Transcript Slide 1

European Forum for Primary Care
TURKEY
PRIMARY CARE INTEGRATIVE APPROACHE TO KIDNEY
DISEASE INTO PUBLIC HEALTH GLOBAL INITIATIVE
DR: OLIMPIA-MARIA VARVA, MEDICAL SCIENTIST (MS)
FAMILY PHYSICIAN, EFPC, EGPRN
Medicine Dr.Varva - Family Medicine Practice Network
Health Insurance Society, Timisoara, Times, Romania
“Victor Babes” University of Medicine and Pharmacy, Romania
American National Institute of Diabetes and Digestive and Kidney Diseases
PRIMARY CARE INTEGRATIVE APPROACH TO KIDNEY DISEASE INTO PUBLIC HEALTH
GLOBAL INITIATIVE – PCIAKD Project
Dr. OLIMPIA-MARIA VARVA, MS, EFPC, EGPRN
Kidney Disease (KD) is increasingly recognized as a public health problem in all the countries
This project rising from a wide data of primary care research approaches for over 10
years, consists of a clinical study attending health economics developments, based on
the international scientific collaborations and physician’s commitment sub-focused on
the study of kidney disease (KD) into a public health initiative improving global
outcomes and featured health care reform .
KD is a thriving modern trend of all cotemporary
societies whatever medical system would exist:
public assistance, health insurance, national
health services and various combinations of these.
KD as a shadow on the population’s health
because of its worsening health outcomes
evolved onto chronic ill status of a gradual
permanently loss of kidney function over time,
irreversible condition called CKD, CK Failure,
Chronic Renal Insufficiency (CRI). This may be due
habitually, to diabetes, hypertension, slowly
cardiovascular diseases, infectious diseases,
nephritis, traumatisms, under influence of ERF,
genetic or biologic risk factors (BRF).
PRIMARY CARE INTEGRATIVE APPROACH TO KIDNEY DISEASE INTO PUBLIC HEALTH
GLOBAL INITIATIVE - PCIAKD project
DR. OLIMPIA-MARIA VARVA, MS
Why the CKD is a burden of primary and
secondary health care systems ?
CKD diagnostic, preventative measures, treatment require an collaborative
medical activity integrated into a public health developing policy worldwide
 PC settings (family physician’s office/organizations/research networks)
are the places of an integrative works by excellence, of an universal directly
addressability providing preventive and curative services to the population
 GPs (general practitioners) concerned on family medicine or carrying on
PC research studies represent a “mediating structure” between the three
main sectors of healthcare system: primary (GPs, PC research networks)
secondary care (polyclinics, hospitals) and special rehabilitation/care
institutions/services (nursing homes, sanatoriums, healthcare residencies)
 High prevalence of CKD on the globe (USA: 9,6% of no-institutionalized
adults are estimated to have CKD; 11% of Americans would have an early
form of CKD. This study of CKD that consists of a precondition for the life’s
quality, has suggested project approaches to an efficient regional health
care system integrated into public health model policy.
PRIMARY CARE INTEGRATIVE APPROACH TO KIDNEY DISEASE INTO PUBLIC
HEALTH GLOBAL INITIATIVE
DR. OLIMPIA-MARIA VARVA, MS, EGPRN, EFPC
Kidney Disease Improving Global Outcomes (KDIGO) approved
as Statement by the Directors Board of Controversies Conferences,
Endorsement of International Community KD Initiatives since2004/2006.
Conceptual model propose by the USA National Kidney Foundation throughout
KDIGO in 2004, modifying the 2002’s Kidney Disease Outcome Quality Initiative.
KDIGO definition of CKD : 1) Structural/functional abnormalities of the kidneys
more than 3months/equally, such as, Kidney Damage (KD) with/without decreased GFR:
Pathological, Imaging Abnormalities, Renal Tubular Syndromes, Proteinuria, KD Markers
2) GFR (Glomerular Filtration Rate)<60ml/1,73m², with/without KD. Usually, eGFR<60
for 3 months or more defines CKD. An eGFR>90 or equally is considered normal.
