CHRONIC KIDNEY DISEASE TIMELY REFERRAL

11

CHRONIC KIDNEY DISEASE CHRONIC KIDNEY DISEASE TIMELY REFERRALTIMELY REFERRAL

Coordinating Care for Improved Coordinating Care for Improved Renal Disease OutcomesRenal Disease Outcomes

22

CKD: Setting a Course for ActionCKD: Setting a Course for Action

How Many Patients Have CKD?How Many Patients Have CKD?

Defining CKDDefining CKD

Why do CKD Patients Need Special Care?Why do CKD Patients Need Special Care?

Does Coordinated Care and Timely Referral Matter?Does Coordinated Care and Timely Referral Matter?

Screening for CKDScreening for CKD

Making Timely Referral & Co-Management WorkMaking Timely Referral & Co-Management Work

33

How many patients have CKD?How many patients have CKD?

USRDS data has provided an accurate USRDS data has provided an accurate assessment of the number of US patients with assessment of the number of US patients with End Stage Renal DiseaseEnd Stage Renal Disease

Chronic Kidney Disease prevalence has been Chronic Kidney Disease prevalence has been estimated from National Health and Nutrition estimated from National Health and Nutrition Examination Surveys (NHANES) data Examination Surveys (NHANES) data

44

The Early NHANES III StudyThe Early NHANES III StudyAnalysis of Prevalence of CKD by StageAnalysis of Prevalence of CKD by Stage

StageStage DescriptionDescription eGFR RangeeGFR Range(ml/min/ 1.73 m(ml/min/ 1.73 m22))

Population Population (1,000’s)(1,000’s)

Population Population (%)(%)

11 Kidney damage with

normal or increase GFR

≥ 90 5,900 3.3 %

22 Mildly decreased

GFR

60-89 5,300 3.0 %

33 Moderately decreased

GFR

30-59 7,600 4.3 %

44 Severely decreased

GFR

15-29 400 0.2 %

55 Kidney Failure < 15 300 0.1%

- Adapted from NHANES III (2000)

55

A Large National Burden in 2009A Large National Burden in 2009The Renal Continuum of CareThe Renal Continuum of Care

NephrologistNephrologistNephrologistNephrologist

Primary Care Primary Care PhysicianPhysician

Primary Care Primary Care PhysicianPhysician

ESRDESRDCKDCKDAt RiskAt Risk

PopulationPopulationAt RiskAt Risk

PopulationPopulation

DiabetesDiabetesHypertensionHypertension

ObesityObesity

CVDCVD

26,000,000+ People26,000,000+ People

500,000+ People500,000+ People~375,000 Dialysis~375,000 Dialysis

~125,000 Transplant~125,000 Transplant

66

Defining CKD: What Constitutes Renal Disease?Defining CKD: What Constitutes Renal Disease?

Kidney Disease Outcome Quality Initiative (KDOQI)Kidney Disease Outcome Quality Initiative (KDOQI)Components of DefinitionComponents of Definition

• Anatomical or Structural DefectAnatomical or Structural Defect Example: Abnormal imaging study (i.e. Polycystic Example: Abnormal imaging study (i.e. Polycystic

Kidney Disease), Abnormal Renal Biopsy or Proteinuria Kidney Disease), Abnormal Renal Biopsy or Proteinuria (spot urine protein/creatinine ratio >30 mg/g)(spot urine protein/creatinine ratio >30 mg/g)

• Functional ComponentFunctional Component Example: Abnormal eGFR (Low or High)Example: Abnormal eGFR (Low or High)

• Time ComponentTime Component ≥ ≥ 3 months duration required3 months duration required

77

KDOQI CKD DefinitionKDOQI CKD Definition

eGFR < 60 ml/min/1.73 meGFR < 60 ml/min/1.73 m22 for 3 months or longer for 3 months or longer

OROR

Spot urine albumin/creatinine ratio of >30 mg/g in Spot urine albumin/creatinine ratio of >30 mg/g in 2 of 3 urine samples2 of 3 urine samples

88

Why use Estimated Glomerular Why use Estimated Glomerular Filtration Rate (eGFR)?Filtration Rate (eGFR)?

