– DaVita Diet Helper
– CKD videos
• 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
Resource for the patients
• Patient information
• Healthcare phone numbers
• History and Physical
• Medication list
• Lab work
• Diabetes and Hypertension
The health diary
• 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.
• 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 patients is the questions to ask the doctor.
• Reminds them of the importance of the medication, BP or
What stage am I?
• Stage 1 – GFR ≥ 90 cc/min/1.73m2
– Kidney Damage with normal or high GFR
• Stage 2 – GFR – 60 to 89 cc/min/1.73m2
– Kidney Damage with mildly decreased GFR
• Stage 3 – GFR – 30 to 59 cc/min/1.73m2
– Moderate decreased GFR
• Stage 4 – GFR – 15 to 29 cc/min/1.73m2
– Severely decreased GFR
• Stage 5 – GFR - < 15 cc/min/1.73m2
– Kidney failure
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.
Glomerular filtration rate
• The serum creatinine by itself is a very POOR way to assess
• It does not take into account variation in muscle mass,
nutritional status or body habitus
• GFR measures how well your kidneys filter waste products,
which tells your doctor how well your kidneys are working.
• In 2002, the National Kidney Foundation began
recommending the use of GFR instead of just serum
creatinine for a more accurate measurement of kidney
• GFR is calculated from your blood creatinine, age, race and
From AAKP Healthline, 2009 – Stephen Z. Fadem
Assessment of kidney disease
• Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD),
but in following its progress.
• 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.
• The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day.
• While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors
mentioned above necessary.
• 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).
• 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.
• 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.
• 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
• 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.
• 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.
• The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators.
• 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.
• 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
From AAKP Healthline, 2009 – Stephen Z. Fadem
You have heard about Cystatin C
• Serum creatinine has a drawback in the measurement of glomerular
filtration rate (GFR) in that it may vary according to muscle mass.
• 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.
• It has been proposed as an alternate marker for estimating GFR by Dr. Joe
• An elevated serum cystatin C level may indicate a worse cardiovascular risk
in patients with the metabolic syndrome. (18456039) .
• 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
• The serum cystatin C calculation is found at http://touchcalc.com
• Joe Coresh recommends averaging the Cystatin C and the MDRD GFR
Clinical evaluation of patients at
increased risk for CKD
• All Patients
• Measurement of blood pressure
• Serum creatinine to estimate GFR
• Protein to creatinine or albumin to creatinine
ratio in first AM or random untimed spot urine
• Examination of the urine sediment or dipstick
for red blood cells and white blood cells
Taking Control of Kidney Disease
Living with Stage 3 and Early Stage 4 CKD
Focus on preserving renal function
• Normal Kidney functions / Kidney Disease
• Control of co-morbidities / Diabetes / HTN
• Diet and medication
• Heart healthy behaviors
• Preserving veins
• Insurance questions
• Questions to ask physician
Treatment of CKD
• Treat the underlying disease
• Treat associated problems
• Slowing the loss of kidney function
• Prevent heart disease
• Reduce complications
• Preparation for dialysis/transplantation
• Kidney transplant or dialysis
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Definition of Chronic Kidney Disease
• Chronic kidney disease is defined as either
kidney damage or GFR < 60 cc/min/1.73m2
≥ 3 months.
