Transcript PowerPoint Presentation - EMPOWER
Slide 1
Slide 2
Goal - Objective
Educate nephrology
community about new PreESRD classes and current
pilot programs in the
greater Houston area
Slide 3
At the end of this presentation the
reader will be able to answer
• Why Kidney Education is important in Chronic Kidney
Disease or CKD
• What is a community-based education program
• What information is included in CKD education program
• How does early CKD education program benefit patient
outcomes and the physician’s practice
• What patients say about early CKD education
• How one can participate or set up a program
Slide 4
Chronic Kidney Disease in the US
• Over 20 Million Americans have some degree of renal
insufficiency….1 in 8 people.
• 20 million others are at risk
• Hypertension & Diabetes are the leading causes of
kidney failure
– 23% of all Americans have hypertension
– 16 million Americans have diabetes
• Both are independent risk factors for cardiovascular
disease
Slide 5
CKD EDUCATION
Knowledge is Power…for us and our patients.
To educate patients is the highest form of
care we can give. It empowers our patients
to make changes big and small to improve
their health and quality of life. It empowers
them with control and information to feel
more relaxed in an anxiety producing
situation of CKD transition to ESRD.
Slide 6
Slide 7
Projection for ESRD Population
USRDS ADR 2008
Slide 8
Incidence by Race
2008
Slide 9
African Americans Develop ESRD at
a Younger Age
Slide 10
New Conditions of Coverage
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ESRD Medicare Reform
– Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 –
MIPPA)
– CKD education is recognized by CMS
– Reimbursement to nephrologists who provide chronic kidney disease
education
Physicians Must Educate CKD Patients on:
– Kidney disease
– Access choices and issues
– ESRD Treatment options
Physician performance is based on
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Influenze vaccine
Blood Pressure control
Referral for an AV fistula
Laboratory values – Ca, PO4, PTH, Lipid profile
*Best physicians educate on much more.
Slide 11
Why Educate?
• Why…Educate? And When? The earlier the better….Start
education by stage 2 or 3 to have the biggest impact.
• One reason is we must. The new cfc regulations are requiring pt
education on kidney disease, treatment options, accesses. I don’t
think this man had his “Save my vessels” class information or he
would not allow anyone to stick him up and down both arms.
• Another reason: It is smart use of patients time and energy. Pts
who use this information stay healthier longer and start dialysis in a
better place both physically and mentally. If they come to us
healthier – they start healthier in ESRD with better Outcomes, more
choices and better quality of life.
• They make better choices: more open to dialysis options when
starting dialysis not an emergency. When pt education is done
ahead of starting dialysis Home dialysis is chosen more often.
Slide 12
What is community-based education?
• Patient education program that includes:
– Multidisciplinary coaching program
– Stage-specific education
– Easy education referral process
– Follow-up with patients and physicians
– Sessions are free for patients and guests
Slide 13
Find a comfortable location and time.
Slide 14
Location
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The course does not need to be held
in Maui, although it would be nice. A
church down the street with a large
conference room works fine.
Experience with renal treatment
options training reveaed we would
gain more patients in a non-medical
location.
And our participants have reinforced
that concept.
The Houston Community-based CKD
program sponsored by DaVita, known
as EMPOWER, has had nearly 200
pts/family/friends
The patient feedback is very positive
Slide 15
What is Community-Based Education?
Multidisciplinary Coaching
Multidisciplinary coaching
program
• Inform patients about their
kidney health
• Improve quality of life
• Preserve renal function
• Help patients identify the best
treatment choice for their
lifestyle
• Tools to organize and track their
health care
• Health Diary
Slide 16
Multidisciplinary education
• Multidisciplinary coaching program can make a difference.
• A nurse, a dietitian and a social worker attend each class to present the
information and answer questions.
• The goal is help patients learn as much as they can about kidney health.
• Informed patients are less anxious and more equipped to effectively
follow their treatment plan, preserve renal function and improve their
quality of life.
• CKD education helps patients to identify the best treatment choice for
their lifestyle and reinforce early fistula placement.
Slide 17
Benefits of early intervention and
education
• Delay or prevent the worsening of cardiovascular
disease, hypertension and diabetes
• Delay or prevent the progression to chronic
kidney disease
• Improve outcomes if kidney replacement therapy
ever becomes necessary
• Psychologically prepare one for kidney disease
• Reduce health care costs
• Keep people employed and out of the hospital
Slide 18
Tools Provided
• An initial postcard and quarterly e-newsletters
• Valuable tools from a well-regarded website,
http://davita.com
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GFR calculator and tracker
500 CKD recipes
DaVita Diet Helper
CKD videos
More.
• The health diary is a tool given to each CKD patient and
is designed to help organize and track their health care.
We recommend that patients utilize their Health Diary
for all provider visits to maintain continuity of care.
Slide 19
TOOLS FOR BETTER CARE
Slide 20
Health Diary
Resource for the patients
• Patient information
• Healthcare phone numbers
• History and Physical
• Medication list
• Lab work
• Diabetes and Hypertension
• Glossary
Slide 21
The health diary
• Both the patients and the doctors really like this diary.
• Not only is it a great resource but it gives the patients a
central location to keep their valuable health information.
• They just ask for copies and file it away.
• When they go to any health professional, they have it.
• Even with Hurricane Ike – pick it up and go.
• The doctors like it when they can see all the information.
• Best from patients is the questions to ask the doctor.
• Reminds them of the importance of the medication, BP or
lab results.
Slide 22
What stage am I?
This is the question most patients ask. We review kidney function and the stages of
kidney disease. We review how this calculation works and that is based on both
kidneys. We discuss that the stages are generally progressive but that patients can
impact or slow the progression of kidney disease with diet, medications and healthy
behaviors. Patients need to be informed and ask lots of questions of their health care
team and physicians.
• Stage 1 – GFR ≥ 90 cc/min/1.73m2
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Kidney Damage with normal or high GFR
• Stage 2 – GFR – 60 to 89 cc/min/1.73m2
– Kidney Damage with mildly decreased GFR
• Stage 3 – GFR – 30 to 59 cc/min/1.73m2
– Moderate decreased GFR
• Stage 4 – GFR – 15 to 29 cc/min/1.73m2
– Severely decreased GFR
• Stage 5 – GFR - < 15 cc/min/1.73m2
– Kidney failure
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 23
Glomerular filtration rate
• The serum creatinine by itself is a very POOR way to assess
kidney disease.
• It does not take into account variation in muscle mass,
nutritional status or body habitus
• GFR measures how well your kidneys filter waste products,
which tells your doctor how well your kidneys are working.
• In 2002, the National Kidney Foundation began
recommending the use of GFR instead of just serum
creatinine for a more accurate measurement of kidney
function.
• GFR is calculated from your blood creatinine, age, race and
gender.
From AAKP Healthline, 2009 – Stephen Z. Fadem
Slide 24
Assessment of kidney disease
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Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD),
but in following its progress.
Although there are various ways to do this, the simplest is the MDRD GFR (glomerular filtration rate) which can be calculated
using a patient’s age, race, gender and a laboratory test, known as the serum creatinine. The muscles are in a constant state
of being broken down and being repaired.
The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day.
While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors
mentioned above necessary.
This equation was derived from a large study published in 1994 that looked at how the modification of dietary protein would
affect renal disease – hence Modification of Diet in Renal Disease (MDRD).
This study required a very accurate measurement of kidney function. The investigators noticed the mathematical
relationships between the accurately measured GFR, age, race, creatinine and gender, and derived the MDRD study
equations still in use today.
It is also referred to as the eGFR. This GFR is used to determine what stage of kidney disease one has, stages 1 and 2
being very mild, with GFRs above 60 ml/min.
When the GFR is greater than 60, other markers of kidney function such as an abnormal urine or abnormal ultrasound are
necessary for making the diagnosis. When the GFR is less than 60 for greater than three months, it indicates the presence of
CKD.
Once the GFR is calculated, and repeated in 3 months we also need to look at other markers of Kidney disease.
While this is necessary if the GFR is > 60, we also recommend testing for markers strongly in everyone since it
helps us reverse the reversible and get a better diagnosis. Markers include the renal ultrasound and the urinalysis.