Why Use an estimated GFR?Why Use an estimated GFR?• It is a more accurate measure of kidney function than It is a more accurate measure of kidney function than

serum creatinine because it accounts for age, gender, serum creatinine because it accounts for age, gender, race and muscle mass variables.race and muscle mass variables.

• Easily calculated for any measured serum creatinineEasily calculated for any measured serum creatinine

• ACLA* endorses an eGFR with every creatinine reportedACLA* endorses an eGFR with every creatinine reported

Impact of a Reduced eGFRImpact of a Reduced eGFR• Reduced eGFR is a 10-20x Reduced eGFR is a 10-20x INDEPENDENTINDEPENDENT risk factor for risk factor for

Cardiovascular DiseaseCardiovascular Disease

• Reduced eGFR is strongly associated with mortalityReduced eGFR is strongly associated with mortality

*ACLA = American Clinical Laboratory Association

CKD Patients and Secondary CKD Patients and Secondary PreventionPrevention

The 2006 CDC expert panel on CKD identified 3 The 2006 CDC expert panel on CKD identified 3 Prevention Strategies:Prevention Strategies:• Primary Prevention-aimed at preventing and Primary Prevention-aimed at preventing and

treating CKD risk factors treating CKD risk factors • Secondary Prevention-begins with the diagnosis of Secondary Prevention-begins with the diagnosis of

CKDCKD CKD stages 1 & 2 (eGFR >60) attention to guidelines for CKD stages 1 & 2 (eGFR >60) attention to guidelines for

good management of DM and HTN and CKD educationgood management of DM and HTN and CKD education CKD stages 3 & 4 (eGFR 15-60) attention to therapy for CKD stages 3 & 4 (eGFR 15-60) attention to therapy for

CKD related complications such as anemia, ESRD CKD related complications such as anemia, ESRD treatment choices and vascular accesstreatment choices and vascular access

• Tertiary Prevention- adequate renal replacement Tertiary Prevention- adequate renal replacement therapytherapy

99

1010

Why do CKD patients need special care?Why do CKD patients need special care?

CKD PrevalenceCKD Prevalence• A worldwide public health conditionA worldwide public health condition• Poor outcomesPoor outcomes• High cost of careHigh cost of care

Morbidity and MortalityMorbidity and Mortality• CKD Stage 3CKD Stage 3

1.1% risk of progression to ESRD1.1% risk of progression to ESRD 24.3% mortality risk before ESRD24.3% mortality risk before ESRD

• CKD stage 4CKD stage 4 17.6% risk of progression to ESRD17.6% risk of progression to ESRD 45.7% mortality risk before ESRD45.7% mortality risk before ESRD

1111

Why Do CKD Patients Need Special Care?Why Do CKD Patients Need Special Care?

eGFR & MortalityeGFR & Mortality

eGFR Adjusted Mortality

0

2

4

6

8

10

12

14

16

>59 45-59 30-44 15-29 <15

eGFR (ml/min/1.73 m2)

Ad

jste

d D

eath

Rat

e(D

eath

s / 1

00 p

t ye

ars

at r

isk)

No. of Events 25,803 11,603 7,802 4,408 1,842

eGFR < 60 ml/min/m2 eGFR < 60 ml/min/m2 Increase Risk of Death Increase Risk of Death

1212

Why Do CKD Patients Need Special Care?Why Do CKD Patients Need Special Care?CKD “CKD “Death Before Dialysis”Death Before Dialysis” is Prominent is Prominent

Early recognition of CKD risk and early intervention for CKD can prevent Early recognition of CKD risk and early intervention for CKD can prevent early death before dialysisearly death before dialysis

CKD patients in a large HMO were more likely to die than reach Renal CKD patients in a large HMO were more likely to die than reach Renal Replacement TherapyReplacement Therapy