KDIGO classification of CKD/Stages/Value of eGFR (ml/min/1,73m²):
 KD with normal or increase in GFR > 90
 KD with mild decrease in GFR
60 - 89
 Moderate reduction in GFR
30 – 59
 Severe reduction in GFR
15 – 29
 Kidney failure
< 15 end-stage renal disease (ESRD)
“CKD is common, harmful and treatable” – World Kidney Day, annually, since March 2006
Primary Care Integrative Approach to Kidney Disease into Public Health Global Initiative
Dr. Olimpia-Maria Varva, MS,EGPRN, EFPC
AIMS of PCIAKD project underlying the health strategies ’purposes of high-developed
and collaborative countries, based on health economics analyses to carrying with highimpact programs for the soundness of an aging contemporary society like as, the
prevention of KD/CKD, the control of RF, the consciousness of the population and
community’s broad professionals, as regards the CKD, early diagnosis to improving
outcomes and therapy: 1) To identifying the RF, the correlative risk concerning KD, the
risk groups for further targeted programs on CKD.
2) To diagnose CKD based on KDIGO definition among the patients with RFs as:
diabetes, cardiovascular disease, family history of KD, renal chronic infections, chronic
inflammations, cancers, older age, exposure to toxic drugs, other ERF, BRF for KD.
3) To identifying population subgroups at risk for barriers to continuously health care
and treatment, as referring to Regular Source of Ambulatory Care (RSAC) consisting of
PC settings correlated with secondary health care services from polyclinics and hospitals.
Primary Care Integrative Approach to Kidney Disease into Public Health Global Initiative
Dr.Olimpia-Maria Varva, MS, EGPRN, EFPC
METHODS: randomized population-based study on 800 patients aged: 18-70 years and over,
from a data associated with psychiatric disorders collected longitudinally since 2002’s (CI: 95%,
attrition bias: 20%). A - clinical part developed at the level of RSAC (PC settings,/PC research
networks and the specialist –collaborations from polyclinics and hospitals); B – special part for
laboratories, all forms of juridical or administrative existence being accepted, validated,
in accordance with the consent form for patients and health care professionals to consciously
understanding what their decisions, attitudes and actions mean. Screening tests are means of
research, measures-outcomes of the primary and secondary health care provision. Tests used :
1) Testing the urine for proteins: albumin >300 mg/g or urinary red blood/hematuria, cellular casts
2) Testing a blood sample, only one measurement of the cretinine-serum expressed in micro-mol/l
to estimate GFR through MDRD Study equation or CKD-EPI equation, specified race (black, white or
other) sex for adults aged > 18 years /equally, Creatinine in mg% or micromol/l .CKD-EPI equation
is more accurate for GFR>60ml/min, adults age>18 years /equally, especially between 60-120ml/min.
Research Rules/Regulations: a) MDRD-derived eGFR for patients older than 70 years
b)
<60ml/min/1,73m² have been reporting as impared kidney’s function
c)
, have to be expressed as “>60ml/min/1,73m²/equally”
d)
should be used only for patients with stable creatinine concentrations
e) GFR estimating equations are less in accordance with hospitalized patients/ abnormal kidney
function. Creatinine Clearance (24 hours urine collection) is used for the patients with abnormal
basal creatinine production: obese,malnutrition,paraplegics,amputees, unusual dietary intake.
Primary Care Integrative Approach to Kidney Disease into Public Health Global Initiative
Dr .Olimpia-Maria Varva, MS, EGPRN, EFPC
Renal Function Evaluation (GFR) through MDRD Study equation and CKD-EPI equations
IDMS
MDRD
Study
equation
CKD-EPI
as a single
equation
CKD-EPI
equation
race/sex/cr
• GFR (mL/min/1.73 m2) = 175 × (Scr)-1.154 × (Age)-0.203 × (0.742 /female)
×(1.212/Race), for Creatinine methods calibrated/traceable to an IDMS (isotope
dilution mass spectrometry) reference, race: African American
• GFR = 141 × min (Scr /κ, 1)α × max(Scr /κ, 1)-1.209 × 0.993Age × 1.018/female ×
1.159/ black, Scr is serum creatinine in mg/dL, κ is 0.7 for females, 0.9 for males, α
is -0.329 for females, -0.411 for males, min = the minimum of Scr /κ or 1, max = the
maximum of Scr /κ or 1.