Although the calculation involves some complicated math tricks, it was programmed for the Internet shortly after it was
discovered, and is on the Web at www.mdrd.com.
The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators.
Many laboratories routinely report the MDRD GFR along with the serum creatinine value. As more and more laboratories
standardize their serum creatinine measurements to the National Institute of Standards, the equation will change slightly, but
that change is also programmed and available at www.mdrd.com.
When using the program, simply key in your serum creatinine, age, race and gender and your GFR value will appear. The
site will also calculate your kidney disease stage. It is important that you personally keep track of your serum creatinine and
GFR values.
From AAKP Healthline, 2009 – Stephen Z. Fadem
Slide 25
You have heard about Cystatin C
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Serum creatinine has a drawback in the measurement of glomerular
filtration rate (GFR) in that it may vary according to muscle mass.
Cystatin C is a 13 kilodalton protein that is filtered by the glomerulus and
reabsorbed and metabolized by tubular cells. The amount that is excreted
into the urine is negligible. Its production is very steady, and not dependent
on muscle mass.
It has been proposed as an alternate marker for estimating GFR by Dr. Joe
Coresh.
An elevated serum cystatin C level may indicate a worse cardiovascular risk
in patients with the metabolic syndrome. (18456039) .
The literature is emerging, and showing that it has benefit as a marker. Here
are two formulae that might be useful in demonstrating the relationships
between serum creatinine and serum cystatin C
The serum cystatin C calculation is found at http://touchcalc.com
Joe Coresh recommends averaging the Cystatin C and the MDRD GFR
Slide 26
Clinical evaluation of patients at
increased risk for CKD
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All Patients
Measurement of blood pressure
Serum creatinine to estimate GFR
Protein to creatinine or albumin to creatinine
ratio in first AM or random untimed spot urine
specimen
• Examination of the urine sediment or dipstick
for red blood cells and white blood cells
Slide 27
Stage-Specific Education
Taking Control of Kidney Disease
Living with Stage 3 and Early Stage 4 CKD
Focus on preserving renal function
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Normal Kidney functions / Kidney Disease
Control of co-morbidities / Diabetes / HTN
Diet and medication
Heart healthy behaviors
Preserving veins
Insurance questions
Questions to ask physician
Slide 28
Treatment of CKD
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Treat the underlying disease
Treat associated problems
Slowing the loss of kidney function
Prevent heart disease
Reduce complications
Preparation for dialysis/transplantation
Kidney transplant or dialysis
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 29
Slide 30
Definition of Chronic Kidney Disease
• Chronic kidney disease is defined as either
kidney damage or GFR < 60 cc/min/1.73m2 for
≥ 3 months.
• Kidney damage is defined as pathologic
abnormalities or markers of damage, including
abnormalities in blood or urine tests or
imaging
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 31
Clinical Practice Guidelines for Management
of Hypertension in CKD
Type of Kidney Disease
Blood Pressure
Target
(mm Hg)
Preferred Agents
for CKD, with or
without
Hypertension
Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target
ACE inhibitor
or ARB
Diuretic preferred,
then BB or CCB
Diabetic Kidney Disease
Nondiabetic Kidney
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
Nondiabetic Kidney
Disease with Spot Urine
Total Protein-to-Creatinine
ratio <200 mg/g
Kidney Disease in Kidney
Transplant Recipient
<130/80
None preferred
Diuretic preferred,
then ACE inhibitor,
ARB, BB or CCB
CCB, diuretic, BB,
ACE inhibitor, ARB
Slide 32
Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage
Description
GFR
Evaluation
Management
At increased
risk
Test for CKD
Risk factor management
1
Kidney
damage with
normal or
GFR
>90
Diagnosis
Comorbid
conditions
CVD and CVD
risk factors
Specific therapy, based on diagnosis
Management of comorbid conditions
Treatment of CVD and CVD risk factors
2
Kidney
damage with
mild GFR
60-89
Rate of
progression
Slowing rate of loss of kidney function 1
3
Moderate
GFR
30-59
Complications
Prevention and treatment of complications
4
Severe GFR
15-29
Preparation for kidney replacement therapy
Referral to Nephrologist
5
Kidney Failure
<15
Kidney replacement therapy
1
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
Slide 33
Stages 1 and 2: Preventing Heart Disease in CKD
• Traditional cv risk
factors
• Non traditional risk
factors
Slide 34
How Can You Protect Yourself Against Heart Disease And High
Blood Pressure?
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Get regular medical checkups
Control your blood pressure
Monitor your blood pressure weekly
Check your cholesterol regularly – watch saturated fats and fructose
Watch your diet - SALT
Regular doctor visits
Blood pressure - 130/80
It make take several medications
Don’t smoke
If you choose to drink, do so in moderation
Exercise regularly
Manage stress
Slide 35
Slide 36
Traditional Risk Factors
• Smoking
• Cholesterol
• Obesity
• Family History
Slide 37
Non Traditional Risk
Factors
• Inflammation
• Mineral-bone
disorder
• Anemia
Slide 38
ACEs and ARBs
• These drugs are critical to care starting in Stage 1 and 2
• ACES and ARBs have a compound effect on blocking
the renin-angiotensin system.
• The goal is to lower the blood pressure to 120 mm Hg
and to titrate proteinuria.
• Contraindications include allergy and bilateral renal
artery stenosis
• Potassium levels should be monitored closely when
patients are on ACES or ARBS
• (Beta blockers, NSAIDS, ACES and ARBS can raise serum
potassium)
Slide 39
Blood Pressure Is Poorly Controlled in
Patients With CKD
Slide 40
Inflammation
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Associated with CKD
Atherosclerosis
Vascular calcification
Statins not helpful in CKD5
CRP not diagnostic
MIA
Slide 41
Exercise And Kidney Care
• Talk to your doctor about starting an
exercise program that’s right for you.
• Exercise can help you improve physical
functioning and emotional well-being,
increase physical stamina, improve blood
pressure and reduce the risk of heart
disease, lower cholesterol, help you sleep
better and control body weight.
• Incorporating consistent aerobic exercise,
even taking a 20-minute walk, can help
especially if your CKD is a result of
hypertension or diabetes.
Slide 42
Watch meds and therapies
Here are some examples:
• Avoid Metformin in Stage 3 and beyond
• Contrast media –
– Nephrogenic sclerosing fibrosis may occur with an
MRI due to galadinium contrast – so procedure
should be done without this contrast agent
– Iodine can be nephrotoxic – and patients should
be well hydrated pre procedure
• NSAIDS should not be given to kidney patients
Slide 43
Diet
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Sodium - 100 mmoles
Lipids - pre dialysis
Carbohydrates - Diabetes
Proteins - MDRD Trial
Potassium - watch because of ARBs
and ACE inhibitors
Slide 44
Nutritional Tips For Healthy Kidneys
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In order to help maintain healthy kidneys it is important to eat properly
Keep track of daily calories
Limit total fat
Watch high fructose corn syrup
Watch excess proteins and phosphorus - Monitor the amount of protein
eaten
You may need to watch potassium - Learn about potassium
Your dietitian can help you with recipes that fit your needs
Control salt intake
Take care of your bones – exercise and take vitamin D
Be sure to get enough iron
Watch fluid intake
Understand your nutritional plan
Slide 45
Stage 3 – Medical Focus
• CKD MBD – Metabolic bone disease
• Acidosis - Bicarbonate
• Anemia – Erythropoietin
Class reinforces
bone and
heart healthy diet.
Slide 46
Stage 3
• a. Cardiovascular risks and therapy –
• b. Preparation:
1. Anemia
2. Acidosis
3. Blood pressure/ACEs and ARBS
4. Inflammation
5. Diet
6. Modality choice
7. Access preparation
• c. Modalities of therapy
stay the course
Slide 47
Preparation
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Anemia
Acidosis
Blood pressure - ACES & ARBS
Inflammation
Diet
Modality Choice
Access Preparation
Slide 48
Anemia in CKD
• Anemia management with EPO since 1990s • Keep Hct < 42
– N Eng J Med 339:584-90, 1998
• Keep hgb 10 - 12
– CHOIR
• N Eng J Med 355:2071-2084, 2006.