11.2%

24.3%

45.7%

73.5%

64.2%

27.8%

17.6%

Stage 2 Stage 3 Stage 4

DeathDeath

DeathDeath

Stable Stable CKDCKD DialysisDialysis

Stable Stable CKDCKD

0 %

100 %

CK

D P

ati

en

ts I

n L

arg

e H

ealt

h P

lan

Lost to Lost to Follow UpFollow Up

1313


Effective Primary Care Can Improve Renal Effective Primary Care Can Improve Renal Patient Outcomes:Patient Outcomes:• Expect to see eGFR reportedExpect to see eGFR reported• Note the significance of the eGFRNote the significance of the eGFR• Make the diagnosis of CKD as indicatedMake the diagnosis of CKD as indicated• Identify the CKD stageIdentify the CKD stage• Context Sensitive Interventions based on eGFRContext Sensitive Interventions based on eGFR

Co-management of DM, HTN, underlying diseasesCo-management of DM, HTN, underlying diseases Intervention for Anemia, HPT, Nutrition and Psychosocial Intervention for Anemia, HPT, Nutrition and Psychosocial

impact of kidney diseaseimpact of kidney disease Referral at 30 ml/min eGFRReferral at 30 ml/min eGFR Vascular Access and Modality Prep at 20 ml/min eGFRVascular Access and Modality Prep at 20 ml/min eGFR Renal Replacement at 10 ml/min eGFRRenal Replacement at 10 ml/min eGFR

1414

Coordinated Roles in theCoordinated Roles in theTotal Care of the CKD PatientTotal Care of the CKD Patient

Primary Care ProviderPrimary Care Provider• Early identification of CKD patientsEarly identification of CKD patients• Focused & Structured evaluation and managementFocused & Structured evaluation and management• Referral and co-management with nephrologist Referral and co-management with nephrologist • Co-Management of Co-Morbid DiseasesCo-Management of Co-Morbid Diseases

Nephrologist and the Renal Care TeamNephrologist and the Renal Care Team• Focused assistance in management of co-morbiditiesFocused assistance in management of co-morbidities

Diabetes, Hypertension, cardiovascular disease Diabetes, Hypertension, cardiovascular disease Anemia, Mineral Metabolism, Nutrition & Volume managementAnemia, Mineral Metabolism, Nutrition & Volume management Vascular Access Preparation & ManagementVascular Access Preparation & Management Education on ESRD treatment options & modality selectionEducation on ESRD treatment options & modality selection

• Co-management of Medications, Family and Social Issues of Co-management of Medications, Family and Social Issues of Renal DiseaseRenal Disease

1515

Impact of Early InterventionImpact of Early Intervention

Slower progression to ESRDSlower progression to ESRD Increased functional statusIncreased functional status Decreased Morbidity and Mortality fromDecreased Morbidity and Mortality from

• HospitalizationsHospitalizations• CVD eventsCVD events• Urgent Care & Emergency VisitsUrgent Care & Emergency Visits• Medication ManagementMedication Management

Decreased costs from fewer urgent Decreased costs from fewer urgent complicationscomplications

1616

Referral Related RealitiesReferral Related Realities

30-40% of referrals to nephrologists occur less than 30-40% of referrals to nephrologists occur less than 120 days prior to starting dialysis120 days prior to starting dialysis

Referral to nephrology <4 months before starting Referral to nephrology <4 months before starting dialysis is considered a “Late Referral” by Medicare dialysis is considered a “Late Referral” by Medicare and other Payersand other Payers

82% of patients having to begin Dialysis start with a 82% of patients having to begin Dialysis start with a cathetercatheter

First year mortality of Dialysis patients is annualized First year mortality of Dialysis patients is annualized at ~40%at ~40%

1717

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

1818EL-CSER 10/06/09

HD Catheter Patients

22,019

(77.4%)


16,048

(72.8%)


6,589

(41.1%)

Admission* (N=28,840)

Day 180 (N=16,046)

Day 90 (N=22,019)

* 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).

Other Access^

6,421 (22.6%)

Died w/ Catheter

1,906 (8.7%)

Other Access^4,065

(18.5%)

Died w/ Catheter

979 (6.1%)

Other Access^ 8,480 (52.84%)

Fate of Catheters From First Dialysis Through 180 days

Among Among Catheters Catheters Overall: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^

1919

Timely Referral: MortalityTimely Referral: Mortality

In the CHOICE Study Late Referral is associated In the CHOICE Study Late Referral is associated with an increased RISK OF DEATHwith an increased RISK OF DEATH

2020

Timely Referral and HypertensionTimely Referral and Hypertension Nephrology support improves BP controlNephrology support improves BP control