• Kidney damage is defined as pathologic
abnormalities or markers of damage, including
abnormalities in blood or urine tests or
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Clinical Practice Guidelines for Management
of Hypertension in CKD
Type of Kidney Disease Blood Pressure
for CKD, with or
to Reduce CVD Risk
and Reach Blood
Diabetic Kidney Disease
then BB or CCB
Disease with Urine Total
Ratio ≥200 mg/g
Disease with Spot Urine
ratio <200 mg/g None preferred
then ACE inhibitor,
ARB, BB or CCB
Kidney Disease in Kidney
CCB, diuretic, BB,
ACE inhibitor, ARB
Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage Description GFR Evaluation Management
Test for CKD Risk factor management
normal or ↑
CVD and CVD
Specific therapy, based on diagnosis
Management of comorbid conditions
Treatment of CVD and CVD risk factors
mild ↓ GFR
Slowing rate of loss of kidney function 1
30-59 Complications Prevention and treatment of complications
4 Severe ↓ GFR 15-29
Preparation for kidney replacement therapy
Referral to Nephrologist
5 Kidney Failure <15 Kidney replacement therapy
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
Stages 1 and 2: Preventing Heart Disease in
• Traditional cv risk
• Non traditional risk
How Can You Protect Yourself Against Heart Disease And High
• Get regular medical checkups
• Control your blood pressure
• Monitor your blood pressure weekly
• Check your cholesterol regularly – watch saturated fats and fructose
• Watch your diet - SALT
• Regular doctor visits
• Blood pressure - 130/80
• It make take several medications
• Don’t smoke
• If you choose to drink, do so in moderation
• Exercise regularly
• Manage stress
Traditional Risk Factors
Non Traditional Risk
ACEs and ARBs
• These drugs are critical to care starting in Stage 1 and 2
• ACES and ARBs have a compound effect on blocking
the renin-angiotensin system.
• The goal is to lower the blood pressure to 120 mm Hg
and to titrate proteinuria.
• Contraindications include allergy and bilateral renal
• Potassium levels should be monitored closely when
patients are on ACES or ARBS
• (Beta blockers, NSAIDS, ACES and ARBS can raise
Blood Pressure Is Poorly Controlled in
Patients With CKD
• Associated with CKD
• Vascular calcification
• Statins not helpful in CKD5
• CRP not diagnostic
Exercise And Kidney Care
• Talk to your doctor about starting an
exercise program that’s right for you.
• 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.
• Incorporating consistent aerobic exercise,
even taking a 20-minute walk, can help
especially if your CKD is a result of
hypertension or diabetes.
Watch meds and therapies
• Avoid Metformin in Stage 3 and beyond
• Contrast media –
– Nephrogenic sclerosing fibrosis may occur with an
MRI due to galadinium contrast – so procedure
should be done without this contrast agent
– Iodine can be nephrotoxic – and patients should
be well hydrated pre procedure
• NSAIDS should not be given to kidney patients
Here are some examples:
• Sodium - 100 mmoles
• Lipids - pre dialysis
• Carbohydrates - Diabetes
• Proteins - MDRD Trial
• Potassium - watch because of ARBs
and ACE inhibitors
Nutritional Tips For Healthy Kidneys
• In order to help maintain healthy kidneys it is important to eat properly
• Keep track of daily calories
• Limit total fat
• Watch high fructose corn syrup
• Watch excess proteins and phosphorus - Monitor the amount of protein
• You may need to watch potassium - Learn about potassium
• Your dietitian can help you with recipes that fit your needs
• Control salt intake
• Take care of your bones – exercise and take vitamin D
• Be sure to get enough iron
• Watch fluid intake
• Understand your nutritional plan
Stage 3 – Medical Focus
• CKD MBD – Metabolic bone disease
• Acidosis - Bicarbonate
• Anemia – Erythropoietin
heart healthy diet.
• a. Cardiovascular risks and therapy – stay the course
• b. Preparation:
3. Blood pressure/ACEs and ARBS
6. Modality choice
7. Access preparation
• c. Modalities of therapy
Anemia in CKD
• Anemia management with EPO since 1990s -
• Keep Hct < 42
– N Eng J Med 339:584-90, 1998
• Keep hgb 10 - 12
• N Eng J Med 355:2071-2084, 2006.
• 34% worse when hgb target is 13.5 than 11.2
• N Eng J Med 355:2084-2098, 2006
• 22% worse when hgb is 13-15 than 10.5-11.5
• Check Iron levels and correct first
• EPO can be given in the office - monitor blood work
• Increased protein catabolism of amino acids
• Inhibition of protein synthesis can cause a low
• Accelerates renal osteodystrophy
• Modulates vitamin D and parathyroid hormone
• Evokes insulin resistance
• Chronic acidosis impairs albumin
synthesis and causes negative nitrogen
– JCI 95:35-45, 1995
• Albumin - major marker for nutrition
• Low serum albumin - risk factor for poor
• It is advisable not to restrict dietary
protein once the serum albumin level
starts to fall
The kidney has a major responsibility to
eliminate and buffer acids. In renal
failure these acids accumulate.
