Improving Care for Chronic Kidney Disease and
Kidney Failure
Lesley Stevens MD MSMassPro 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
Kidneydamage and
Normal or GFR
Kidneydamage and
Mild GFR
Severe GFR
Kidneyfailure
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 SpecialistPrimary care physician
Outline
• Kidney Failure• Chronic kidney disease
– Definition– Outcomes
• CKD: Clinical Action Plan– Detect CKD– Prevent progression of CKD– Diagnosis and treat CVD– Treat co-morbid conditions and complications– Refer to nephrology
Kidney Failure (ESRD) in the US
LungCancer
KidneyFailure
ColonCancer
BreastCancer
ProstateCancer
57
99
4232
Kidney Failure Compared toCancer 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
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.
Disparities in ESRD Incidence
USRDS 2006
Life Expectancy after ESRD
0
10
20
30
40
50
60
70
80
0-14 25-29 40-44 55-59 70-74 85+Age
Ye
ars
General Population
Transplant
Dialysis
USRDS 2006
General Population
Transplant
Dialysis
CKDCKDdeathdeathCKDCKDdeathdeath
Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies
ComplicationsComplicationsComplicationsComplications
Screening Screening for CKDfor CKD
risk factors:risk factors:diabetesdiabetes
hypertensionhypertensionage >60age >60
family historyfamily historyUS ethnic US ethnic minoritiesminorities
CKD riskCKD riskreduction;reduction;
Screening forScreening forCKDCKD
DiagnosisDiagnosis& treatment;& treatment;
Treat Treat comorbidcomorbid
conditions;conditions;Slow Slow
progressionprogression
EstimateEstimateprogression;progression;
TreatTreatcomplications;complications;
Prepare forPrepare forreplacementreplacement
ReplacementReplacementby dialysisby dialysis
& transplant& transplant
NormalNormalNormalNormal IncreasedIncreasedriskrisk
IncreasedIncreasedriskrisk
KidneyKidneyfailurefailureKidneyKidneyfailurefailureDamageDamageDamageDamage GFRGFR GFRGFR
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 Wesson Human Physiology of the KidneyHuman Physiology of the Kidney 1969 1969
Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 99-00)
%N (1000s)
0.1391< 15 or DialysisKidney Failure5
0.130015-29Severe GFR4
3.77,40030-59Moderate GFR3
2.85,70060-89Kidney Damage with
Mild GFR2
2.85,600 90Kidney Damage with
Normal or GFR1
Prevalence*GFR
(ml/min/1.73 m2DescriptionStage
*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 585.1 Chronic kidney disease, Stage 1
New code 585.2 Chronic kidney disease, Stage 2 (mild)
New code 585.3 Chronic kidney disease, Stage 3 (moderate)
New code 585.4 Chronic kidney disease, Stage 4 (severe)
New code 585.5 Chronic kidney disease, Stage 5
New code 585.6 End stage renal disease
New code 585.9 Chronic kidney disease, unspecified
Chronic renal disease
Chronic renal failure NOS
Chronic renal insufficiency
Add Use additional code to identify kidney transplant status, if applicable (V42.0)
Complications Related to CKD
0
10
20
30
40
50
60
70
80
90
15-29 30-59 60-89 90+
Estimated GFR (ml/min/1.73 m2)
Pro
porti
on o
f pop
ulat
ion
(%)
Hypertension* Hemoglobin < 12.0 g/dLUnable to walk 1/4 mile Serum albumin < 3.5 g/dL
Serum calcium < 8.5 mg/dL Serum phosphorus > 4.5 mg/dL
USRDS Annual Data USRDS Annual Data Report 2005Report 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.