2121

Timely Referral: Emergent DialysisTimely Referral: Emergent Dialysis

Timely Referral reduces the occurrence of Timely Referral reduces the occurrence of emergent first dialysisemergent first dialysis

2222

Timely Referral: Modality and AccessTimely Referral: Modality and Access

Patient Education and Preparation associated Patient Education and Preparation associated with Early Referral are critical for:with Early Referral are critical for:• Timely vascular access placementTimely vascular access placement• Reduced use of dialysis cathetersReduced use of dialysis catheters• Modality Choice for PatientsModality Choice for Patients

Home TherapiesHome Therapies• Peritoneal DialysisPeritoneal Dialysis• Home HemodialysisHome Hemodialysis

TransplantationTransplantation In-Center HemodialysisIn-Center Hemodialysis Palliative or End of Life CarePalliative or End of Life Care

2323

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

improved with Timely Referralimproved with Timely Referral

2424

Timely Referral: Nutrition and Bone DiseaseTimely Referral: Nutrition and Bone Disease

Early Nutritional CounselingEarly Nutritional Counseling• Avoid protein malnutritionAvoid protein malnutrition• Avoidance of volume overload and hyperkalemia which Avoidance of volume overload and hyperkalemia which

might lead to emergent dialysismight lead to emergent dialysis

Bone Disease and derangements of Bone Disease and derangements of Calcium/Phosphorus metabolism occur early in Calcium/Phosphorus metabolism occur early in CKD. Treatment and dietary counseling are CKD. Treatment and dietary counseling are necessary to prevent complications.necessary to prevent complications.

2525

Timely Referral: Quality of LifeTimely Referral: Quality of Life

Timely Referral improvesTimely Referral improves

Quality of Life in CKD patientsQuality of Life in CKD patients• First dialysis is a planned event avoiding a “Crash” into First dialysis is a planned event avoiding a “Crash” into

DialysisDialysis

• Dialysis Access is establishedDialysis Access is established

• Families and Patients are preparedFamilies and Patients are prepared

• Appropriate use of Erythropoeisis-Stimulating Agent Appropriate use of Erythropoeisis-Stimulating Agent (ESA) therapy for treating anemia(ESA) therapy for treating anemia

2626

Timely Referral: Healthcare CostsTimely Referral: Healthcare Costs

Timely Referral Timely Referral Lower Healthcare Costs Lower Healthcare Costs• Reduced HospitalizationsReduced Hospitalizations• Improved management of co-morbiditiesImproved management of co-morbidities• Reduced complications from cardiovascular Reduced complications from cardiovascular

disease disease • Delayed deterioration of residual renal Delayed deterioration of residual renal

function and the need to start Renal function and the need to start Renal Replacement TherapyReplacement Therapy

• Enhances patient choices for treatment Enhances patient choices for treatment modalitiesmodalities

2727


Renal Disease Care is ExpensiveRenal Disease Care is Expensive

Other Medicare

ESRD + Late Stage Chronic Kidney Disease (CKD)

~ $30B peryear

~1.5% of Patients ~10% of Federal Healthcare Costs

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

2828


Incident ESRD Care is Very CostlyIncident ESRD Care is Very Costly

2929

Timely Referral: Long-lasting benefitsTimely Referral: Long-lasting benefits

Late Referral patients have a 44% Late Referral patients have a 44% higher risk of mortality in the first higher risk of mortality in the first year of dialysis compared to Early year of dialysis compared to Early Referral patients Referral patients

3030

Who Should be Screened for CKD?Who Should be Screened for CKD?

