CHRONIC KIDNEY DISEASE TIMELY REFERRAL

1. CHRONIC KIDNEY DISEASE TIMELY REFERRAL Coordinating Care for Improved Renal Disease Outcomes

2. CKD: Setting a Course for Action How Many Patients Have CKD? Defining CKD Why do CKD Patients Need Special Care? Does Coordinated Care and Timely Referral Matter? Screening for CKD Making Timely Referral & Co-Management Work

3. How many patients have CKD? USRDS data has provided an accurate assessment of the number of US patients with End Stage Renal Disease Chronic Kidney Disease prevalence has been estimated from National Health and Nutrition Examination Surveys (NHANES) data

4. The Early NHANES III StudyAnalysis of Prevalence of CKD by Stage - Adapted from NHANES III (2000)

5. A Large National Burden in 2009The Renal Continuum of Care Primary Care Physician Nephrologist DiabetesHypertension Obesity CVD At Risk Population CKD ESRD 500,000+ People ~375,000 Dialysis ~125,000 Transplant 26,000,000+ People

6. Defining CKD: What Constitutes Renal Disease? • Kidney Disease Outcome Quality Initiative (KDOQI) Components of Definition • Anatomical or Structural Defect • Example: Abnormal imaging study (i.e. Polycystic Kidney Disease), Abnormal Renal Biopsy or Proteinuria (spot urine protein/creatinine ratio >30 mg/g) • Functional Component • Example: Abnormal eGFR (Low or High) • Time Component • ≥ 3 months duration required

7. KDOQI CKD Definition • eGFR < 60 ml/min/1.73 m2 for 3 months or longer OR • Spot urine albumin/creatinine ratio of >30 mg/g in 2 of 3 urine samples

8. Why use Estimated Glomerular Filtration Rate (eGFR)? • Why Use an estimated GFR? • It is a more accurate measure of kidney function than serum creatinine because it accounts for age, gender, race and muscle mass variables. • Easily calculated for any measured serum creatinine • ACLA* endorses an eGFR with every creatinine reported • Impact of a Reduced eGFR • Reduced eGFR is a 10-20x INDEPENDENT risk factor for Cardiovascular Disease • Reduced eGFR is strongly associated with mortality *ACLA = American Clinical Laboratory Association

9. CKD Patients and Secondary Prevention • The 2006 CDC expert panel on CKD identified 3 Prevention Strategies: • Primary Prevention-aimed at preventing and treating CKD risk factors • Secondary Prevention-begins with the diagnosis of CKD • CKD stages 1 & 2 (eGFR >60) attention to guidelines for good management of DM and HTN and CKD education • CKD stages 3 & 4 (eGFR 15-60) attention to therapy for CKD related complications such as anemia, ESRD treatment choices and vascular access • Tertiary Prevention- adequate renal replacement therapy

10. Why do CKD patients need special care? • CKD Prevalence • A worldwide public health condition • Poor outcomes • High cost of care • Morbidity and Mortality • CKD Stage 3 • 1.1% risk of progression to ESRD • 24.3% mortality risk before ESRD • CKD stage 4 • 17.6% risk of progression to ESRD • 45.7% mortality risk before ESRD

11. Why Do CKD Patients Need Special Care?eGFR & Mortality No. of Events 25,803 11,603 7,802 4,408 1,842 eGFR < 60 ml/min/m2  Increase Risk of Death

12. Why Do CKD Patients Need Special Care?CKD “Death Before Dialysis” is Prominent Lost to Follow Up 100 % Stable CKD Stable CKD Dialysis CKD Patients In Large Health Plan Death Death 0 % Early recognition of CKD risk and early intervention for CKD can prevent early death before dialysis CKD patients in a large HMO were more likely to die than reach Renal Replacement Therapy Stage 2 Stage 3 Stage 4

