Manisha Singh MD 2019 · HTN- Hypertension DM- Diabetes Mellitus ... Medicare spending for patients with CKD ages 65 and older expanded from 4.2% in 1995 to 7.7% in 2003, and 20.8%

Manisha Singh MD

2019

Presentation includes data from Telemedicine study sponsored by Baxter. I am CO-PI in that study.

Presentation includes mention of QI study at Dialysis clinic inc (DCI ). Dr Shree Sharma and I hold the copyright to the wallet mentioned in the study.

1. Chronic kidney disease (CKD) - Define and Diagnose.

2. Prevention of progression of CKD- Manage and Treat complications

3. Describe renal replacement options

4. Describe patient centered educational initiatives

CKD- Chronic kidney diseaseESRD- End stage renal

diseaseCVD- cardiovascular

diseaseHTN- HypertensionDM- Diabetes MellitusAAM- African American

man

Hb- HemoglobinWBC- White blood cellsRBC- Red blood cellsHR- Heart rate BP- Blood pressure RR- respiratory rateBID- two times a dayAKI- Acute kidney injuryeGFR- estimated glomerular filtration rate.

A 55 year old AAM comes to the clinic for a routine follow up to my clinic. Past medical history- DM- moderate control with Metformin, known since last 2

years. Last HbA1C 7 HTN- uncontrolled over last 5 years – Takes Lisinopril 40 , Lasix 60 bid, Amlodepin

5 mg Other medications - 2 multivitamins daily, Viagra as needed, garlic capsules,

cinnamon capsule. Average readings 150/90s No prior surgeries. Family history – HTN Vitals -: HR 80, BP 165/95, RR 12 Labs -: Significant for Hb 10, Creatinine 2.4 from 2 last year(which co-relates to

decrease in eGFR from 43 to 34) , urine with 4 gm/day proteinuria, few rbc, wbcs.

Patient – “What does this mean for me? What should I do ?”

His wife – “I already have 9 medications to give him! Does this mean more medications ? How will I keep a track of this?”

His mother –in- law – “There is a herb Sylvia’s brother’s friend got from Dr Fixitall –it cured his cancer ! Shall we try that first?”

Hospital admin- IS this needed for good clinic utilization?

Division head- Research opportunity?

Department head- Education opportunities?

Government – what does this mean in healthcare dollars?

https://www.niddk.nih.gov/health-information/health-statistics/kidney-diseasehttps://www.usrds.org/adrhighlights.aspx

Medicare spending for beneficiaries with CKD who were younger than age 65 exceeded $8 billion in 2014, representing 44% of spending in this age group.

Medicare spending for patients with CKD ages 65 and older expanded from 4.2% in 1995 to 7.7% in 2003, and 20.8% in 2014. exceeded $50 billion in 2013 and represented 20 percent of all Medicare spending in this age group.

In 2014, the proportion of CKD patients with no known coverage was 12%

Without CKD cost of 65 and older 8400, with CKD 16176, with CKD +hf+ DM- 39506

In 2013, adjusted mortality rates remained higher for Medicare patients with CKD (117.9/1,000) than for those without CKD (47.5/1,000); and these rates increased with CKD severity.

The dialysis population has an adjusted 76% 1-year survival rate and only a 36% 5-year survival rate . (breast ca stage 3, colorectal staget 2 has 55-80% )

Rates of re-hospitalization for CKD patients were higher (22.3%) than those for patients without diagnosed CKD (15.8%). Regardless of CKD stage ranging from Stage 1 to 4, the risk of

coronary death or nonfatal MI in adults over the age of 50 was >10% over 10 years

https://www.medicare.gov/people-like-me/esrd/esrd.html

I am going to over simplify to fix this issue.

The presence of either kidney damage or decreased kidney function for ≥3 months, irrespective of cause.

CKD is defined as abnormalities of kidney structure or function, present for > 3 months, with implications for health.

CKD is classified based on cause, GFR category, and albuminuria category (CGA).

Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD)

CGA

Green can reflect CKD follow-up measurements annually; Yellow requires caution and measurements at least once per year; Orange requires measurements twice per year; Red requires measurements at 3 Deep red 4 times per year.

Evidence model for stages in the initiation and progression of chronic kidney disease, and therapeutic interventions.

