Transcript Document
Public Health Nutrition and
Chronic Kidney Disease
ASTPHND 2011
Salt Lake City
Andrew S. Narva, MD
U.S. Department of Health
and Human Services
National Institute of Health
Public Health Nutrition and CKD
Public health burden of chronic kidney disease
Barriers to improving outcomes in CKD
Patient and provider education is a component of
systems change
Diet education materials for people with CKD and
their providers
Age-adjusted* prevalence of diagnosed diabetes, by race or
ethnicity, United States, 1997−2008
10
Percent
8
6
4
Blacks
Mex/Amer
2
0
*Based
Whites
on the 2000 US standard population
Source: NHIS and National Diabetes Surveillance System
www.cdc.gov/diabetes/statistics
Puerto Ricans
Cubans
Diabetes is Driving the Increase in ESRD
Incident ESRD patients; rates adjusted for age, gender, & race.
USRDS ADR, 2008
Health Disparities in Kidney Disease
Rate per million population
Af Am
N Am
Hispanic
Asian
Non-Hispanic
White
Incident ESRD patients; rates adjusted for age & gender.
USRDS ADR, 2007
National Kidney Foundation (NKF) Definition of CKD
Kidney Function. Glomerular filtration rate
(GFR) <60 mL/min/ 1.73 m2 for 3
months with or without kidney damage
OR
Kidney damage for 3 months, with or
without decreased GFR, manifested by
either
− Pathologic abnormalities; or
− Markers of kidney damage, i.e., proteinuria
(National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1):S1-S266)
Diabetes (DM) and Hypertension (HTN) Often Coexist in CKD
Distribution of CKD, HTN, & diabetic patients in Medicare population, 2004.
USRDS ADR, 2006
Even Early Referral Is Too Late to Intervene
GFR (mL/min/1.732)
100
No Treatment
Current Treatment
Early Treatment
10
Kidney Failure
0
4
7
Time (years)
9
11
Challenges to Improving CKD Care
CKD remains under diagnosed
Implementation of recommended care is
poor
Many clinicians feel inadequately educated
– Uncertain about how to interpret diagnostic tests
– Unclear about clinical recommendations
– Low confidence in their ability to successfully
manage CKD
– Indications for, and process of, referral poorly
defined
HP2010: Increase the proportion of treated chronic
kidney failure patients who have received counseling on
nutrition, treatment choices, and cardiovascular care 12
months before the start of renal replacement therapy.
Goal = 45%
Percent of incident ESRD patients (2006)
USRDS 2008 ADR
Lack of Appropriate Care/Late Referral
More rapid progression
Worse health status at time of initiation
Higher mortality after starting RRT
Decreased access to transplant
Defining optimal care is not the primary
barrier to improved outcomes.
Delivering appropriate care to those
who need it is the problem we must
overcome.
The National Kidney Disease Education Program
NKDEP aims to reduce the morbidity and
mortality caused by kidney disease and its
complications by:
Improving early detection of CKD
Facilitating identification of patients at greatest
risk for progression to kidney failure
Promoting evidence-based interventions to slow
progression of kidney disease
Supporting the coordination of Federal responses
to CKD
What Can Primary Care Providers Do?