•GFR = 144 × (Scr/0.7)-0.329 × (0.993)Age Scr (mg/dL), ≤ 0.7, Female, White/other
•GFR = 144 × (Scr/0.7)-1.209 × (0.993)Age Scr (mg/dL) > 0.7 Female, White/other
•GFR = 141 × (Scr/0.9)-0.411 × (0.993)Age Scr (mg/dL) ≤ 0.9 Male, White/other
• GFR = 141 × (Scr/0.9)-1.209 × (0.993)Age Scr (mg/dL) > 0,9 Male, White/other
CKD-EPI equations
Scr µmol/L ≤ 61.9 , F, white/other: GFR = 144 × (Scr/61.9)-0.329 × (0.993)Age
Scr µmol/L > 61,9, F, white/other: GFR = 144 × (Scr/61.9)-1.209 ×(0.993)Age
Scr µmol/L ≤ 79.6, M, white/other: GFR = 141 × (Scr/79.6)-0.411 × (0.993)Age
Scr µmol/L > 79,6, M, white/other: GFR = 141 × (Scr/79.6)-1.209 × (0.993)Age
PRIMARY CARE INTEGRATIVE APPROACH TO KIDNEY DISEASE INTO
PUBLIC HEALTH GLOBAL INITIATIVE
DR. OLIMPIA-MARIA VARVA, MS
The Study of CKD Suggested Integrative Approaches to a Public Health Model System
Results on Clinic Assessment of Integrated Developments
1) 48% of patients with CKD excluding ESRD - diabetes, 91% -hypertension
46% - atherosclerotic heart disease.
2) CKD associated with adverse health outcomes : increasing risk for death, CVD,
fractures, bone structural modification, infections, cognitive impairments, frailty.
3) African-Americans are 3 to 5 times more likely to suffering from ESRD than white
Americans (meta-analyses).
Results on Health Economics
Prevention and slowing progression of CKD is cost–effective: the rate of
decline in GFR decreased by 10% and 30% for eGFR of 60 ml/min/1,73 m²
or less, the gross direct cumulative health care savings over the following
10 years amount to $18,56 and $60,61 billion respectively. Modeling of
great life savings determining more effective possibilities for prevention,
diagnosis or slowing the progression of CKD, is influenced by different
factors (behavioral RF, ERF)such as, financial behavior, educational,
cultural levels, societal traditions, socio-economic development.
Primary Care Integrative Approach to Kidney Disease into Public Health Global Initiative
DR.OLIMPIA-MARIA VARVA, MS, EFPC, EGPRN
Dr.Olimpia-Maria
Varva, MS, EFPC, EGPRN
CONCLUSIONS
CONCLUSIONS
 CKD patients are at high risk of CVD and cerebrovascular disease, they are
more likely to die of CVD than to develop ESRD/terminal renal failure.
 CVD patients often develop CKD during the course of their disease; a great
proportion of people whose death and disability are attributed to CVD have
KD, as well (inefficient currently cause research evaluations).
 GFR from the serum creatinine /MDRD Study eqquation and CKD-EPI
equations, on this PCIAKD project in addition to KDIGO initiative, is used as a single
kidney function to guiding the detection, management, evaluation of CKD, dosage of
medication excreted by the kidneys, to improving the general knowledge of renal
function and drug dosing, that is likely consisting of the innovative approaches to
delivery of high quality health care integrated into public health policy .
 This ongoing PIAKD project constitutes an effective insight into contribution of specific
KD to the global burden disease, knowing that CKD is the 12th cause of death and the 17th
cause of disability determining ,approximately 15010,167 disability-adjusted life
years and 1850,000 deaths annualy, on the reports of World Health Organization (WHO).
 A reform could represent a heavy financial burden and risk for the many small urban
or rural communities that already are in a stressful economic situations. Cooperation
Reform Proposal enhancing the role of RSC would represent a challenge in
health care strategy, based on the previous reforms, taking elements and learning
from the same policy areas of advanced health care systems and ideology of Europe,
Americas, Asia with their bringing up.