The The AT RISKAT RISK Population: Population:

• HYPERTENSIONHYPERTENSION

• DIABETES MELLITUSDIABETES MELLITUS

• CARDIOVASCULAR DISEASECARDIOVASCULAR DISEASE

• FAMILY HISTORY OF CKDFAMILY HISTORY OF CKD

3131

Screening RecommendationsScreening Recommendations

Screening Should Include:Screening Should Include:• Laboratory studies to include serum creatinine Laboratory studies to include serum creatinine

and eGFRand eGFR• Urinalysis to determine the presence of Urinalysis to determine the presence of

proteinuriaproteinuria• Imaging studies such as ultrasoundImaging studies such as ultrasound

Screening recommendations are provided in Screening recommendations are provided in KDOQI, Guideline 1KDOQI, Guideline 1

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htmhttp://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm

3232

Make the Diagnosis of CKDMake the Diagnosis of CKD

CriteriaCriteria(The ICD9 Code for CKD is 585.x)(The ICD9 Code for CKD is 585.x)

Decreased kidney functionDecreased kidney functioneGFR of <60 ml/min/1.73 meGFR of <60 ml/min/1.73 m22 for ≥ 3 months for ≥ 3 months

Abnormal urinalysis including the presence of Abnormal urinalysis including the presence of proteinuria or hematuriaproteinuria or hematuria

Request a spot urine protein/creatinine ratioRequest a spot urine protein/creatinine ratio((Normal is <30 mg/g)Normal is <30 mg/g)

Document an abnormal Renal Imaging StudyDocument an abnormal Renal Imaging Study

3333

How to Implement Timely Referral?How to Implement Timely Referral? Establish CKD diagnosis and Details:Establish CKD diagnosis and Details:

• Make a specific renal disease diagnosis Make a specific renal disease diagnosis if possibleif possible• Identify co-morbiditiesIdentify co-morbidities

HypertensionHypertension DiabetesDiabetes Cardiovascular DiseaseCardiovascular Disease

• Determine the severity of CKD (know the eGFR)Determine the severity of CKD (know the eGFR)• Identify CKD ComplicationsIdentify CKD Complications

Anemia (know the Hgb)Anemia (know the Hgb) Secondary Hyperparathyroidism (know the Ca and Phos)Secondary Hyperparathyroidism (know the Ca and Phos) Malnutrition (know the albumin)Malnutrition (know the albumin)

• Assess stability of Kidney Function and CKD StageAssess stability of Kidney Function and CKD Stage

Recommendations for further evaluation are outlined in KDOQI Guideline 2Recommendations for further evaluation are outlined in KDOQI Guideline 2

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htmhttp://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm

3434

Timely Referral Decision Timely Referral Decision MakingMaking

Timely Referral Guidance:Timely Referral Guidance:

• Rapidly decreasing renal function Rapidly decreasing renal function REFERREFER

• Abnormal eGFR AND proteinuria Abnormal eGFR AND proteinuria REFERREFER

• eGFR ≤ 30 ml/min/ 1.73 meGFR ≤ 30 ml/min/ 1.73 m22 REFERREFER

• eGFR <60 ml/min/1.73 meGFR <60 ml/min/1.73 m22 and Cardiovascular Disease and Cardiovascular Disease Present Present REFERREFER

• Uncontrolled Hypertension Present Uncontrolled Hypertension Present REFERREFER

3535

Timely Referral to NephrologistTimely Referral to Nephrologist

Consult the Nephrology team:Consult the Nephrology team:

• To assist in specific diagnosis of renal diseaseTo assist in specific diagnosis of renal disease

• To assist in the evaluation and treatment of co-To assist in the evaluation and treatment of co-morbiditiesmorbidities

• To assist in developing and/or implementing a To assist in developing and/or implementing a clinical co-management planclinical co-management plan

3636

CKD Care: PCP & Nephrology TeamCKD Care: PCP & Nephrology Team

Various Descriptors of the PCP / Various Descriptors of the PCP / Nephrology Team RelationshipNephrology Team Relationship

• ““Joint Care” between PCP and Nephrology TeamJoint Care” between PCP and Nephrology Team

• ““Interwoven Collaboration”Interwoven Collaboration”

• ““Co-Management” as shared care with defined roles Co-Management” as shared care with defined roles between PCP and Nephrology Teambetween PCP and Nephrology Team

• ““Combicare” as care from an informed PCP working with Combicare” as care from an informed PCP working with support from the Nephrology teamsupport from the Nephrology team