CKD Mortality: Kaiser Permanente Northern California
Go A, et alGo A, et al. NEJM. NEJM 2004 2004
All Cause Mortality Cardiovascular Deaths
Longitudinal Follow-up and Outcomes Among Population With Chronic Kidney Disease in a Large Managed Care
Organization
6.610.316.214.9 Disenrolled
45.724.319.510.2 Death
2.30.20.20.01 Received Tx
17.61.10.90.06 Initiated Dialysis
27.864.263.374.8 None of above
Events (%)
37.651.149.853.9FU (months)
73.671.660.861.4Age (years)
77711378174114202N
Stage 4Stage 3Stage 2GFR 60-89, No U prot
Keith et al Arch Intern Med 2005Keith et al Arch Intern Med 2005
Chronic Kidney Disease: A Clinical Action Plan
Stage Description GFR(ml/min/1.73 m2)
Action†
At Increased Risk >60(CKD Risk Factors)
Screening,CKD Risk Reduction
1 Kidney Damage with Normal or GFR
>90 Diagnosis and Treatment,Treatment of Comorbid
Conditions,Slowing Progression,CVD Risk Reduction
2 Kidney Damage with Mild GFR
60-89 Estimating Progression
3 Moderate GFR 30-59 Evaluating and Treating Complications
4 Severe GFR 15-29 Preparation for Kidney Replacement Therapy
5 Kidney Failure <15 or Dialysis
Replacement,if Uremia Present
CKD Testing
• Serum creatinine to estimate the GFR
• Urine albumin testing
Creatinine Generation
Muscle massVaries 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
Creatinine = 0.94 mg/dL when
eGFR = 60 mL/min/1.73 m2
Actual eGFR at this creatinine = 37 mL/min/1.73m2
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 GuidelinesSource: NKF CKD Clinical Practice Guidelines
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
To
ld T
hey
Hav
e W
eak
or
Fai
lin
g K
idn
eys,
%
0
10
20
30
40
50
60
70
80
90
100
Creatinine Glucose Lipids CBC Electrolytes
Laboratory Tests
Pec
enta
ges
Age >60 Diabetes Hypertension 3 Risk Factors No Risk Factors
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 2005Stevens LA et al. JASN 2005
Probability of the assessment of 1+ microalbuminuria or proteinuria tests
within a year, 2004Figure 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
8%10%
13%11%
0%
10%
20%
Proteinuria >1+ S. Cr. > 1.5 mg/dl
Discharge Documentation of Kidney AbnormalitiesDetected During Hospitalization
DM HTN
McClellan WM McClellan WM et al.et al. AJKD 1997 AJKD 1997
Treatments to Slow the Progression of Chronic Kidney Disease in Adults
Diabetic Kidney
Disease Nondiabetic
Kidney Disease
Strict glycemic control
Yesa NA
ACE-inhibitors or angiotensin-
receptor blockers
Yes Yes
(greater effect in patients with proteinuria)
Strict blood pressure control
Yes <130/80 mm Hg
Yes <130/80 mm Hg
Dietary protein restriction
Uncertain 0.6-0.8 g/kg/d
Uncertain 0.6-0.8 g/kg/d
Lipid-lowering therapy
Probable LDL<100 mg/dl
Probable LDL<100 mg/dl
a Prevents or delays the onset of diabetic kidney disease. Inconclusive with regard to progression of established disease.
Incident ESRD patients; adjusted for age, gender, & race.
ESRD incidence: leveling off?
USRDS 2006
Change in Incidence of ESRD: Effect of better blood pressure or ACEI?
Adjusted incident rates of ESRD due to diabetes
Incident ESRD patients, adjusted for gender.
USRDS USRDS Annual ReportAnnual Report 2005 2005
Interventions to Delay Progression: Boston-area chart audit
39%
22%
49%
65%
0%
20%
40%
60%
80%
100%
ACEI Overall ACEI in DM ACEI inNon-DM
Low ProteinDiet
Per
cen
t o
f P
atie
nts
Kausz JASN 2001: 12 1501-7Kausz 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 Retained CK MB and troponins; false negative inducible-perfusion scans (balanced ischemia); increased risk of acute kidney injury from contrast studies
Heart Failure 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
Hypertension BP goal <130/80; ACEI or ARB if proteinuria; increased frequency of monitoring
Diabetes Glipizide preferred, avoid metformin
Dyslipidemia LDL <100, reduce dose of fibrates, increased risk of side effects from combination therapy
Anemia 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: 479-486Kinchen 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
Period prevalent hemodialysis patients. Data from Part B claims. Some patients may have more than one access at a given point in time.
Vascular Access 1992-2004
USRDS 2006
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.
Influenza vaccinations 1993-2003
USRDS 2006
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.
Pneumococcal vaccinations 2000-2004
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 Awareness2. 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 Awareness2. Help with Education3. 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 You have the Power to Prevent Kidney DiseasePrevent Kidney Disease
New Elderly ESRD Patients: Many Diagnoses in Preceding 2 Years
incident ESRD patients age 75 & older.
New ESRDpatients aged75+
USRDS 2006
Frequent Admissions Just Before ESRD
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