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