• 34% worse when hgb target is 13.5 than 11.2
– CREATE
• N Eng J Med 355:2084-2098, 2006
• 22% worse when hgb is 13-15 than 10.5-11.5
• Check Iron levels and correct first
• EPO can be given in the office - monitor blood work
Slide 49
EPO
RBC
RBC PRECURSOR
Slide 50
Acidosis
• Increased protein catabolism of amino acids
• Inhibition of protein synthesis can cause a low
albumin
• Accelerates renal osteodystrophy
• Modulates vitamin D and parathyroid hormone levels
• Evokes insulin resistance
Slide 51
Albumin Synthesis
• Chronic acidosis impairs albumin
synthesis and causes negative nitrogen
balance
– JCI 95:35-45, 1995
• Albumin - major marker for nutrition
• Low serum albumin - risk factor for poor
dialysis outcome
• It is advisable not to restrict dietary
protein once the serum albumin level
starts to fall
Slide 52
Metabolic Acidosis
REGENERATES
BUFFER
The kidney has a major responsibility to
eliminate and buffer acids. In renal
failure these acids accumulate.
When the clearance falls below 25 cc
per minute, the accumulated acids
cause loss of appetite. Protein stores
and albumin fall, and muscle is broken
down and used as a nutrient.
It is not clear whether correction of
acidosis with bicarbonate solution is
helpful, but there is consensus that as
renal function deteriorates and albumin
falls, the diet needs to be adjusted, and
if that does not work, dialysis is needed
to correct the acidosis.
SECRETES
ACIDS
Slide 53
Benefits of anemia correction
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Improved work and aerobic capacity
Reduced cardiovascular complications
Reduced hospitalizations
Decreased mortality
Improved quality of life
Improved cognition
Improved sexual function
Besarab. Am J Kidney Dis. 2000;36 (suppl 3):S13.
Fink. Am J Kidney Dis. 2001;37:348.
Kausz. Am J Kidney Dis. 2000;36(suppl 3):S39.
Slide 54
Vascular Calcification
• Kidney damage causes decreased phosphorus
excretion. This stimulates phosphotonins to
increase phosphorus excretion.
• Phosphotonins and kidney damage decrease the
activation of vitamin D
• This weakens muscles, decreasing bone strength.
• This decreases the calcium depositing in bone, and
along with phosphorus – leads to changes in blood
vessel cells
• Calcium deposits in blood vessels
• Inflammation and Hyperlipidemia (metabolic
syndrome) make this worse
• High fructose corn syrup makes metabolic
syndrome works
DIET IS IMPORTANT!!!
Slide 55
Chronic Kidney Disease
And Mineral Bone Disorder
• Too much phosphorus and
• Damaged kidneys do not produce enough vitamin D
• Vitamin D helps maintain calcium levels which keep
bones strong
• Calcium may build up in blood vessels with CKD
• Without enough vitamin D, you are more likely to
have weak bones that may break easily
Slide 56
How to Protect Against
CKD MBD?
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Vitamin D level
Parathyroid hormone level
Ergocalciferol over the counter
Vitamin D is probably for everyone –regargless
of stage
• At later stages you might need an active form of
vitamin D
• Exercise and diet management
• The doctor may want to check for vascular
calcification
Slide 57
What Effect Can Chronic Kidney Disease Have On
The Body?
• Heart disease
• High blood pressure
• Vitamin D deficiency - bone and mineral
disorder
• Anemia
• Malnutrition and low serum albumin
• Acid buildup
Slide 58
Recommendations
• Inflammation - Dental hygiene, fiber in early stages,
exercise, keep trim. If we develop a stomach illness like
helicobacter, get it treated. Keep toenails trim.
• Atherosclerosis - Check the serum cholesterol, LDL,
VLDL, HDL - use diet, exercise, medications (statins,
usually) to keep these numbers in the proper range
Slide 59
PHOSPHORUS AND VITMIN D
• CKD-MBD - Avoid excess
phosphorus in the diet and
have vitamin D levels
checked. If low, start on
ergocalciferol or
cholecalciferol. Later, an
active vitamin D like
calcitriol, doxercalciferol or
paricalcitol will be needed
• Vascular calcification - As the
disease progresses, restrict
phosphorus and use a
phosphate binder.
Slide 60
Stage-Specific Education
Making Healthy Choices
Preparing for dialysis for Stages 4 and 5 CKD
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Symptoms of Uremia
Controlled dialysis start
CKD and dialysis diet
Control of co-morbidities – DM/HTN
Medications – Call your Nephrologist
Access – No to catheters, Yes to fistulas – Vein Map
All treatment choices
Insurance issues
Slide 61
Stage 4 and 5 CKD Class
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Making Healthy Choices
Preparing for dialysis in later Stage 4 to early Stage 5 Chronic Kidney Disease
This is the longer class due to the number of questions we have from the patients and family members.
We focus on maintaining the patients kidney health as long as possible but also educate the patients on the symptoms of uremia and the transition
process to ESRD.
Class detail:
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What kidneys do
What causes kidney disease – Symptoms of Uremia – Nausea and vomiting, Taste changes, Swelling, SOB, Itching, Lack of concentration and memory issues.
Preparing for dialysis – Preventing the “Crash and Burn” admission to dialysis. No one knows the exact moment but working with your doctor will help to get
the time right for you. We can delay but not forever without it damaging your health due to malnutrition or heart or stroke.
Managing your health through diet. Review diet changes at the end of stage4, especially related to low protein, potassium, phosphorus, salt and fluid. What
the stage 5 diet is for the different treatment modalities. Most of the pts enjoy knowing their diet will get more protein on ESRD than in stage 4.
Control of DM and HTN – Protect your heart and vasculature as well as your kidney function never stops. Dialysis patients do not die from dialysis. They die
from infection and Cardiac/Vascular disease due to DM and HTN. BP and BS – Heart healthy behaviors. Diet, Exercise, Stop smoking. We all know it ….
Common medicines for people with kidney disease Phosphorus binders, Vitamin D, Renal Vitamins, Bicarbonate, EPO. Stay off magnesium, aluminum
products. Call doctor for any new meds prescribed or OTC or from other doctors. Stay away from IV dye contrast.
Access information and planning early with stage4 – No to catheters – yes to fistula’s. Lots of info about best choice and get it now. Fistulas may take
months to mature. Be sure to get vein mapping done prior to surgery for improved success with fistulas. You don’t take a trip without a map – you don’t
want surgery without a map either. CVC catheters have more infections, clotting, hospitalizations and deaths. Be sure to remove CVC catheters as soon as
possible. Getting a CVC catheter may be necessary for a short while for initial dialysis but getting your fistula now will shorten that time and may save your
life.
An in-depth look at all of treatment choices:
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Peritoneal Dialysis (PD)
Home Hemodialysis (HHD)
Hemodialysis (HD)
Nocturnal hemodialysis
Self-Care hemodialysis
Transplant
Conservative treatment
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Choosing the right treatment for your lifestyle, especially if you want to continue working or have active life.
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Understanding Insurance– state and federal insurances and when to apply for secondary insurance especially if want transplant due to medication
cost. We have saved patients money by assisting with insurance questions.