3737

CKD Care: PCP & Nephrology TeamCKD Care: PCP & Nephrology Team

Characteristics:Characteristics:• GOOD COMMUNICATIONGOOD COMMUNICATION• Who is responsible for what care issue?Who is responsible for what care issue?• Sharing of the most recent clinical dataSharing of the most recent clinical data• For each patient all providers should For each patient all providers should

know:know: CKD Stage & Progression RateCKD Stage & Progression Rate Each Co-morbidityEach Co-morbidity CKD ComplicationsCKD Complications ESRD Preparation & modality plansESRD Preparation & modality plans

3838

Barriers to Timely ReferralBarriers to Timely Referral

Disease RelatedDisease Related• Rapid and/or unexpected onset of renal Rapid and/or unexpected onset of renal

disease with an acute decompensationdisease with an acute decompensation

• An acute decompensation of existing CKDAn acute decompensation of existing CKD

• An intercurrent new diagnosis with An intercurrent new diagnosis with implications on kidney functionimplications on kidney function

3939


Patient RelatedPatient Related• There is NO Primary CareThere is NO Primary Care• The Patient has poor understanding of CKDThe Patient has poor understanding of CKD• The patient has unaddressed fears related to The patient has unaddressed fears related to

CKD and its treatment resulting in avoidanceCKD and its treatment resulting in avoidance• Co-morbid problems with multiple providersCo-morbid problems with multiple providers• Poor socioeconomic resources impacting Poor socioeconomic resources impacting

access to care, travel & family supportaccess to care, travel & family support

4040


Primary Care ProviderPrimary Care Provider• Uneasiness with patient eligibility for Renal Replacement Uneasiness with patient eligibility for Renal Replacement

TherapyTherapy• Not knowing the criteria for referral to nephrologistsNot knowing the criteria for referral to nephrologists• Fear of losing the patient to follow-upFear of losing the patient to follow-up• Past difficulties with poor communication and poor Past difficulties with poor communication and poor

coordinated care with Nephrologistcoordinated care with Nephrologist• Avoidance of potential rebuke from nephrologistsAvoidance of potential rebuke from nephrologists• Sense of failure as disease progresses or conditions are Sense of failure as disease progresses or conditions are

not in controlnot in control

4141


NephrologistNephrologist• Long wait times for appointmentsLong wait times for appointments• Lack of Receptivity for ReferralsLack of Receptivity for Referrals• Poor Organization of Nephrology TeamPoor Organization of Nephrology Team• Poor communication of clinical information and urgency Poor communication of clinical information and urgency

of referral of referral • Poor communicationPoor communication

Dialysis UnitDialysis Unit• Slow response to request for informationSlow response to request for information

Social WorkSocial Work Nutritional SupportNutritional Support Patient EducationPatient Education

4242

Overcoming Barriers to Timely ReferralOvercoming Barriers to Timely Referral

Primary Care Providers should be committed to Primary Care Providers should be committed to screening all high risk patients initially and annuallyscreening all high risk patients initially and annually

Primary Care Providers should be comfortable with:Primary Care Providers should be comfortable with:• The definition of CKD and its StagingThe definition of CKD and its Staging

• The importance of a reduced eGFR and the The importance of a reduced eGFR and the presence of proteinuriapresence of proteinuria

• Recognition that CKD is an independent risk factor Recognition that CKD is an independent risk factor for CVD and Deathfor CVD and Death

4343


Primary Care Providers AND the Primary Care Providers AND the Nephrology Team must:Nephrology Team must:

• Communicate well to manage progression Communicate well to manage progression of disease, CVD and CKD Co-morbidities & of disease, CVD and CKD Co-morbidities & ComplicationsComplications

• Provide “Interwoven Collaboration” and Provide “Interwoven Collaboration” and “Co-Management” for the benefit of the “Co-Management” for the benefit of the patientpatient

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?

4545


The Nephrology Team must:The Nephrology Team must:• Provide PCP support and informationProvide PCP support and information• Manage underlying Renal Conditions to:Manage underlying Renal Conditions to:

Prevent or Delay progressionPrevent or Delay progression Manage CVDManage CVD Manage CKD complicationsManage CKD complications

• AnemiaAnemia• Metabolic Bone DiseaseMetabolic Bone Disease• NutritionNutrition

Provide Modality Options EducationProvide Modality Options Education

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?

