Improving Care for Chronic Kidney Disease and Kidney Failure

Improving Care for Chronic Kidney Disease and Kidney Failure Lesley Stevens MD MS MassPro Liaison Meeting February 8, 2007 Why Kidney? A sample of calls we receive: Is this the …. department? • Neurology • Urology • Allergy • Phrenology • Necrology Chronic Kidney Disease is a Public Health Problem • CKD is common – 11% of US adults – Higher prevalence in patients with CVD risk factors • CKD is harmful – Increased risk for CVD – Complications of decreased kidney function – Progression to kidney failure • We have treatment Practice Model for Detection, Evaluation and Management in CKD At increased risk Kidney damage and Normal or  GFR Kidney damage and Mild  GFR Moderate  GFR Severe  GFR Kidney failure Stage 1 GFR 90 Stage 2 60 Stage 3 30 Stage 4 15 Stage 5 Primary care physician Kidney Specialist Other health care providers Outline • Kidney Failure • Chronic kidney disease – – – – – – – Definition Outcomes Detect CKD Prevent progression of CKD Diagnosis and treat CVD Treat co-morbid conditions and complications Refer to nephrology • CKD: Clinical Action Plan Kidney Failure (ESRD) in the US 157 Kidney Failure Compared to Cancer Deaths in the U.S. in 2000* (in Thousands) 99 57 42 *SEER, 2003 32 Lung Cancer Kidney Failure Colon Cancer Breast Cancer Prostate Cancer Annual mortality 100 Dialysis 10 1 0.1 0.01 General population Male Female Black White 25–34 35–44 45–54 55–64 65–74 75–84 Age (years) 8 5 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 Life Expectancy after ESRD 80 70 60 50 Years General Population General Population Transplant 40 30 20 10 0 0-14 25-29 40-44 Age 55-59 70-74 85+ Transplant Dialysis Dialysis USRDS 2006 Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Normal Increased risk Damage  GFR Kidney failure CKD death Screening CKD risk for CKD reduction; risk factors: Screening for diabetes CKD hypertension age >60 family history US ethnic minorities Diagnosis Estimate Replacement & treatment; progression; by dialysis Treat Treat & transplant comorbid complications; conditions; Prepare for Slow replacement progression NKF K/DOQI Definition of Chronic Kidney Disease Structural or functional abnormalities of the kidneys for >3 months, as manifested by either: 1. GFR <60 ml/min/1.73 m2, with or without kidney damage 2. Kidney damage, with or without decreased GFR, as defined by • pathologic abnormalities • markers of kidney damage – urinary abnormalities (proteinuria) – blood abnormalities (renal tubular syndromes) – imaging abnormalities • kidney transplantation Normal GFR Wesson Human Physiology of the Kidney 1969 Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 99-00) Stage Description Kidney Damage with Normal or  GFR Kidney Damage with Mild  GFR GFR (ml/min/1.73 m2 Prevalence* N (1000s) % 1 2 3 4 5  90 60-89 30-59 15-29 < 15 or Dialysis 5,600 5,700 7,400 300 391 2.8 2.8 3.7 0.1 0.1 Moderate  GFR Severe  GFR Kidney Failure *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. New ICD-9-CM Codes Revise 585 Chronic renal failure Chronic kidney disease (CKD) New code New code New code New code New code New code New code 585.1 585.2 585.3 585.4 585.5 585.6 585.9 Add Chronic kidney disease, Stage 1 Chronic kidney disease, Stage 2 (mild) Chronic kidney disease, Stage 3 (moderate) Chronic kidney disease, Stage 4 (severe) Chronic kidney disease, Stage 5 End stage renal disease Chronic kidney disease, unspecified Chronic renal disease Chronic renal failure NOS Chronic renal insufficiency Use additional code to identify kidney transplant status, if applicable (V42.0) Complications Related to CKD Hypertension* Unable to walk 1/4 mile Serum calcium < 8.5 mg/dL Proportion of population (%) Hemoglobin < 12.0 g/dL Serum albumin < 3.5 g/dL Serum phosphorus > 4.5 mg/dL 90 80 70 60 50 40 30 20 10 0 15-29 30-59 60-89 90+ Estimated GFR (ml/min/1.73 m2) 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. USRDS Annual Data Report 