13. Why Do CKD Patients Need Special Care? • Effective Primary Care Can Improve Renal Patient Outcomes: • Expect to see eGFR reported • Note the significance of the eGFR • Make the diagnosis of CKD as indicated • Identify the CKD stage • Context Sensitive Interventions based on eGFR • Co-management of DM, HTN, underlying diseases • Intervention for Anemia, HPT, Nutrition and Psychosocial impact of kidney disease • Referral at 30 ml/min eGFR • Vascular Access and Modality Prep at 20 ml/min eGFR • Renal Replacement at 10 ml/min eGFR

14. Coordinated Roles in theTotal Care of the CKD Patient • Primary Care Provider • Early identification of CKD patients • Focused & Structured evaluation and management • Referral and co-management with nephrologist • Co-Management of Co-Morbid Diseases • Nephrologist and the Renal Care Team • Focused assistance in management of co-morbidities • Diabetes, Hypertension, cardiovascular disease • Anemia, Mineral Metabolism, Nutrition & Volume management • Vascular Access Preparation & Management • Education on ESRD treatment options & modality selection • Co-management of Medications, Family and Social Issues of Renal Disease

15. Impact of Early Intervention • Slower progression to ESRD • Increased functional status • Decreased Morbidity and Mortality from • Hospitalizations • CVD events • Urgent Care & Emergency Visits • Medication Management • Decreased costs from fewer urgent complications

16. Referral Related Realities 30-40% of referrals to nephrologists occur less than 120 days prior to starting dialysis Referral to nephrology <4 months before starting dialysis is considered a “Late Referral” by Medicare and other Payers 82% of patients having to begin Dialysis start with a catheter First year mortality of Dialysis patients is annualized at ~40%

17. High Catheter Use At Initiation Of Dialysis is the Primary Cause of Early Morbidity and Mortality

18. Fate of Catheters From First Dialysis Through 180 days Admission* (N=28,840) Day 90 (N=22,019) Day 180 (N=16,046) • Among Catheters Overall: • 6,589 of 22,019 (29.9%) still w/ HD Catheter • 2,885 of 22,019 (13.1%) Died w/ Catheter • 12,545 of 22,019 (57.0%) converted to Graft or Fistula^ HD Catheter Patients 6,589 (41.1%) HD Catheter Patients 22,019 (77.4%) HD Catheter Patients 16,048 (72.8%) Died w/ Catheter 979 (6.1%) Died w/ Catheter 1,906 (8.7%) Other Access^ 8,480 (52.84%) Other Access^ 6,421 (22.6%) Other Access^ 4,065 (18.5%) * Total of 28,440 HD patients admitted within 15 days of first dialysis (ever) during 2008. ^ Some of the patients with grafts or fistula may have failed and reverted to catheters after 90-180 days (Not Counted). EL-CSER 10/06/09

19. Timely Referral: Mortality In the CHOICE Study Late Referral is associated with an increased RISK OF DEATH

20. Timely Referral and Hypertension Nephrology support improves BP control

21. Timely Referral: Emergent Dialysis Timely Referral reduces the occurrence of emergent first dialysis

22. Timely Referral: Modality and Access • Patient Education and Preparation associated with Early Referral are critical for: • Timely vascular access placement • Reduced use of dialysis catheters • Modality Choice for Patients • Home Therapies • Peritoneal Dialysis • Home Hemodialysis • Transplantation • In-Center Hemodialysis • Palliative or End of Life Care

23. Timely Referral: Anemia Complications of anemia may occur early in CKD Evaluation and treatment of anemia with Erythropoietin is improved with Timely Referral

24. Timely Referral: Nutrition and Bone Disease • Early Nutritional Counseling • Avoid protein malnutrition • Avoidance of volume overload and hyperkalemia which might lead to emergent dialysis • Bone Disease and derangements of Calcium/Phosphorus metabolism occur early in CKD. Treatment and dietary counseling are necessary to prevent complications.