Slide 62
Modality Choice
• PD - 7% of population
– Preference values higher than for HD 74-69
– Physicians in practice 11 years along more likely to refer to PD
– More likely recommended to men, people with residual function,
with weight less than 200 lb and the absence of diabetes
• Hong Kong
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Half the mortality
5 staff for 300 patients
Less mortality because residual function preservation
Loss of residual function is a cardiovascular risk factor
Slide 63
Stage 4 – Medical focus
• Modalities – Incenter and Home Dialysis,
Transplant or Conservative therapy
• Referral for access – Vein mapping and surgery
• Serum Albumin – Prevent malnutrition
• Continue other therapies – ACE or ARB
• Anemia – Erythropoietin therapy
Slide 64
Stage 5 – but not yet on dialysis
• One-on-one modality options
– Conservative treatment – Medical, diet management,
Hospice Assistance
– Transplant – refer early
– Home therapies (Peritoneal, Home Hemodialysis)
– In-center therapies (ICHD, Nocturnal, Self-Care)
– Physicians focus - Therapy choice/transition
Slide 65
PD References – Early referral helps
1. Bass EB, Wills S, Fink NE, et al: How strong are patients' preferences
in choices between dialysis modalities and doses? Am J Kidney Dis
44:695-705, 2004
2. Winkelmayer WC, Glynn RJ, Levin R, et al: Late referral and modality
choice in end-stage renal disease. Kidney Int 60:1547-1554, 2001
3. Lin C-L, Chuang F-R, Wu C-F, et al: Early referral as an independent
predictor of clinical outcome in end-stage renal disease on hemodialysis
and continuous ambulatory peritoneal dialysis. Ren Fail 26:531-537, 2004
4. Thamer M, Hwang W, Fink NE, et al: US nephrologists'
recommendation of dialysis modality: results of a national survey. Am J
Kidney Dis 36:1155-1165, 2000
5. Wang AY-M, Wang M, Woo J, et al: Inflammation, residual kidney
function, and cardiac hypertrophy are interrelated and combine adversely
to enhance mortality and cardiovascular death risk of peritoneal dialysis
patients. J Am Soc Nephrol 15:2186-2194, 2004
Slide 66
Home Hemodialysis
• Short - 2 hour per day X 6 days per week
• Long - Overnight X 6
• Prospective patients
– Visit during CKD
– Logistics, location and type of equipment
• NxStage - 70 pounds
• 2008K@home (BabyK)
– May need plumbing and electrical
• Need ample storage
• Need for vascular access
• Need a partner
Slide 67
Nocturnal Home Hemodialysis
• May be able to stop binders
• May need supplemental
phosphorus
• Less hypertensives
• Less epo
• Less fluid restriction
• Nocturnal in-center for select
patients
Slide 68
Access Preparation
• Arteriovenous fistula 1966
• Lasts many years
– Veins arterialize
– Arteries expand
– Capillaries and larger
vessels absorb shock
– Graft transmits shock and
lasts only around 18
months
Slide 69
Slide 70
Easy Education Referral Process
Easy education referral process
– Identify patient
– Inform patient
– Order education
– Refer & Fax
Empower Team
– Call patient
– Schedule class
Slide 71
How the program works
•
The CKD community-based process begins and ends with the office team
•
First, the office will need to identify patients who are Stage 3, 4 and 5 that need CKD education.
•
Next, refer those patients for education by completing and faxing the referral form (show form).
The patients are notified, enrolled in a class and called to remind them of class approximately 1
week prior. The day of class, patients will complete an attendance form and evaluate the class.
This data will be recorded at the call center.
•
The recorded data allows the educators to provide the office with information affecting patients
and practice. We can extract the number of your patients who have attended a class, which class
they have attended, their stage of CKD, access preparation for dialysis, type of access, modality
choice just to name a few of the components.
•
Ultimately, the goal is help patients to take control of their CKD and, if dialysis is needed, that they
begin dialysis healthier and prepared.
Slide 72
Communication is crucial
• Nephrologist receives a letter from CKD educator
– Indicates what class patient attended
– High lights “no shows”
– Lists concerns and/or modality interests if expressed
• CKD patient receives a phone call from CKD
educator & education materials
– Assess for additional teaching
– Answer questions and provide resources
– Initial postcard mailing & quarterly e-newsletters
Slide 73
Follow-up
• We will provide a follow up letter for every patient that is educated,
indicating which class the patient attended; what material was
covered; any concerns they expressed and for late stage patients,
their modality interest.
• We maintain telephonic contact with your patients referred and
educated to develop an understanding of their education needs and
to help support them through additional classes and guidance to
resources. As previously mentioned, an initial postcard and
quarterly e-newsletter are delivered to introduce the valuable tools
that a well known website, DaVita.com offers – GFR calculator and
tracker, over 500 CKD recipies, DaVita Diet Helper, CKD videos and
more.
• All medical questions will be referred the physician.
Slide 74
Summary of Stages
•
•
Pre-ESRD patient education does better when referred early to an education program. An
educated patient will adhere better to the therapy that slows progression of disease
In the early stages, 1 and 2 – it is important to control for diabetes and blood pressure.
Generally an ACE or an ARB is recommended
–
–
–
•
By Stage 3 patients are starting to manifest signs of anemia, metabolic acidosis and early
metabolic bone disease.
–
•
They need to have laboratory studies – Ca, PO4, PTH, lipid profile
By stage 4, the serum phosphorus is elevated. Vitamin D analogs may be necessary.
Phosphorus control can be done with diet, but most likely at this stage will require a binder.
–
–
•
Vitamin D management should start early in the course of disease
Some recommend restricting the use of process foods early
In addition to diet and blood pressure control with an ACE or ARB, control of glucose is valuable in
diabetics
Patients have other choices beside in center hemodialyssi. In stage 4 it is important to discuss options
such as home hemodialysis and home peritoneal dialysis. Patients who have been educated are more
likely to choose these modalities, and are more satisfied with them.
The patient should be evaluated early for a permanent vascular access, and depending upon the
modality chosen, a fistula or peritoneal dialysis access placed.
Pre-ESRD classes lead to a smoother transition into a dialysis (stage 5) regimen.
Slide 75
CKD Education Benefits
• Feel more engaged and in-control
Patients
• Slow the progression of renal disease
• Healthier on First Date of Dialysis
• Free education to patients and community
Physician
• Physician able to compliment own education
• Saves physician time, resources and money
• Patients learn of laws that protect them
Taxpayers
• Patients stay employed and insured
• Decrease burden on Medicare
Slide 76
Win – Win - Win
• CKD Education is a Win-Win-Win program. It is provided to
patients and the community at no cost or obligation.
• Patients who attend are empowered to take control of their
kidney health. They are provided with the tools they need
to preserve renal function.
• Physicians are able to compliment their own excellent
education, saving them time, resources and money.
• Finally, by helping patient to understand the laws that
protect them, we can help keep patients employed and
maintain their insurance, thus decreasing the burden on
Medicare.
Slide 77
How Do You Participate?
• Establish CKD Education as part of your practice
• Protocol: Educate all patients Stages 3,4 and 5
• Process:
– Identify eligible patient during office visit
– Patient communication (discussion and flyer)
– Clinician orders education need using:
• Sticky note
• Referral form
– Office staff completes and faxes referral form
– CKD education team contacts patient and schedules
class
Slide 78
How to work with a physician
office
• Every physician practice operates differently. The 3 biggest
things to walk away from the meeting with are:
– The physicians commitment to refer their CKD pts (get granular
as to are they willing to send Stage 3 pts as well as 4 and 5 or
just 4 and 5 which is fine too)
– A solid detailed process in writing on how the doctor is going to
notify the administrative team of the order for education and
how the administrative team is going to send the fax referral. If
the Physicians are willing to set a "protocol" or "standing order"
that states the admin staff is to refer all CKD pts (or all Stage 4/5
pts) that is great because it takes the step of the physicians
remembering to refer for education out of the mix.
• An agreement on how often you and the administrative
staff will touch base to make sure everything is good.
Slide 79
Early CKD Education Benefit Patient’s?
What Houston CKD patients say about CKD Education:
– “I wish I had this information sooner”
– “I will really study my lab values and check my diet”
– “I will talk to my doctor about my NSAID’s and
decongestants”
– “The health diary is excellent. I really like the glossary”
– “As a family member, I think my father (patient) will feel
more comfortable about the possibility of dialysis”.
Success Stories…
Slide 80
Success Stories
• Patients need information and change can happen
– Pt went from stage 4 to stage 3 and thanked us for the
class….
• Office staff tell of a pt they were dreading to tell about
time to start dialysis
– Pt said “It’s OK, I know about it”. The office nurse was
amazed.
• Access placements before starting dialysis
– As they should be
• Insurances saved or supplemental insurance obtained
before ESRD.