2005 CKD Mortality: Kaiser Permanente Northern California All Cause Mortality Cardiovascular Deaths Go A, et al. NEJM 2004 Longitudinal Follow-up and Outcomes Among Population With Chronic Kidney Disease in a Large Managed Care Organization GFR 60-89, No U prot Stage 2 Stage 3 Stage 4 N Age (years) FU (months) Events (%) Disenrolled Death 14202 61.4 53.9 14.9 10.2 1741 60.8 49.8 16.2 19.5 11378 71.6 51.1 10.3 24.3 777 73.6 37.6 6.6 45.7 Received Tx Initiated Dialysis None of above 0.01 0.06 74.8 0.2 0.9 63.3 0.2 1.1 64.2 2.3 17.6 27.8 Keith et al Arch Intern Med 2005 Chronic Kidney Disease: A Clinical Action Plan Stage Description At Increased Risk GFR (ml/min/1.73 m2) >60 (CKD Risk Factors) Action† Screening, CKD Risk Reduction 1 Kidney Damage with Normal or  GFR >90 Diagnosis and Treatment, Treatment of Comorbid Conditions, Slowing Progression, CVD Risk Reduction Estimating Progression Evaluating and Treating Complications Preparation for Kidney Replacement Therapy Replacement, if Uremia Present 2 3 4 5 Kidney Damage with Mild  GFR Moderate  GFR Severe  GFR Kidney Failure 60-89 30-59 15-29 <15 or Dialysis CKD Testing • Serum creatinine to estimate the GFR • Urine albumin testing Creatinine Generation Muscle mass Varies by age, sex, race, weight Diet Short and long term meat intake GFR Estimating Equations Cockcroft-Gault formula Ccr (ml/min) = (140-age) x weight *0.85 if female 72 Scr MDRD Study equation GFR (ml/min/1.73 m2) = 186 x (Scr)-1.154 x (age)-.203 x (0.742 if female) x (1.210 if African American) All labs will be reporting GFR within a few years On Line Calculator: www.kidney.org Serum Creatinine vs. est. GFR A serum creatinine of 1.2 mg/dl represents: – eGFR 102 in an 18 year-old African American man – eGFR 66 in a 57 year-old Caucasian man – eGFR 59 in a 62 year-old African American woman – eGFR 46 in a 76 year-old Caucasian woman 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 Actual eGFR at this creatinine = 37 mL/min/1.73m2 Creatinine = 0.94 mg/dL when eGFR = 60 mL/min/1.73 m2 Coresh, et al. J Am Soc Nephrol 2005;16:180-188. Who should be Tested? • Age > 60 • African Americans, Native Americans, Hispanics and Asian & Pacific Islanders • Diabetics & Hypertensives • Individuals with known CVD • Individuals with a family history of CKD Source: NKF CKD Clinical Practice Guidelines Fewer than 20% with CKD know they have the disease Told They Have Weak or Failing Kidneys, % 50 % 40 % 30 % 20 % 10 % 17.9 % 2.9 % Female Male 0% Coresh, et al. J Am Soc Nephrol 2005;16:180-188. Frequency of Testing of Serum Creatinine compared to other analytes in 277,111 patients who had blood work testing in Columbus, Ohio 100 90 80 70 Pecentages 60 50 40 30 20 10 0 Creatinine Glucose Lipids Laboratory Tests Age >60 Diabetes Hypertension 3 Risk Factors No Risk Factors CBC Electrolytes Stevens LA et al. JASN 2005 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. Even High-risk Patients’ Kidney Disease Rarely Documented Discharge Documentation of Kidney Abnormalities Detected During Hospitalization 20% DM HTN 13% 11% 10% 8% 10% 0% Proteinuria >1+ S. Cr. > 1.5 mg/dl McClellan WM et al. AJKD 1997 Treatments to Slow the Progression of Chronic Kidney Disease in Adults Strict glycemic control ACE-inhibitors or angiotensinreceptor blockers Strict blood pressure control Dietary protein restriction Lipid-lowering therapy a Diabetic Kidney Disease Yesa Yes Nondiabetic Kidney Disease NA Yes (greater effect in patients with proteinuria) Yes <130/80 mm Hg Uncertain 0.6-0.8 g/kg/d Probable LDL<100 mg/dl Yes <130/80 mm Hg Uncertain 0.6-0.8 g/kg/d Probable LDL<100 mg/dl Prevents or delays the onset of diabetic kidney disease. Inconclusive with regard to progression of established disease. ESRD incidence: leveling off? Incident ESRD patients; adjusted for age, gender, & race. USRDS 2006 Change in Incidence of ESRD: Effect of better blood pressure or ACEI? Adjusted incident rates of ESRD due to diabetes illi illi