Sarnak MJ, Levey AS: Cardiovascular disease and chronic renal disease: A new paradigm. Am J Kidney Dis 35:S117-S131, 2000 (suppl 1)

African-American decent

Older age

Low birth weight

Family history of kidney disease

Smoking

Obesity

Hypertension

Diabetes mellitus

Exposure to heavy metals

Excessive alcohol consumption

Analgesic medications

Acute kidney injury

History of cardiovascular disease, hyperlipidemia, metabolic syndrome,

Hepatitis C virus, HIV infection,

Malignancies.

Kazancioğlu R. Risk factors for chronic kidney disease: an update. Kidney International Supplements. 2013;3(4):368-371. doi:10.1038/kisup.2013.79.

Primary causes of CKD Incidence %

Diabetes 42.9

HTN 26.4

Glomerulonephritis (GN) 9.9

Cystic, Congenital disease 3.1

Interstitial Nephritis 4

Secondary GN, vasculitis 2.4

Miscellaneous 3.8

Unknown 7.5

Nonspecific and can mimic many other clinical conditions, depends on severity.

Weisbord et al. found a median of 9.0 symptoms among dialysis patients

• Disorders of fluid & electrolytes: K, Acidosis

• Disorders of mineral metabolism: Ca, Phos, PTH

• Anemia of CKD

• Resistant Hypertension

• Dyslipidemia

• Endocrine: sexual dysfunction

• Uremia, AKI & ESRD

Atherosclerotic heart disease (ASHD) is the most frequent cardiovascular disease linked to CKD; its prevalence in CKD patients aged 66 years and older exceeds 40% (2013)

1. Refer to nephrology early ->CKD clinic.

2. Slow progression- treat reversible causes

3. Treat complications

4. Prepare patient for ESRD

Identify reversible causes of unexpected eGFR decline:Pre and post renal etiologies, nephrotoxinsCKD cause- controlMineral bone disease-hold stable and replete as neededFluid and electrolyte balance-maintain Control anemia with erythropoietin hormone, iron repletion.Drugs: Toxic effects, renal dose adjustment.

Smoking cessation, diet modificationsHyperlipidemia –management with statins.

Slow Progression of eGFR decline: 4 steps

1. Attain the blood pressure goal <140/80 (130/80 in albuminuria)

2. Attaining the proteinuria goal- RAAS blockade-: ACEI, ARBs

3. Diabetes control to HbA1C 7

4. Correction of metabolic acidosis to serum bicarb of 22

Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician Joseph A. Vassalotti, MD,a,bRobert Centor, MD,c Barbara J. Turner, MD, MSED,d Raquel C. Greer, MD, MHS,e Michael Choi, MD,e Thomas D. Sequist, MD, MPH,fNational Kidney Foundation Kidney Disease Outcomes Quality Initiative

1. Attain the blood pressure goal 130/0

2. Attaining proteinuria goal of <500 mg daily (RAAS: Renin Angiotensin Aldosterone System – blockade-: Ace Inhibitors, Angiotensin receptor blockers, (can also use non-dihydropyridine CCB Calcium channel blockers (Verapamil, Cardizem)

3. Diabetes control to HbA1c of 7%

4. Correction of metabolic acidosis to serum bicarb of about 22 (get a venous blood gas at least once with renal panel)

5. Referral to Nephrology specialty clinic at stage 3b (eGFR<45 ml/min) for co-managed care.

6. Age appropriate vaccinations, age appropriate cancer screening

7. Have lab calculate eGFR for your patients and obtain a renal panel once a year.

8. Diet modifications for salt restriction 2gm daily, and based on kidney function by stage potassium and phosphorous restriction. In late stages of chronic kidney disease you consider protein restriction

9. Smoking cessation referral

10. Medication reconciliation for dose adjustment if needed based on kidney function and avoidance of medications such as NSAIDs that could cause further loss of kidney function and/or acute exacerbations of kidney injury.

https://www.kidney.org/kidneydisease/siemens_hcp_quickreference

1.Know the definition for CKD2.Classify CKD to guide testing and treatment3.Recognize risk factors. CKD risk factors include, but are not limited to the following:

1. Diabetes2. Hypertension3. Family history of kidney disease4. Age 60 or older (GFR declines normally with age)5. Race/U.S. ethic minority status - African Americans, Hispanics,

Asians/Pacific Islanders, and American Indians6. Frequent NSAID use7. History of acute kidney injury

4.Management -Implement a clinical action plan based on patient's CKD classification

Symptoms of uremia begin to occur.Malnutrition, anorexia, nausea, vomiting, fatigue, sexual

dysfunction, platelet dysfunction, pericarditis, neuropathy.