Slide 81
The End
Slide 2
Goal - Objective
Educate nephrology
community about new PreESRD classes and current
pilot programs in the
greater Houston area
Slide 3
At the end of this presentation the
reader will be able to answer
• Why Kidney Education is important in Chronic Kidney
Disease or CKD
• What is a community-based education program
• What information is included in CKD education program
• How does early CKD education program benefit patient
outcomes and the physician’s practice
• What patients say about early CKD education
• How one can participate or set up a program
Slide 4
Chronic Kidney Disease in the US
• Over 20 Million Americans have some degree of renal
insufficiency….1 in 8 people.
• 20 million others are at risk
• Hypertension & Diabetes are the leading causes of
kidney failure
– 23% of all Americans have hypertension
– 16 million Americans have diabetes
• Both are independent risk factors for cardiovascular
disease
Slide 5
CKD EDUCATION
Knowledge is Power…for us and our patients.
To educate patients is the highest form of
care we can give. It empowers our patients
to make changes big and small to improve
their health and quality of life. It empowers
them with control and information to feel
more relaxed in an anxiety producing
situation of CKD transition to ESRD.
Slide 6
Slide 7
Projection for ESRD Population
USRDS ADR 2008
Slide 8
Incidence by Race
2008
Slide 9
African Americans Develop ESRD at
a Younger Age
Slide 10
New Conditions of Coverage
•
•
•
ESRD Medicare Reform
– Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 –
MIPPA)
– CKD education is recognized by CMS
– Reimbursement to nephrologists who provide chronic kidney disease
education
Physicians Must Educate CKD Patients on:
– Kidney disease
– Access choices and issues
– ESRD Treatment options
Physician performance is based on
–
–
–
–
Influenze vaccine
Blood Pressure control
Referral for an AV fistula
Laboratory values – Ca, PO4, PTH, Lipid profile
*Best physicians educate on much more.
Slide 11
Why Educate?
• Why…Educate? And When? The earlier the better….Start
education by stage 2 or 3 to have the biggest impact.
• One reason is we must. The new cfc regulations are requiring pt
education on kidney disease, treatment options, accesses. I don’t
think this man had his “Save my vessels” class information or he
would not allow anyone to stick him up and down both arms.
• Another reason: It is smart use of patients time and energy. Pts
who use this information stay healthier longer and start dialysis in a
better place both physically and mentally. If they come to us
healthier – they start healthier in ESRD with better Outcomes, more
choices and better quality of life.
• They make better choices: more open to dialysis options when
starting dialysis not an emergency. When pt education is done
ahead of starting dialysis Home dialysis is chosen more often.
Slide 12
What is community-based education?
• Patient education program that includes:
– Multidisciplinary coaching program
– Stage-specific education
– Easy education referral process
– Follow-up with patients and physicians
– Sessions are free for patients and guests
Slide 13
Find a comfortable location and time.
Slide 14
Location
•
•
•
•
•
The course does not need to be held
in Maui, although it would be nice. A
church down the street with a large
conference room works fine.
Experience with renal treatment
options training reveaed we would
gain more patients in a non-medical
location.
And our participants have reinforced
that concept.
The Houston Community-based CKD
program sponsored by DaVita, known
as EMPOWER, has had nearly 200
pts/family/friends
The patient feedback is very positive
Slide 15
What is Community-Based Education?
Multidisciplinary Coaching
Multidisciplinary coaching
program
• Inform patients about their
kidney health
• Improve quality of life
• Preserve renal function
• Help patients identify the best
treatment choice for their
lifestyle
• Tools to organize and track their
health care
• Health Diary
Slide 16
Multidisciplinary education
• Multidisciplinary coaching program can make a difference.
• A nurse, a dietitian and a social worker attend each class to present the
information and answer questions.
• The goal is help patients learn as much as they can about kidney health.
• Informed patients are less anxious and more equipped to effectively
follow their treatment plan, preserve renal function and improve their
quality of life.
• CKD education helps patients to identify the best treatment choice for
their lifestyle and reinforce early fistula placement.
Slide 17
Benefits of early intervention and
education
• Delay or prevent the worsening of cardiovascular
disease, hypertension and diabetes
• Delay or prevent the progression to chronic
kidney disease
• Improve outcomes if kidney replacement therapy
ever becomes necessary
• Psychologically prepare one for kidney disease
• Reduce health care costs
• Keep people employed and out of the hospital
Slide 18
Tools Provided
• An initial postcard and quarterly e-newsletters
• Valuable tools from a well-regarded website,
http://davita.com
–
–
–
–
–
GFR calculator and tracker
500 CKD recipes
DaVita Diet Helper
CKD videos
More.
• The health diary is a tool given to each CKD patient and
is designed to help organize and track their health care.
We recommend that patients utilize their Health Diary
for all provider visits to maintain continuity of care.
Slide 19
TOOLS FOR BETTER CARE
Slide 20
Health Diary
Resource for the patients
• Patient information
• Healthcare phone numbers
• History and Physical
• Medication list
• Lab work
• Diabetes and Hypertension
• Glossary
Slide 21
The health diary
• Both the patients and the doctors really like this diary.
• Not only is it a great resource but it gives the patients a
central location to keep their valuable health information.
• They just ask for copies and file it away.
• When they go to any health professional, they have it.
• Even with Hurricane Ike – pick it up and go.
• The doctors like it when they can see all the information.
• Best from patients is the questions to ask the doctor.
• Reminds them of the importance of the medication, BP or
lab results.
Slide 22
What stage am I?
This is the question most patients ask. We review kidney function and the stages of
kidney disease. We review how this calculation works and that is based on both
kidneys. We discuss that the stages are generally progressive but that patients can
impact or slow the progression of kidney disease with diet, medications and healthy
behaviors. Patients need to be informed and ask lots of questions of their health care
team and physicians.
• Stage 1 – GFR ≥ 90 cc/min/1.73m2
–
Kidney Damage with normal or high GFR
• Stage 2 – GFR – 60 to 89 cc/min/1.73m2
– Kidney Damage with mildly decreased GFR
• Stage 3 – GFR – 30 to 59 cc/min/1.73m2
– Moderate decreased GFR
• Stage 4 – GFR – 15 to 29 cc/min/1.73m2
– Severely decreased GFR
• Stage 5 – GFR - < 15 cc/min/1.73m2
– Kidney failure
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 23
Glomerular filtration rate
• The serum creatinine by itself is a very POOR way to assess
kidney disease.
• It does not take into account variation in muscle mass,
nutritional status or body habitus
• GFR measures how well your kidneys filter waste products,
which tells your doctor how well your kidneys are working.
• In 2002, the National Kidney Foundation began
recommending the use of GFR instead of just serum
creatinine for a more accurate measurement of kidney
function.
• GFR is calculated from your blood creatinine, age, race and
gender.
From AAKP Healthline, 2009 – Stephen Z. Fadem
Slide 24
Assessment of kidney disease
•
•
•
•
•
•
•
•
•
•
•
•
•
Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD),
but in following its progress.
Although there are various ways to do this, the simplest is the MDRD GFR (glomerular filtration rate) which can be calculated
using a patient’s age, race, gender and a laboratory test, known as the serum creatinine. The muscles are in a constant state
of being broken down and being repaired.
The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day.
While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors
mentioned above necessary.
This equation was derived from a large study published in 1994 that looked at how the modification of dietary protein would
affect renal disease – hence Modification of Diet in Renal Disease (MDRD).
This study required a very accurate measurement of kidney function. The investigators noticed the mathematical
relationships between the accurately measured GFR, age, race, creatinine and gender, and derived the MDRD study
equations still in use today.
It is also referred to as the eGFR. This GFR is used to determine what stage of kidney disease one has, stages 1 and 2
being very mild, with GFRs above 60 ml/min.
When the GFR is greater than 60, other markers of kidney function such as an abnormal urine or abnormal ultrasound are
necessary for making the diagnosis. When the GFR is less than 60 for greater than three months, it indicates the presence of
CKD.
Once the GFR is calculated, and repeated in 3 months we also need to look at other markers of Kidney disease.
While this is necessary if the GFR is > 60, we also recommend testing for markers strongly in everyone since it
helps us reverse the reversible and get a better diagnosis. Markers include the renal ultrasound and the urinalysis.
Although the calculation involves some complicated math tricks, it was programmed for the Internet shortly after it was
discovered, and is on the Web at www.mdrd.com.