lla lla Incident ESRD patients, adjusted for gender. USRDS Annual Report 2005 Interventions to Delay Progression: Boston-area chart audit 100% Percent of Patients 80% 60% 40% 20% 0% 49% 65% 39% 22% ACEI Overall ACEI in DM ACEI in Non-DM Low Protein Diet Kausz JASN 2001: 12 1501-7 Continuation of ACEI/ARBs by New CKD Patients incident CKD patients, 2000–2004 combined, from the Medstat database, 1999–2004. USRDS 2006 CVD Diagnosis in CKD Condition Additional diagnostic considerations in CKD Ischemia Heart Failure Retained CK MB and troponins; false negative inducible-perfusion scans (balanced ischemia); increased risk of acute kidney injury from contrast studies ECF fluid overload in kidney failure or nephrotic syndrome; absence of ECF fluid overload in dialysis patients CVD Risk Factor Management in CKD Risk Factor Additional therapeutic considerations in CKD BP goal <130/80; ACEI or ARB if proteinuria; increased frequency of monitoring Glipizide preferred, avoid metformin Hypertension Diabetes Dyslipidemia Anemia LDL <100, reduce dose of fibrates, increased risk of side effects from combination therapy Erythropoietin stimulating proteins; iron Reasons for Referral to Nephrologist • GFR <30 mL/min/1.73 m2 • Unable to carry out CKD Action Plan – – – – – – – – Undetermined cause Spot urine protein/creatinine ratio >500 mg/g High risk for progression Difficult to manage complications GFR decline without adequate explanation Hyperkalemia (>5.5 mEq/l) Resistant hypertension (>130/80 mm Hg) Age <18 (pediatric nephrologist) Referral to Nephrologists Kinchen et al. Ann Intern Med 2002; 137: 479-486 In-Center Hemodialysis Should Not Be the Default First Choice • Peritoneal dialysis • Home hemodialysis – conventional 3x/week – daily short hemodialysis – nocturnal hemodialysis Home Hemodialysis: Seattle, 1964 Home Hemodialysis 2007 Fistula First Vascular Access 1992-2004 illi illi lla lla 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 Influenza vaccinations 1993-2003 illi illi lla lla 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 Pneumococcal vaccinations 2000-2004 illi illi lla lla 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 How Might You Improve CKD Care? 1. Raise Awareness – – – – Medical record: correct classification Patients, their families and friends Clinicians Make sure educational materials are readily available How Might You Improve CKD Care? 1. Raise Awareness 2. Help with Education – Who is at risk – Benefits of continued ACE inhibitor/ARB use and of lower blood pressure targets – CKD is a risk factor for CVD, and need aggressive risk factor modification – Consider kidney replacement options early • Living donor transplant the first choice, for some even in 70s • Home hemodialysis & peritoneal dialysis the second choice • early AVF creation important How Might You Improve CKD Care? 1. Raise Awareness 2. Help with Education 3. Coordinate – Screening of high-risk groups – Nephrologist and dietician referrals – Prior authorization: erythropoietin, vitamin D analogs, ACE inhibitors, ARBs – Access creation: arranging early appointments – Transportation and reminders – Immunizations – Medication follow-up Take-Home Messages • Chronic kidney disease is a public health problem – outcomes include loss of kidney function and cardiovascular disease • Clinical assessment from laboratory tests – spot albumin/creatinine ratio to assess kidney damage – serum creatinine to estimate GFR • You can help improve outcomes – Facilitate clinical action plan based on stages of severity – Physician, patient, and public education You have the Power to Prevent Kidney Disease New Elderly ESRD Patients: Many Diagnoses in Preceding 2 Years illi illi lla lla New ESRD patients aged 75+ USRDS 2006 incident ESRD patients age 75 & older. Frequent Admissions Just Before ESRD illi illi lla lla 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 Healthy People 2010 Targets for ESRD & Levels Achieved USRDS 2006