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.
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.
Benefits of anemia correction
• Improved work and aerobic capacity
• Reduced cardiovascular complications
• Reduced hospitalizations
• Decreased mortality
• Improved quality of life
• Improved cognition
• Improved sexual function
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.
• Kidney damage causes decreased phosphorus
excretion. This stimulates phosphotonins to
increase phosphorus excretion.
• Phosphotonins and kidney damage decrease the
activation of vitamin D
• This weakens muscles, decreasing bone strength.
• This decreases the calcium depositing in bone, and
along with phosphorus – leads to changes in blood
• Calcium deposits in blood vessels
• Inflammation and Hyperlipidemia (metabolic
syndrome) make this worse
• High fructose corn syrup makes metabolic
DIET IS IMPORTANT!!!
Chronic Kidney Disease
And Mineral Bone Disorder
• Too much phosphorus and
• Damaged kidneys do not produce enough vitamin D
• Vitamin D helps maintain calcium levels which keep
• Calcium may build up in blood vessels with CKD
• Without enough vitamin D, you are more likely to
have weak bones that may break easily
How to Protect Against
• Vitamin D level
• Parathyroid hormone level
• Ergocalciferol over the counter
• Vitamin D is probably for everyone –regargless
• At later stages you might need an active form of
• Exercise and diet management
• The doctor may want to check for vascular
What Effect Can Chronic Kidney Disease Have On
• Heart disease
• High blood pressure
• Vitamin D deficiency - bone and mineral
• Malnutrition and low serum albumin
• Acid buildup
• Inflammation - Dental hygiene, fiber in early stages,
exercise, keep trim. If we develop a stomach illness like
helicobacter, get it treated. Keep toenails trim.
• Atherosclerosis - Check the serum cholesterol, LDL,
VLDL, HDL - use diet, exercise, medications (statins,
usually) to keep these numbers in the proper range
PHOSPHORUS AND VITMIN D
• CKD-MBD - Avoid excess
phosphorus in the diet and
have vitamin D levels
checked. If low, start on
cholecalciferol. Later, an
active vitamin D like
calcitriol, doxercalciferol or
paricalcitol will be needed
• Vascular calcification - As the
disease progresses, restrict
phosphorus and use a
Making Healthy Choices
Preparing for dialysis for Stages 4 and 5 CKD
– Symptoms of Uremia
– Controlled dialysis start
– CKD and dialysis diet
– Control of co-morbidities – DM/HTN
– Medications – Call your Nephrologist
– Access – No to catheters, Yes to fistulas – Vein Map
– All treatment choices
– Insurance issues
Stage 4 and 5 CKD Class
• 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 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.
– 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, 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.
– 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
– An in-depth look at all of treatment choices:
• Peritoneal Dialysis (PD)
• Home Hemodialysis (HHD)
• Hemodialysis (HD)
• Nocturnal hemodialysis
• Self-Care hemodialysis
– 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.