The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators.
Many laboratories routinely report the MDRD GFR along with the serum creatinine value. As more and more laboratories
standardize their serum creatinine measurements to the National Institute of Standards, the equation will change slightly, but
that change is also programmed and available at www.mdrd.com.
When using the program, simply key in your serum creatinine, age, race and gender and your GFR value will appear. The
site will also calculate your kidney disease stage. It is important that you personally keep track of your serum creatinine and
GFR values.
From AAKP Healthline, 2009 – Stephen Z. Fadem
Slide 25
You have heard about Cystatin C
•
•
•
•
•
•
•
Serum creatinine has a drawback in the measurement of glomerular
filtration rate (GFR) in that it may vary according to muscle mass.
Cystatin C is a 13 kilodalton protein that is filtered by the glomerulus and
reabsorbed and metabolized by tubular cells. The amount that is excreted
into the urine is negligible. Its production is very steady, and not dependent
on muscle mass.
It has been proposed as an alternate marker for estimating GFR by Dr. Joe
Coresh.
An elevated serum cystatin C level may indicate a worse cardiovascular risk
in patients with the metabolic syndrome. (18456039) .
The literature is emerging, and showing that it has benefit as a marker. Here
are two formulae that might be useful in demonstrating the relationships
between serum creatinine and serum cystatin C
The serum cystatin C calculation is found at http://touchcalc.com
Joe Coresh recommends averaging the Cystatin C and the MDRD GFR
Slide 26
Clinical evaluation of patients at
increased risk for CKD
•
•
•
•
All Patients
Measurement of blood pressure
Serum creatinine to estimate GFR
Protein to creatinine or albumin to creatinine
ratio in first AM or random untimed spot urine
specimen
• Examination of the urine sediment or dipstick
for red blood cells and white blood cells
Slide 27
Stage-Specific Education
Taking Control of Kidney Disease
Living with Stage 3 and Early Stage 4 CKD
Focus on preserving renal function
•
•
•
•
•
•
•
Normal Kidney functions / Kidney Disease
Control of co-morbidities / Diabetes / HTN
Diet and medication
Heart healthy behaviors
Preserving veins
Insurance questions
Questions to ask physician
Slide 28
Treatment of CKD
•
•
•
•
•
•
•
Treat the underlying disease
Treat associated problems
Slowing the loss of kidney function
Prevent heart disease
Reduce complications
Preparation for dialysis/transplantation
Kidney transplant or dialysis
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 29
Slide 30
Definition of Chronic Kidney Disease
• Chronic kidney disease is defined as either
kidney damage or GFR < 60 cc/min/1.73m2 for
≥ 3 months.
• Kidney damage is defined as pathologic
abnormalities or markers of damage, including
abnormalities in blood or urine tests or
imaging
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
Slide 31
Clinical Practice Guidelines for Management
of Hypertension in CKD
Type of Kidney Disease
Blood Pressure
Target
(mm Hg)
Preferred Agents
for CKD, with or
without
Hypertension
Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target
ACE inhibitor
or ARB
Diuretic preferred,
then BB or CCB
Diabetic Kidney Disease
Nondiabetic Kidney
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
Nondiabetic Kidney
Disease with Spot Urine
Total Protein-to-Creatinine
ratio <200 mg/g
Kidney Disease in Kidney
Transplant Recipient
<130/80
None preferred
Diuretic preferred,
then ACE inhibitor,
ARB, BB or CCB
CCB, diuretic, BB,
ACE inhibitor, ARB
Slide 32
Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage
Description
GFR
Evaluation
Management
At increased
risk
Test for CKD
Risk factor management
1
Kidney
damage with
normal or
GFR
>90
Diagnosis
Comorbid
conditions
CVD and CVD
risk factors
Specific therapy, based on diagnosis
Management of comorbid conditions
Treatment of CVD and CVD risk factors
2
Kidney
damage with
mild GFR
60-89
Rate of
progression
Slowing rate of loss of kidney function 1
3
Moderate
GFR
30-59
Complications
Prevention and treatment of complications
4
Severe GFR
15-29
Preparation for kidney replacement therapy
Referral to Nephrologist
5
Kidney Failure
<15
Kidney replacement therapy
1
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
Slide 33
Stages 1 and 2: Preventing Heart Disease in CKD
• Traditional cv risk
factors
• Non traditional risk
factors
Slide 34
How Can You Protect Yourself Against Heart Disease And High
Blood Pressure?
•
•
•
•
•
•
•
•
•
•
•
•
Get regular medical checkups
Control your blood pressure
Monitor your blood pressure weekly
Check your cholesterol regularly – watch saturated fats and fructose
Watch your diet - SALT
Regular doctor visits
Blood pressure - 130/80
It make take several medications
Don’t smoke
If you choose to drink, do so in moderation
Exercise regularly
Manage stress
Slide 35
Slide 36
Traditional Risk Factors
• Smoking
• Cholesterol
• Obesity
• Family History
Slide 37
Non Traditional Risk
Factors
• Inflammation
• Mineral-bone
disorder
• Anemia
Slide 38
ACEs and ARBs
• These drugs are critical to care starting in Stage 1 and 2
• ACES and ARBs have a compound effect on blocking
the renin-angiotensin system.
• The goal is to lower the blood pressure to 120 mm Hg
and to titrate proteinuria.
• Contraindications include allergy and bilateral renal
artery stenosis
• Potassium levels should be monitored closely when
patients are on ACES or ARBS
• (Beta blockers, NSAIDS, ACES and ARBS can raise serum
potassium)
Slide 39
Blood Pressure Is Poorly Controlled in
Patients With CKD
Slide 40
Inflammation
•
•
•
•
•
•
Associated with CKD
Atherosclerosis
Vascular calcification
Statins not helpful in CKD5
CRP not diagnostic
MIA
Slide 41
Exercise And Kidney Care
• Talk to your doctor about starting an
exercise program that’s right for you.
• Exercise can help you improve physical
functioning and emotional well-being,
increase physical stamina, improve blood
pressure and reduce the risk of heart
disease, lower cholesterol, help you sleep
better and control body weight.
• Incorporating consistent aerobic exercise,
even taking a 20-minute walk, can help
especially if your CKD is a result of
hypertension or diabetes.
Slide 42
Watch meds and therapies
Here are some examples:
• Avoid Metformin in Stage 3 and beyond
• Contrast media –
– Nephrogenic sclerosing fibrosis may occur with an
MRI due to galadinium contrast – so procedure
should be done without this contrast agent
– Iodine can be nephrotoxic – and patients should
be well hydrated pre procedure
• NSAIDS should not be given to kidney patients
Slide 43
Diet
•
•
•
•
•
Sodium - 100 mmoles
Lipids - pre dialysis
Carbohydrates - Diabetes
Proteins - MDRD Trial
Potassium - watch because of ARBs
and ACE inhibitors
Slide 44
Nutritional Tips For Healthy Kidneys
•
•
•
•
•
•
•
•
•
•
•
•
In order to help maintain healthy kidneys it is important to eat properly
Keep track of daily calories
Limit total fat
Watch high fructose corn syrup
Watch excess proteins and phosphorus - Monitor the amount of protein
eaten
You may need to watch potassium - Learn about potassium
Your dietitian can help you with recipes that fit your needs
Control salt intake
Take care of your bones – exercise and take vitamin D
Be sure to get enough iron
Watch fluid intake
Understand your nutritional plan
Slide 45
Stage 3 – Medical Focus
• CKD MBD – Metabolic bone disease
• Acidosis - Bicarbonate
• Anemia – Erythropoietin
Class reinforces
bone and
heart healthy diet.
Slide 46
Stage 3
• a. Cardiovascular risks and therapy –
• b. Preparation:
1. Anemia
2. Acidosis
3. Blood pressure/ACEs and ARBS
4. Inflammation
5. Diet
6. Modality choice
7. Access preparation
• c. Modalities of therapy
stay the course
Slide 47
Preparation
•
•
•
•
•
•
•
Anemia
Acidosis
Blood pressure - ACES & ARBS
Inflammation
Diet
Modality Choice
Access Preparation
Slide 48
Anemia in CKD
• Anemia management with EPO since 1990s • Keep Hct < 42
– N Eng J Med 339:584-90, 1998
• Keep hgb 10 - 12
– CHOIR
• N Eng J Med 355:2071-2084, 2006.