4747


The Nephrology team must:The Nephrology team must:• Plan Modality Selection with PatientPlan Modality Selection with Patient

• Insure placement of permanent AccessInsure placement of permanent Access

• Coordinate the Nephrology Multidisciplinary Coordinate the Nephrology Multidisciplinary Education TeamEducation Team

• Coordinate initiation of Renal Replacement Coordinate initiation of Renal Replacement Therapy with the dialysis facilityTherapy with the dialysis facility

4848

TIMELY REFERRALTIMELY REFERRAL

ANDAND

JOINT CLINICAL CAREJOINT CLINICAL CARE

LEAD TOLEAD TO

BETTER PATIENT OUTCOMESBETTER PATIENT OUTCOMES

4949

Timely Referral Reference ListTimely Referral Reference List1.1. Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with

chronic kidney disease referred late to nephrologists: A meta-analysis. chronic kidney disease referred late to nephrologists: A meta-analysis. Am Am J MedJ Med. 2007;120:1063-1070.. 2007;120:1063-1070.

2.2. Richards N, Harris K, Whitfield M, et.al. Primary care-based disease Richards N, Harris K, Whitfield M, et.al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. glomerular filtration rate (eGFR) reporting, improves patient outcomes. NDT.NDT. 2007;0:1-7. 2007;0:1-7.

3.3. Lee BJ, Forbes K. The role of specialists in managing the health of Lee BJ, Forbes K. The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. populations with chronic illness: the example of chronic kidney disease. BMJBMJ. 2009;339:b2395.. 2009;339:b2395.

4.4. Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. to advanced chronic kidney disease. NDT. NDT. 2006;21:2133-2143. 2006;21:2133-2143.

5.5. Kazmi WH, Obrador GT, Khan SS, et.al. Late nephrology referral and Kazmi WH, Obrador GT, Khan SS, et.al. Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score mortality among patients with end-stage renal disease: a propensity score analysis. analysis. NDTNDT. 2004;19:1808-1814.. 2004;19:1808-1814.

6.6. Caskey FJ, Wordsworth S, Ben T, et.al. Early referral and planned initiation Caskey FJ, Wordsworth S, Ben T, et.al. Early referral and planned initiation of dialysis: what impact on quality of life? of dialysis: what impact on quality of life? NDTNDT. 2003;18:1330-1338.. 2003;18:1330-1338.

5050

Timely Referral Reference ListTimely Referral Reference List7.7. Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on

emergent first dialyses, health care costs, and outcome. emergent first dialyses, health care costs, and outcome. AJKD.AJKD. 1998;32(2):278-283.1998;32(2):278-283.

8.8. Go AS, Chertow GM, Fan D, et.al. Chronic kidney disease and the risks of Go AS, Chertow GM, Fan D, et.al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. death, cardiovascular events, and hospitalization. NEJMNEJM. 2004;351:1296-. 2004;351:1296-1305.1305.

9.9. Roubicek C, Brunet P, Huiart L, et.al. Timing of nephrology referral: Roubicek C, Brunet P, Huiart L, et.al. Timing of nephrology referral: Influence on mortality and morbidity. Influence on mortality and morbidity. AJKDAJKD. 2000;36:35-41.. 2000;36:35-41.

10.10. Levey AS, Eckardt KU, Tsukamoto Y, et.al. Definition and classification of Levey AS, Eckardt KU, Tsukamoto Y, et.al. Definition and classification of chronic kidney disease: A position statement from Kidney Disease: chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Improving Global Outcomes (KDIGO). KI. KI. 2005;67:2089-2100. 2005;67:2089-2100.

11.11. Huisman RM. The deadly risk of late referral. Huisman RM. The deadly risk of late referral. NDTNDT. 2004;19:2175-2180.. 2004;19:2175-2180.

12.12. Noble E, Johnson DW, Gray N, et.al. The impact of automated eGFR Noble E, Johnson DW, Gray N, et.al. The impact of automated eGFR reporting and education on nephrology service referrals. reporting and education on nephrology service referrals. NDT. NDT. 2008;23:3845-3850.2008;23:3845-3850.

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kidney disease are referred late to the nephrologist: on causes and kidney disease are referred late to the nephrologist: on causes and proposals for improvement. proposals for improvement. NDTNDT. 2005;20:490-496.. 2005;20:490-496.

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