1. DialysisIn Center Hemodialysis (IHD) Home Dialysis (HOD)- PD, HHD

2. Kidney TransplantLiving Deceased Donor

3. Palliative Care

Renal transplantSo far, the best modality of replacement long term for the patient.

https://www.thesun.co.uk/news/4463649/kidney-transplant-recovery-symptoms-rejection-leave-scar/

• The dialysis machine pumps the blood through a dialyzer filter

• Solute and water are cleared through diffusion and /or convective transport

https://www.passenlaw.com/images/dialysis-hemorrhage.jpg

• 3 days a week• 3-4 hours per

treatment

• Patient and partners do the hemodialysis treatments at home

• 5-6 sessions per week

• Training may take 1 to 3 months

Peritoneal DialysisSolute and water transport across the peritoneal membrane

http://kidney.org.au/cms_uploads/images/819_thumbnail.jpg

Five-Year Survival for End-Stage Renal Disease Patients in the United States, Europe, and Japan, 1982 to 1987

Philip J. Held,Felix Brunner,Michio Odaka,Jose R. Garcia,Friedrich K. Port,Daniel S. Gaylin

American Journal of Kidney Diseases

May 1990

The mean age for prevalent dialysis patients in the United States is now 62.7 years, and the prevalence of maintenance dialysis among patients≥75 years of age has doubled during the last 2 decades

The dialysis population has an adjusted 76% 1-year survival rate and only a 36% 5-year survival rate .

The adjusted mortality rate of maintenance dialysis patients is nearly twice that of adults with some cancers and more than twice that of adults with congestive heart failure or stroke.

U.S. Renal Data System: USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD, 2013.

All-cause mortality rates (per 1,000 patient years at

risk) for Medicare patients aged 66+, by CKD status and year, 2001-2013 (adjusted)

584 stage 4 and stage 5 CKD patients were surveyed as they presented to dialysis, transplantation, or predialysis clinics in a Canadian, university-based renal program between January and April 2008.

A total of 61% of patients regretted their decision to start dialysis. More patients wanted to die at home (36.1%) or in an inpatient hospice (28.8%) compared with in a hospital (27.4%).

Less than 10% of patients reported having had a discussion about end-of-life care issues with their nephrologist in the past 12 months.

Much work is needed to facilitate incorporation of this approach into the existing dialysis delivery infrastructure in the United States in order to realize its most effective use.

Davison SN: End-of-life care preferences and needs: Perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol 5: 195–204, 2010

As the patient nears the end of life (dashed arrow), there is an increasing focus on symptom control and patient goals of care and a shift in the approach to dialysis care from conventional

to palliative.

Vanessa Grubbs et al. CJASN doi:10.2215/CJN.00650114

©2014 by American Society of Nephrology

In a survey of urban African-American adults, <3% named kidney disease as an important health problem, compared to 61% and 55% naming hypertension and diabetes, respectively

Waterman AD, Browne T, Waterman BM, Gladstone EH, Hostetter T. Attitudes and behaviors of African Americans regarding early detection of kidney disease. Am J Kidney Dis. 2008;51(4):554–562.

Reported physician documentation of CKD with ICD-9 codes in a large managed care cohort with greater than 10,000 individuals with CKD stages 3–5, was 14.4%

Guessous I, McClellan W, Vupputuri S, Wasse H. Low documentation of chronic kidney disease among high-risk patients in a managed care population: a retrospective cohort study. BMC Nephrol. 2009;10:25.

Data Source: National Health and Nutrition Examination Survey (NHANES), 2001-2012 participants aged 20 & older. Abbreviations: CKD, chronic kidney disease.

Figure 1.16 NHANES participants with CKD aware of their kidney disease, 2001-2012

By stage

2016 Annual Data Report, Vol 1, CKD, Ch 147

It’s a bad disease

High mortality

Can be controlled, there are optionsPeople don’t know much about it

Patients themselves don’t know much about it.

Physicians don’t seem to know enough either.

So how do we figure out what is the best option going forward ?

Merighi et al. Hemodial Int. 2012;16(2): 242-251

N=51

Data source: Special analyses, USRDS ESRD Database. Denominator is calculated as the sum of patients receiving HD, PD, or Home HD; does not include patients with other/unknown modality. ^United Kingdom: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Belgium do not include patients younger than 20. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; APD, automated peritoneal dialysis; IPD, intermittent peritoneal dialysis; ESRD, end-stage renal disease; HD, hemodialysis; PD, peritoneal dialysis; sp., speaking.