• 34% worse when hgb target is 13.5 than 11.2
– CREATE
• N Eng J Med 355:2084-2098, 2006
• 22% worse when hgb is 13-15 than 10.5-11.5
• Check Iron levels and correct first
• EPO can be given in the office - monitor blood work
Slide 49
EPO
RBC
RBC PRECURSOR
Slide 50
Acidosis
• Increased protein catabolism of amino acids
• Inhibition of protein synthesis can cause a low
albumin
• Accelerates renal osteodystrophy
• Modulates vitamin D and parathyroid hormone levels
• Evokes insulin resistance
Slide 51
Albumin Synthesis
• Chronic acidosis impairs albumin
synthesis and causes negative nitrogen
balance
– JCI 95:35-45, 1995
• Albumin - major marker for nutrition
• Low serum albumin - risk factor for poor
dialysis outcome
• It is advisable not to restrict dietary
protein once the serum albumin level
starts to fall
Slide 52
Metabolic Acidosis
REGENERATES
BUFFER
The kidney has a major responsibility to
eliminate and buffer acids. In renal
failure these acids accumulate.
When the clearance falls below 25 cc
per minute, the accumulated acids
cause loss of appetite. Protein stores
and albumin fall, and muscle is broken
down and used as a nutrient.
It is not clear whether correction of
acidosis with bicarbonate solution is
helpful, but there is consensus that as
renal function deteriorates and albumin
falls, the diet needs to be adjusted, and
if that does not work, dialysis is needed
to correct the acidosis.
SECRETES
ACIDS
Slide 53
Benefits of anemia correction
•
•
•
•
•
•
•
Improved work and aerobic capacity
Reduced cardiovascular complications
Reduced hospitalizations
Decreased mortality
Improved quality of life
Improved cognition
Improved sexual function
Besarab. Am J Kidney Dis. 2000;36 (suppl 3):S13.
Fink. Am J Kidney Dis. 2001;37:348.
Kausz. Am J Kidney Dis. 2000;36(suppl 3):S39.
Slide 54
Vascular Calcification
• Kidney damage causes decreased phosphorus
excretion. This stimulates phosphotonins to
increase phosphorus excretion.
• Phosphotonins and kidney damage decrease the
activation of vitamin D
• This weakens muscles, decreasing bone strength.
• This decreases the calcium depositing in bone, and
along with phosphorus – leads to changes in blood
vessel cells
• Calcium deposits in blood vessels
• Inflammation and Hyperlipidemia (metabolic
syndrome) make this worse
• High fructose corn syrup makes metabolic
syndrome works
DIET IS IMPORTANT!!!
Slide 55
Chronic Kidney Disease
And Mineral Bone Disorder
• Too much phosphorus and
• Damaged kidneys do not produce enough vitamin D
• Vitamin D helps maintain calcium levels which keep
bones strong
• Calcium may build up in blood vessels with CKD
• Without enough vitamin D, you are more likely to
have weak bones that may break easily
Slide 56
How to Protect Against
CKD MBD?
•
•
•
•
Vitamin D level
Parathyroid hormone level
Ergocalciferol over the counter
Vitamin D is probably for everyone –regargless
of stage
• At later stages you might need an active form of
vitamin D
• Exercise and diet management
• The doctor may want to check for vascular
calcification
Slide 57
What Effect Can Chronic Kidney Disease Have On
The Body?
• Heart disease
• High blood pressure
• Vitamin D deficiency - bone and mineral
disorder
• Anemia
• Malnutrition and low serum albumin
• Acid buildup
Slide 58
Recommendations
• Inflammation - Dental hygiene, fiber in early stages,
exercise, keep trim. If we develop a stomach illness like
helicobacter, get it treated. Keep toenails trim.
• Atherosclerosis - Check the serum cholesterol, LDL,
VLDL, HDL - use diet, exercise, medications (statins,
usually) to keep these numbers in the proper range
Slide 59
PHOSPHORUS AND VITMIN D
• CKD-MBD - Avoid excess
phosphorus in the diet and
have vitamin D levels
checked. If low, start on
ergocalciferol or
cholecalciferol. Later, an
active vitamin D like
calcitriol, doxercalciferol or
paricalcitol will be needed
• Vascular calcification - As the
disease progresses, restrict
phosphorus and use a
phosphate binder.
Slide 60
Stage-Specific Education
Making Healthy Choices
Preparing for dialysis for Stages 4 and 5 CKD
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Symptoms of Uremia
Controlled dialysis start
CKD and dialysis diet
Control of co-morbidities – DM/HTN
Medications – Call your Nephrologist
Access – No to catheters, Yes to fistulas – Vein Map
All treatment choices
Insurance issues
Slide 61
Stage 4 and 5 CKD Class
•
•
•
•
•
Making Healthy Choices
Preparing for dialysis in later Stage 4 to early Stage 5 Chronic Kidney Disease
This is the longer class due to the number of questions we have from the patients and family members.
We focus on maintaining the patients kidney health as long as possible but also educate the patients on the symptoms of uremia and the transition
process to ESRD.
Class detail:
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What kidneys do
What causes kidney disease – Symptoms of Uremia – Nausea and vomiting, Taste changes, Swelling, SOB, Itching, Lack of concentration and memory issues.
Preparing for dialysis – Preventing the “Crash and Burn” admission to dialysis. No one knows the exact moment but working with your doctor will help to get
the time right for you. We can delay but not forever without it damaging your health due to malnutrition or heart or stroke.
Managing your health through diet. Review diet changes at the end of stage4, especially related to low protein, potassium, phosphorus, salt and fluid. What
the stage 5 diet is for the different treatment modalities. Most of the pts enjoy knowing their diet will get more protein on ESRD than in stage 4.
Control of DM and HTN – Protect your heart and vasculature as well as your kidney function never stops. Dialysis patients do not die from dialysis. They die
from infection and Cardiac/Vascular disease due to DM and HTN. BP and BS – Heart healthy behaviors. Diet, Exercise, Stop smoking. We all know it ….
Common medicines for people with kidney disease Phosphorus binders, Vitamin D, Renal Vitamins, Bicarbonate, EPO. Stay off magnesium, aluminum
products. Call doctor for any new meds prescribed or OTC or from other doctors. Stay away from IV dye contrast.
Access information and planning early with stage4 – No to catheters – yes to fistula’s. Lots of info about best choice and get it now. Fistulas may take
months to mature. Be sure to get vein mapping done prior to surgery for improved success with fistulas. You don’t take a trip without a map – you don’t
want surgery without a map either. CVC catheters have more infections, clotting, hospitalizations and deaths. Be sure to remove CVC catheters as soon as
possible. Getting a CVC catheter may be necessary for a short while for initial dialysis but getting your fistula now will shorten that time and may save your
life.
An in-depth look at all of treatment choices:
•
•
•
•
•
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Peritoneal Dialysis (PD)
Home Hemodialysis (HHD)
Hemodialysis (HD)
Nocturnal hemodialysis
Self-Care hemodialysis
Transplant
Conservative treatment
•
Choosing the right treatment for your lifestyle, especially if you want to continue working or have active life.
•
Understanding Insurance– state and federal insurances and when to apply for secondary insurance especially if want transplant due to medication
cost. We have saved patients money by assisting with insurance questions.