• PD - 7% of population
– Preference values higher than for HD 74-69
– Physicians in practice 11 years along more likely to refer to PD
– More likely recommended to men, people with residual function,
with weight less than 200 lb and the absence of diabetes
• Hong Kong
– Half the mortality
– 5 staff for 300 patients
– Less mortality because residual function preservation
– Loss of residual function is a cardiovascular risk factor
Stage 4 – Medical focus
• Modalities – Incenter and Home Dialysis,
Transplant or Conservative therapy
• Referral for access – Vein mapping and
• Serum Albumin – Prevent malnutrition
• Continue other therapies – ACE or ARB
• Anemia – Erythropoietin therapy
Stage 5 – but not yet on dialysis
• One-on-one modality options
– Conservative treatment – Medical, diet management,
– Transplant – refer early
– Home therapies (Peritoneal, Home Hemodialysis)
– In-center therapies (ICHD, Nocturnal, Self-Care)
– Physicians focus - Therapy choice/transition
PD References – Early referral
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
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
• Short - 2 hour per day X 6 days per week
• Long - Overnight X 6
• Prospective patients
– Visit during CKD
– Logistics, location and type of equipment
• NxStage - 70 pounds
• 2008K@home (BabyK)
– May need plumbing and electrical
• Need ample storage
• Need for vascular access
• Need a partner
Nocturnal Home Hemodialysis
• May be able to stop binders
• May need supplemental
• Less hypertensives
• Less epo
• Less fluid restriction
• Nocturnal in-center for select
• Arteriovenous fistula -
• Lasts many years
– Veins arterialize
– Arteries expand
– Capillaries and larger
vessels absorb shock
– Graft transmits shock and
lasts only around 18
Easy Education Referral Process
Easy education referral process
– Identify patient
– Inform patient
– Order education
– Refer & Fax
– Call patient
– Schedule class
How the program works
• The CKD community-based process begins and ends with the office team
• First, the office 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 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.
• 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.
• Ultimately, the goal is help patients to take control of their CKD and, if dialysis is needed, that they
begin dialysis healthier and prepared.
Communication is crucial
• Nephrologist receives a letter from CKD educator
– Indicates what class patient attended
– High lights “no shows”
– Lists concerns and/or modality interests if expressed
• CKD patient receives a phone call from CKD
educator & education materials
– Assess for additional teaching
– Answer questions and provide resources
– Initial postcard mailing & quarterly e-newsletters
• 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.
• 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
• All medical questions will be referred the physician.
Summary of Stages
• 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
• 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
– Vitamin D management should start early in the course of disease
– Some recommend restricting the use of process foods early
– In addition to diet and blood pressure control with an ACE or ARB, control of glucose is valuable in
• By Stage 3 patients are starting to manifest signs of anemia, metabolic acidosis and early
metabolic bone disease.
– They need to have laboratory studies – Ca, PO4, PTH, lipid profile
• 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.
– 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.
– The patient should be evaluated early for a permanent vascular access, and depending upon the
modality chosen, a fistula or peritoneal dialysis access placed.
• Pre-ESRD classes lead to a smoother transition into a dialysis (stage 5) regimen.
CKD Education Benefits
• Feel more engaged and in-control
• Slow the progression of renal disease
• Healthier on First Date of Dialysis
• Free education to patients and community
• Physician able to compliment own education
• Saves physician time, resources and money
• Patients learn of laws that protect them
• Patients stay employed and insured
• Decrease burden on Medicare
Win – Win - Win
• CKD Education is a Win-Win-Win program. It is provided to
patients and the community at no cost or obligation.
• Patients who attend are empowered to take control of
their kidney health. They are provided with the tools they
need to preserve renal function.
• Physicians are able to compliment their own excellent
education, saving them time, resources and money.
• 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
How Do You Participate?
• Establish CKD Education as part of your practice
• Protocol: Educate all patients Stages 3,4 and 5
– Identify eligible patient during office visit
– Patient communication (discussion and flyer)
– Clinician orders education need using:
• Sticky note
• Referral form
– Office staff completes and faxes referral form
– CKD education team contacts patient and schedules
How to work with a physician
• Every physician practice operates differently. The 3 biggest
things to walk away from the meeting with are:
– 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)
– 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 "protocol" or "standing order"
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.
• An agreement on how often you and the administrative
staff will touch base to make sure everything is good.
Early CKD Education Benefit Patient’s?
What Houston CKD patients say about CKD Education:
– “I wish I had this information sooner”
– “I will really study my lab values and check my diet”
– “I will talk to my doctor about my NSAID’s and
– “The health diary is excellent. I really like the glossary”
– “As a family member, I think my father (patient) will feel
more comfortable about the possibility of dialysis”.
• Patients need information and change can happen
– Pt went from stage 4 to stage 3 and thanked us for the
• Office staff tell of a pt they were dreading to tell about
time to start dialysis
– Pt said “It’s OK, I know about it”. The office nurse was
• Access placements before starting dialysis
– As they should be
• Insurances saved or supplemental insurance obtained