Figure 13.17 Distribution of the percentage of prevalent dialysis

patients using in-center HD, home HD, or peritoneal (CAPD/APD/IPD), 2013

Vol 2, ESRD, Ch 13522015 USRDS Annual

Report

Home appears to be a good option.

Most of our patients are not on it.

Patient, provider, public

Barriers-:Out reach areasEducational level of our patient populationExpenseWhat tools to use?

We needTo be able to reach every body, teach in a manner everyone can understand, have validated and standardized teaching tools.

Increase CKD awareness, detection and education for patients and providers through community engagement activities that provide baseline AR data that can be utilized to obtain future grants, promote CKD patient education, improve systems of care and clinical outcomes while decreasing health care costs.

1. Attain the blood pressure goal <140/80 (130/80 when albuminuria is present)

2. Attaining proteinuria goal of <500 mg daily (RAAS: Renin Angiotensin Aldosterone System –blockade-: Ace Inhibitors, Angiotensin receptor blockers, (can also use non-dihydropyridine CCB Calcium channel blockers (Verapamil, Cardizem)

3. Diabetes control to HbA1c of 7% or less

4. Correction of metabolic acidosis to serum bicarb of about 22 (get a venous blood gas at least once)

5. Referral to Nephrology specialty clinic at stage 3b (eGFR<45 ml/min) for co-managed care.

6. Age appropriate vaccinations, age appropriate cancer screening

7. Have lab calculate eGFR for your patients and obtain a renal panel once a year.

8. Diet modifications for salt restriction 2gm daily, and based on kidney function by stage potassium and phosphorous restriction. In late stages of chronic kidney disease you consider protein restriction

9. Smoking cessation referral

10. Medication reconciliation for dose adjustment if needed based on kidney function and avoidance of medications such as NSAIDs that could cause further loss of kidney function and/or acute exacerbations of kidney injury.

In order to provide the best possible medical care for you, your medical provider would like to improve your kidney health inaddition to everything else. Listed below are the ten talking points for you and your provider put together by Arkansas statechronic kidney disease advisory committee.

What are my blood pressure goals?

Do I have protein in my urine?

If I have diabetes, what is my target HbA1c ?

What other complications could I have from kidney disease? Is there acid buildup?

When do I need to see a kidney doctor?

Did I get my age-appropriate vaccinations and cancer screening?Getting vaccinations and cancer screening appropriate for your age are some of the easiest ways to ensure that you maintain long-term health.

What blood tests are needed to check my kidney function?

What are my diet goals? How much salt and protein can I eat?

If I smoke or use tobacco in any form how does that affect me?

Are my medications dosed correctly and am I on all the medications I should be on with kidney disease? What medications should I avoid? Are my medication lists updated?

ICD 10 codes for Primary care

Chronic Kidney disease N18.1, CKD stage 1, • N18.2, CKD, stage 2 (mild), • N18.3, CKD, stage 3 (moderate), • N18.4, CKD, stage 4 (severe), • N18.5, CKD, stage 5, • N18.6, End-stage renal disease, • N18.9, CKD, unspecified

Hypertension: I12.9, BP >140/90 Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease. These two codes require an additional N18 code given above to identify the stage of kidney disease

ProteinuriaR80.1 – persistentR80.8- DM type 2 with proteinuriaR80.9-Protienuria,unspecified

Diabetic Nephropathy (DNP)E10.21- DM-type1 with DNPE11.22-DM-type 2 with DNP

Metabolic acidosis. E87.2E87.8-Other disorders of electrolyte and fluid balance, not elsewhere classified

Referral- co-managed care: can put the appropriate CKD code, or N15.9

Vaccination and malignancy Vaccination schedule CDC guideline give in the next pageZ 23 – encounter for vaccination (Procedure code required for the type of vaccination given)Z12.9- encounter for screening for malignant neoplasm, site unspecified

AnemiaD 63.1-Anemia of chronic kidney diseaseD 50.9- Anemia -iron deficiency, unspecified

Dietary and exercise counselling Z 71.3- Dietary surveillance and counselingE66.9- Obesity -NOSZ 71.82- exercise counseling

Smoking cessationF 17.2- Nicotine dependenceZ72.0- Tobacco use NOSZ 71.6- Tobacco abuse counseling

Medication reconciliationZ 76.89 -review of medications

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