25. Timely Referral: Quality of Life • Timely Referral improves Quality of Life in CKD patients • First dialysis is a planned event avoiding a “Crash” into Dialysis • Dialysis Access is established • Families and Patients are prepared • Appropriate use of Erythropoeisis-Stimulating Agent (ESA) therapy for treating anemia

26. Timely Referral: Healthcare Costs • Timely Referral  Lower Healthcare Costs • Reduced Hospitalizations • Improved management of co-morbidities • Reduced complications from cardiovascular disease • Delayed deterioration of residual renal function and the need to start Renal Replacement Therapy • Enhances patient choices for treatment modalities

27. Why Do CKD Patients Need Special Care?Renal Disease Care is Expensive ~10% of Federal Healthcare Costs ~1.5% of Patients ESRD + Late Stage Chronic Kidney Disease (CKD) ~ $30B peryear Other Medicare Other Medicare Source: USRDS (publicly available comprehensive clinical and financial dataset reported to and used by CMS) ~375,000 ESRD + ~300,000 Stage 4 Chronic Kidney Disease

28. Why Do CKD Patients Need Special Care?Incident ESRD Care is Very Costly

29. Timely Referral: Long-lasting benefits Late Referral patients have a 44% higher risk of mortality in the first year of dialysis compared to Early Referral patients

30. Who Should be Screened for CKD? • The AT RISK Population: • HYPERTENSION • DIABETES MELLITUS • CARDIOVASCULAR DISEASE • FAMILY HISTORY OF CKD

31. Screening Recommendations • Screening Should Include: • Laboratory studies to include serum creatinine and eGFR • Urinalysis to determine the presence of proteinuria • Imaging studies such as ultrasound Screening recommendations are provided in KDOQI, Guideline 1 http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm

32. Make the Diagnosis of CKD • Criteria (The ICD9 Code for CKD is 585.x) • Decreased kidney function eGFR of <60 ml/min/1.73 m2 for ≥ 3 months • Abnormal urinalysis including the presence of proteinuria or hematuria • Request a spot urine protein/creatinine ratio (Normal is <30 mg/g) • Document an abnormal Renal Imaging Study

33. How to Implement Timely Referral? • Establish CKD diagnosis and Details: • Make a specific renal disease diagnosis if possible • Identify co-morbidities • Hypertension • Diabetes • Cardiovascular Disease • Determine the severity of CKD (know the eGFR) • Identify CKD Complications • Anemia (know the Hgb) • Secondary Hyperparathyroidism (know the Ca and Phos) • Malnutrition (know the albumin) • Assess stability of Kidney Function and CKD Stage Recommendations for further evaluation are outlined in KDOQI Guideline 2 http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm

34. Timely Referral Decision Making • Timely Referral Guidance: • Rapidly decreasing renal function REFER • Abnormal eGFR AND proteinuria REFER • eGFR ≤ 30 ml/min/ 1.73 m2 REFER • eGFR <60 ml/min/1.73 m2 and Cardiovascular Disease Present REFER • Uncontrolled Hypertension Present REFER

35. Timely Referral to Nephrologist • Consult the Nephrology team: • To assist in specific diagnosis of renal disease • To assist in the evaluation and treatment of co-morbidities • To assist in developing and/or implementing a clinical co-management plan

36. CKD Care: PCP & Nephrology Team • Various Descriptors of the PCP / Nephrology Team Relationship • “Joint Care” between PCP and Nephrology Team • “Interwoven Collaboration” • “Co-Management” as shared care with defined roles between PCP and Nephrology Team • “Combicare” as care from an informed PCP working with support from the Nephrology team

37. CKD Care: PCP & Nephrology Team • Characteristics: • GOOD COMMUNICATION • Who is responsible for what care issue? • Sharing of the most recent clinical data • For each patient all providers should know: • CKD Stage & Progression Rate • Each Co-morbidity • CKD Complications • ESRD Preparation & modality plans

38. Barriers to Timely Referral • Disease Related • Rapid and/or unexpected onset of renal disease with an acute decompensation • An acute decompensation of existing CKD • An intercurrent new diagnosis with implications on kidney function

39. Barriers to Timely Referral • Patient Related • There is NO Primary Care • The Patient has poor understanding of CKD • The patient has unaddressed fears related to CKD and its treatment resulting in avoidance • Co-morbid problems with multiple providers • Poor socioeconomic resources impacting access to care, travel & family support