Recognize and test at-risk patients:
monitor eGFR and UACR
Screen for anemia (Hgb), malnutrition
(albumin), metabolic bone disease (Ca,
Phos., PTH)
Treat cardiovascular risk, especially with
smokers and hypercholesterolemia
Refer to dietitian for nutritional guidance
Educate patients about CKD and treatment
Brochures for At-Risk Audiences
Quick Reference on UACR and GFR
GFR Urine Albumin Tear Pad
GFR Pad –
Provider reference
(back)
CKD Brochure
New Materials
CKD Brochure
New Materials
CKD Brochure
New Materials
CKD Brochure
New Materials
CKD Brochure
New Materials
CKD Brochure
CKD Brochure
Dietitian Outreach
Goal: Transfer specialty knowledge from CKD diet
expert RDs to general practice dietitians
An NKDEP initiative since May 2007
– Several rounds of research with dietitians
– Comprehensive materials and outreach strategies
– Key partner: American Dietetic Association
Two key elements
– Nutrition materials
– Certificate Program in CKD Nutrition Management
New Suite of Nutrition Materials
Helps RDs effectively provide medical nutrition
therapy (MNT) to CKD patients not on dialysis
Role of MNT in CKD management
– Can help slow progression, treat complications
– RDs can deliver in primary care setting
NKDEP materials fill unmet needs
– Concise content and “clean” design
– Free, downloadable, reproducible
– Patient materials: 7th grade reading level or lower
Published May 2010
Diet Report Card
New Suite of Nutrition Materials
All providers can use to explain basic CKD diet
changes using a stepped approach
http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf
Factsheet on reading the food label
New Suite of Nutrition Materials
Certificate Program in CKD Nutrition Management
A comprehensive Certificate Training Program for
RDs who want to improve their expertise in CKD
– CKD novices as well as those looking to “brush up”
NKDEP developing content on key topics
–
–
–
–
–
–
Burden of disease
Identifying and monitoring CKD
Slowing progression – albuminuria, CVD, diabetes
Complications, including mineral bone disorders
Key nutrients
Renal replacement therapy
ADA will transform into an online training program
– An official ADA Certificate Training Program; members
will earn certificate and CE credits for completing
– Scheduled for Sept 2011 release
– ADA will promote to all members
Kidney Disease Education Kit
Prompted by MIPPA KDE benefit
A new six-lesson kit for patient educators
– Jointly conceived by NKDEP and IHS
– Everything to develop and deliver tailored lessons;
for professionals educating low-literacy patients
– Features materials from NKDEP, NIDDK, NIH, CMS
Lessons reflect key (and CMS-specified) content
– Kidney disease basics
– Managing your kidney disease
– What happens when kidney disease gets worse?
– Choices for treating kidney failure
– Getting ready for treatment
– Living with kidney failure
Kidney Disease Education Kit
Each lesson includes
– Learning objectives
– Suggested lesson outline
– Supplemental “take away” resources for patients
– Additional background/clinical info for educators
– Sample outcome assessment questions (in
compliance with the new MIPPA benefit)
Helping Pharmacists Educate People with CKD
A new brochure to caution people
with CKD about medicines
– Some medicines may be harmful
– Some doses will need to change
– Talk with your pharmacist
Developed in conjunction with
Pharmacy Working Group
Encouraging Urinalysis for Children At Risk
Various diseases and conditions
put children at risk for CKD
Routine urinalysis is no longer
recommended by AAP
Educational materials for
pediatric offices that encourage
urine testing for at-risk children
Developing Q&A fact sheet for
providers
Nephrology Referral Form
Created interactive form in response to requests
– Facilitates transfer of information about patients
– Allows for more informed and immediate evaluation
by nephrologists
– Based on IHS form
Form includes various fields
– Comorbidities
– Lab results
– Family history
Supporting information explains why items are
important for evaluation
Nephrology Referral
Regardless of when you refer, consider:
• Obtaining preliminary evaluation (e.g.
ultrasound, screening serologies)
• Providing consultant with patient history
including serial measures of renal function
Like all successful relationships, this requires work
and good communication. Be explicit about what
you want out of this relationship. Help your
referring nephrologist be the consultant you need
him/her to be
Lessons Learned
CKD is part of primary care
Changing patterns of care requires changing “the
system” (CCM)
Improvement in care results from changes
implemented by physicians and non-physician health
professionals
Implemented through diabetes care delivery
system; not specialty clinic based
Surveillance and prevention are part of multisystem
chronic disease control
Emphasis on ensuring that patient received care
from competent and interested individual, not
referral
Incident Rates of ESRD due to Diabetes 1980-2008
per million population, by age, gender, race, & ethnicity
600.0
500.0
400.0
White DM
300.0
African American DM
Native American DM
Asian DM
200.0
100.0
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0.0
Improving CKD Care
Improving the care of people with CKD requires
changing clinical practice in settings where high risk
populations are served
Providers change their practice based on scientific
evidence and the expectations of their patients
Improving care of patients prior to referral to
subspecialty care is necessary to provide better
longterm outcomes and to promote selfmanagement
Nutrition professionals are key to improving care for
people with diabetes and kidney disease
NKDEP will collaborate closely with dietitians to
develop effective models for CKD intervention
Questions & Comments: [email protected]
nkdep.nih.gov