Slide 62
Modality Choice
• PD - 7% of population
– Preference values higher than for HD 74-69
– Physicians in practice 11 years along more likely to refer to PD
– More likely recommended to men, people with residual function,
with weight less than 200 lb and the absence of diabetes
• Hong Kong
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Half the mortality
5 staff for 300 patients
Less mortality because residual function preservation
Loss of residual function is a cardiovascular risk factor
Slide 63
Stage 4 – Medical focus
• Modalities – Incenter and Home Dialysis,
Transplant or Conservative therapy
• Referral for access – Vein mapping and surgery
• Serum Albumin – Prevent malnutrition
• Continue other therapies – ACE or ARB
• Anemia – Erythropoietin therapy
Slide 64
Stage 5 – but not yet on dialysis
• One-on-one modality options
– Conservative treatment – Medical, diet management,
Hospice Assistance
– Transplant – refer early
– Home therapies (Peritoneal, Home Hemodialysis)
– In-center therapies (ICHD, Nocturnal, Self-Care)
– Physicians focus - Therapy choice/transition
Slide 65
PD References – Early referral helps
1. Bass EB, Wills S, Fink NE, et al: How strong are patients' preferences
in choices between dialysis modalities and doses? Am J Kidney Dis
44:695-705, 2004
2. Winkelmayer WC, Glynn RJ, Levin R, et al: Late referral and modality
choice in end-stage renal disease. Kidney Int 60:1547-1554, 2001
3. Lin C-L, Chuang F-R, Wu C-F, et al: Early referral as an independent
predictor of clinical outcome in end-stage renal disease on hemodialysis
and continuous ambulatory peritoneal dialysis. Ren Fail 26:531-537, 2004
4. Thamer M, Hwang W, Fink NE, et al: US nephrologists'
recommendation of dialysis modality: results of a national survey. Am J
Kidney Dis 36:1155-1165, 2000
5. Wang AY-M, Wang M, Woo J, et al: Inflammation, residual kidney
function, and cardiac hypertrophy are interrelated and combine adversely
to enhance mortality and cardiovascular death risk of peritoneal dialysis
patients. J Am Soc Nephrol 15:2186-2194, 2004
Slide 66
Home Hemodialysis
• Short - 2 hour per day X 6 days per week
• Long - Overnight X 6
• Prospective patients
– Visit during CKD
– Logistics, location and type of equipment
• NxStage - 70 pounds
• 2008K@home (BabyK)
– May need plumbing and electrical
• Need ample storage
• Need for vascular access
• Need a partner
Slide 67
Nocturnal Home Hemodialysis
• May be able to stop binders
• May need supplemental
phosphorus
• Less hypertensives
• Less epo
• Less fluid restriction
• Nocturnal in-center for select
patients
Slide 68
Access Preparation
• Arteriovenous fistula 1966
• Lasts many years
– Veins arterialize
– Arteries expand
– Capillaries and larger
vessels absorb shock
– Graft transmits shock and
lasts only around 18
months
Slide 69
Slide 70
Easy Education Referral Process
Easy education referral process
– Identify patient
– Inform patient
– Order education
– Refer & Fax
Empower Team
– Call patient
– Schedule class
Slide 71
How the program works
•
The CKD community-based process begins and ends with the office team
•
First, the office will need to identify patients who are Stage 3, 4 and 5 that need CKD education.
•
Next, refer those patients for education by completing and faxing the referral form (show form).
The patients are notified, enrolled in a class and called to remind them of class approximately 1
week prior. The day of class, patients will complete an attendance form and evaluate the class.
This data will be recorded at the call center.
•
The recorded data allows the educators to provide the office with information affecting patients
and practice. We can extract the number of your patients who have attended a class, which class
they have attended, their stage of CKD, access preparation for dialysis, type of access, modality
choice just to name a few of the components.
•
Ultimately, the goal is help patients to take control of their CKD and, if dialysis is needed, that they
begin dialysis healthier and prepared.
Slide 72
Communication is crucial
• Nephrologist receives a letter from CKD educator
– Indicates what class patient attended
– High lights “no shows”
– Lists concerns and/or modality interests if expressed
• CKD patient receives a phone call from CKD
educator & education materials
– Assess for additional teaching
– Answer questions and provide resources
– Initial postcard mailing & quarterly e-newsletters
Slide 73
Follow-up
• We will provide a follow up letter for every patient that is educated,
indicating which class the patient attended; what material was
covered; any concerns they expressed and for late stage patients,
their modality interest.
• We maintain telephonic contact with your patients referred and
educated to develop an understanding of their education needs and
to help support them through additional classes and guidance to
resources. As previously mentioned, an initial postcard and
quarterly e-newsletter are delivered to introduce the valuable tools
that a well known website, DaVita.com offers – GFR calculator and
tracker, over 500 CKD recipies, DaVita Diet Helper, CKD videos and
more.
• All medical questions will be referred the physician.
Slide 74
Summary of Stages
•
•
Pre-ESRD patient education does better when referred early to an education program. An
educated patient will adhere better to the therapy that slows progression of disease
In the early stages, 1 and 2 – it is important to control for diabetes and blood pressure.
Generally an ACE or an ARB is recommended
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•
By Stage 3 patients are starting to manifest signs of anemia, metabolic acidosis and early
metabolic bone disease.
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•
They need to have laboratory studies – Ca, PO4, PTH, lipid profile
By stage 4, the serum phosphorus is elevated. Vitamin D analogs may be necessary.
Phosphorus control can be done with diet, but most likely at this stage will require a binder.
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•
Vitamin D management should start early in the course of disease
Some recommend restricting the use of process foods early
In addition to diet and blood pressure control with an ACE or ARB, control of glucose is valuable in
diabetics
Patients have other choices beside in center hemodialyssi. In stage 4 it is important to discuss options
such as home hemodialysis and home peritoneal dialysis. Patients who have been educated are more
likely to choose these modalities, and are more satisfied with them.
The patient should be evaluated early for a permanent vascular access, and depending upon the
modality chosen, a fistula or peritoneal dialysis access placed.
Pre-ESRD classes lead to a smoother transition into a dialysis (stage 5) regimen.
Slide 75
CKD Education Benefits
• Feel more engaged and in-control
Patients
• Slow the progression of renal disease
• Healthier on First Date of Dialysis
• Free education to patients and community
Physician
• Physician able to compliment own education
• Saves physician time, resources and money
• Patients learn of laws that protect them
Taxpayers
• Patients stay employed and insured
• Decrease burden on Medicare
Slide 76
Win – Win - Win
• CKD Education is a Win-Win-Win program. It is provided to
patients and the community at no cost or obligation.
• Patients who attend are empowered to take control of their
kidney health. They are provided with the tools they need
to preserve renal function.
• Physicians are able to compliment their own excellent
education, saving them time, resources and money.
• Finally, by helping patient to understand the laws that
protect them, we can help keep patients employed and
maintain their insurance, thus decreasing the burden on
Medicare.
Slide 77
How Do You Participate?
• Establish CKD Education as part of your practice
• Protocol: Educate all patients Stages 3,4 and 5
• Process:
– Identify eligible patient during office visit
– Patient communication (discussion and flyer)
– Clinician orders education need using:
• Sticky note
• Referral form
– Office staff completes and faxes referral form
– CKD education team contacts patient and schedules
class
Slide 78
How to work with a physician
office
• Every physician practice operates differently. The 3 biggest
things to walk away from the meeting with are:
– The physicians commitment to refer their CKD pts (get granular
as to are they willing to send Stage 3 pts as well as 4 and 5 or
just 4 and 5 which is fine too)
– A solid detailed process in writing on how the doctor is going to
notify the administrative team of the order for education and
how the administrative team is going to send the fax referral. If
the Physicians are willing to set a "protocol" or "standing order"
that states the admin staff is to refer all CKD pts (or all Stage 4/5
pts) that is great because it takes the step of the physicians
remembering to refer for education out of the mix.
• An agreement on how often you and the administrative
staff will touch base to make sure everything is good.
Slide 79
Early CKD Education Benefit Patient’s?
What Houston CKD patients say about CKD Education:
– “I wish I had this information sooner”
– “I will really study my lab values and check my diet”
– “I will talk to my doctor about my NSAID’s and
decongestants”
– “The health diary is excellent. I really like the glossary”
– “As a family member, I think my father (patient) will feel
more comfortable about the possibility of dialysis”.
Success Stories…
Slide 80
Success Stories
• Patients need information and change can happen
– Pt went from stage 4 to stage 3 and thanked us for the
class….
• Office staff tell of a pt they were dreading to tell about
time to start dialysis
– Pt said “It’s OK, I know about it”. The office nurse was
amazed.
• Access placements before starting dialysis
– As they should be
• Insurances saved or supplemental insurance obtained
before ESRD.
Slide 81
The End