40. Barriers to Timely Referral • Primary Care Provider • Uneasiness with patient eligibility for Renal Replacement Therapy • Not knowing the criteria for referral to nephrologists • Fear of losing the patient to follow-up • Past difficulties with poor communication and poor coordinated care with Nephrologist • Avoidance of potential rebuke from nephrologists • Sense of failure as disease progresses or conditions are not in control

41. Barriers to Timely Referral • Nephrologist • Long wait times for appointments • Lack of Receptivity for Referrals • Poor Organization of Nephrology Team • Poor communication of clinical information and urgency of referral • Poor communication • Dialysis Unit • Slow response to request for information • Social Work • Nutritional Support • Patient Education

42. Overcoming Barriers to Timely Referral • Primary Care Providers should be committed to screening all high risk patients initially and annually • Primary Care Providers should be comfortable with: • The definition of CKD and its Staging • The importance of a reduced eGFR and the presence of proteinuria • Recognition that CKD is an independent risk factor for CVD and Death

43. Overcoming Barriers to Timely Referral • Primary Care Providers AND the Nephrology Team must: • Communicate well to manage progression of disease, CVD and CKD Co-morbidities & Complications • Provide “Interwoven Collaboration” and “Co-Management” for the benefit of the patient

44. Overcoming Barriers to Timely Referral • Primary Care Providers AND the Nephrology Team can jointly decide optimal BP management for a patient: • Should we use an ACEI or an ARB instead of a Beta Blocker? • Will diuresis and volume management improve the BP control? • What is the appropriate target BP?

45. Overcoming Barriers to Timely Referral • The Nephrology Team must: • Provide PCP support and information • Manage underlying Renal Conditions to: • Prevent or Delay progression • Manage CVD • Manage CKD complications • Anemia • Metabolic Bone Disease • Nutrition • Provide Modality Options Education

46. Overcoming Barriers to Timely Referral • The Nephrology Team may primarily manage specific CKD complications such as hyperphosphatemia, hypocalcemia and hyperparathyroidism: • When should vitamin D therapy be started? • Which binders should be used to lower the phosphorus? • What diet is appropriate?

47. Overcoming Barriers to Timely Referral • The Nephrology team must: • Plan Modality Selection with Patient • Insure placement of permanent Access • Coordinate the Nephrology Multidisciplinary Education Team • Coordinate initiation of Renal Replacement Therapy with the dialysis facility

48. TIMELY REFERRAL AND JOINT CLINICAL CARE LEAD TO BETTER PATIENT OUTCOMES

49. Timely Referral Reference List • Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with chronic kidney disease referred late to nephrologists: A meta-analysis. Am J Med. 2007;120:1063-1070. • Richards N, Harris K, Whitfield M, et.al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. NDT. 2007;0:1-7. • Lee BJ, Forbes K. The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. BMJ. 2009;339:b2395. • Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. NDT. 2006;21:2133-2143. • Kazmi WH, Obrador GT, Khan SS, et.al. Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis. NDT. 2004;19:1808-1814. • Caskey FJ, Wordsworth S, Ben T, et.al. Early referral and planned initiation of dialysis: what impact on quality of life? NDT. 2003;18:1330-1338.

50. Timely Referral Reference List • Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on emergent first dialyses, health care costs, and outcome. AJKD. 1998;32(2):278-283. • Go AS, Chertow GM, Fan D, et.al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. NEJM. 2004;351:1296-1305. • Roubicek C, Brunet P, Huiart L, et.al. Timing of nephrology referral: Influence on mortality and morbidity. AJKD. 2000;36:35-41. • Levey AS, Eckardt KU, Tsukamoto Y, et.al. Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). KI. 2005;67:2089-2100. • Huisman RM. The deadly risk of late referral. NDT. 2004;19:2175-2180. • Noble E, Johnson DW, Gray N, et.al. The impact of automated eGFR reporting and education on nephrology service referrals. NDT. 2008;23:3845-3850.