Role of Nephrologist PowerPoint presentation

The Role of the Nephrologist in The Role of the Nephrologist in Care of CKD patientsCare of CKD patients

James Brandes, M.D.James Brandes, M.D.Chair, Medical Review CommitteeChair, Medical Review Committee

Network 11Network 11Medical Director, Midwest DialysisMedical Director, Midwest Dialysis

MilwaukeeMilwaukee

Chronic Kidney DiseaseChronic Kidney Disease

NKF/DOQI has produced treatment guidelines NKF/DOQI has produced treatment guidelines for patients with CKD to optimize outcomesfor patients with CKD to optimize outcomes

Based on creatinine clearance (derived from Based on creatinine clearance (derived from the MDRD formula), CKD divided into 5 the MDRD formula), CKD divided into 5 stagesstages

Prevalence of CKD StagesPrevalence of CKD Stages

StageStage GFR GFR (ml/min/1.73 m(ml/min/1.73 m22

Prevalence Prevalence (millions)(millions)

II > 90> 90 16,400,00016,400,000

IIII 60-8960-89 12,400,00012,400,000

IIIIII 30-5930-59 7,600,0007,600,000

IVIV 15-2915-29 400,000400,000

VV <15<15 350,000350,000

Rate of Growth of CKD PopulationRate of Growth of CKD Population

From USRDS, projection of number of patients at From USRDS, projection of number of patients at Stage V is 661,330 by 2010. By 2030, 2.24 million Stage V is 661,330 by 2010. By 2030, 2.24 million prevalent CKD, Stage Vprevalent CKD, Stage V

Rate of growth for Stages I-IV largely unknown, but Rate of growth for Stages I-IV largely unknown, but is increasingis increasing

More referrals to nephrologists are occurring at More referrals to nephrologists are occurring at Stages III-IV. This greatly increases the number of Stages III-IV. This greatly increases the number of patients needed to be seen by a nephrologistpatients needed to be seen by a nephrologist

Growth of Practicing NephrologistsGrowth of Practicing Nephrologists

AMA shows about 4,900 nephrologists of 6,800 AMA shows about 4,900 nephrologists of 6,800 listed are full timelisted are full time

Currently, about 340 fellows in nephrology complete Currently, about 340 fellows in nephrology complete their training per year. About 240 nephrologists their training per year. About 240 nephrologists retire per year. Net gain of nephrologists is about retire per year. Net gain of nephrologists is about 2 % per year 2 % per year

Of this 2 % net gain, about 33 % are females many of Of this 2 % net gain, about 33 % are females many of whom will work limited hours. About 10 % of this whom will work limited hours. About 10 % of this net gain have visa restrictions requiring primary care net gain have visa restrictions requiring primary care time time

Shortage of NephrologistsShortage of Nephrologists

Rate of growth of Stage V CKD patient population is Rate of growth of Stage V CKD patient population is 9-10 % per annum9-10 % per annum

Rate of growth of nephrologists is less than 2 % per Rate of growth of nephrologists is less than 2 % per annumannum

U.S. would need to train a 3-fold increase of new U.S. would need to train a 3-fold increase of new nephrologists per year compared to current numbers nephrologists per year compared to current numbers to match the increase in demandto match the increase in demand

This analysis does not even account for the increasing This analysis does not even account for the increasing burden of patients referred at stages III-IVburden of patients referred at stages III-IV

A Solution: Physician ExtendersA Solution: Physician Extenders

Need for NP’s and PA’s who can bill for servicesNeed for NP’s and PA’s who can bill for services ““CKD program” developed by the nephrologist with CKD program” developed by the nephrologist with

respect to NKF/DOQI practice guidelinesrespect to NKF/DOQI practice guidelines ““CKD program” protocol developed by the nephrologist CKD program” protocol developed by the nephrologist

allowing them to keep control establishing their particular allowing them to keep control establishing their particular practice habits within the protocol and maintaining their practice habits within the protocol and maintaining their standard of care (e.g. referral to surgeon for vascular standard of care (e.g. referral to surgeon for vascular access)access)

Ideal extender would be an NP/PA with dialysis Ideal extender would be an NP/PA with dialysis experienceexperience

Financial Costs of Extenders to the Financial Costs of Extenders to the Nephrology PracticeNephrology Practice

Extenders may command a median pay of Extenders may command a median pay of $66,000 per year$66,000 per year

Need to tie in anemia management Need to tie in anemia management reimbursement to offset costs of extenders in reimbursement to offset costs of extenders in the nephrology practicethe nephrology practice

Components of CKD ProgramComponents of CKD Program

CKD ClinicCKD Clinic

-manage the manifestations of CKD-manage the manifestations of CKD

-Anemia Clinic-Anemia Clinic QA/QIQA/QI

--Are we doing what we say we’re doing?Are we doing what we say we’re doing? Educational ResourceEducational Resource Liaison with Dialysis FacilityLiaison with Dialysis Facility

-Coordinate transfer from CKD to Dialysis Clinic-Coordinate transfer from CKD to Dialysis Clinic

CKD Clinic: Patient VisitsCKD Clinic: Patient Visits

Determine Stage of CKD using MDRD GFR estimationDetermine Stage of CKD using MDRD GFR estimation Treat complications of CKD (bone disease, disorders of Ca and P, Treat complications of CKD (bone disease, disorders of Ca and P,

hypertension)hypertension) Anemia managementAnemia management Risk reduction for cardiovascular diseaseRisk reduction for cardiovascular disease Vascular access placement by Stage IVVascular access placement by Stage IV Provide immunizations (Hep B, influenza, pneumovax, tetanus)Provide immunizations (Hep B, influenza, pneumovax, tetanus) Nutritional counselingNutritional counseling Education on dialysis modalities and transplantationEducation on dialysis modalities and transplantation Avoidance of nephrotoxic agentsAvoidance of nephrotoxic agents

CKD Clinic: Serum Phosphate LevelsCKD Clinic: Serum Phosphate Levels

Phosphate excess has been linked to Phosphate excess has been linked to calcification of the coronary arteries and aortacalcification of the coronary arteries and aorta

Phosphate excess independently linked to Phosphate excess independently linked to cardiovascular and all-cause mortality in the cardiovascular and all-cause mortality in the setting of ESRDsetting of ESRD

CKD Clinic: Control of Serum CKD Clinic: Control of Serum Phosphate LevelsPhosphate Levels

The following conclusions are based on a study at the The following conclusions are based on a study at the University of Washington, VA system, in 6730 CKD patients University of Washington, VA system, in 6730 CKD patients (JASN ’05)(JASN ’05)

Serum phosphate levels >3.5 mg/dl in CKD patients are Serum phosphate levels >3.5 mg/dl in CKD patients are associated with a significantly increased risk for deathassociated with a significantly increased risk for death

Mortality risk increased linearly with each subsequent 0.5 Mortality risk increased linearly with each subsequent 0.5 mg/dl increase in phosphate levelsmg/dl increase in phosphate levels

Elevated phosphate levels were independently associated with Elevated phosphate levels were independently associated with increased mortality risk in CKDincreased mortality risk in CKD

CKD Clinic: Guidelines for Bone CKD Clinic: Guidelines for Bone Metabolism and DiseaseMetabolism and Disease

Based on KDOQI, October 2003Based on KDOQI, October 2003 Calcium, phosphate, intact PTH measured in all CKD Calcium, phosphate, intact PTH measured in all CKD

patients by Stage III (every 12 months for Stage III; patients by Stage III (every 12 months for Stage III; every 3 months for Stage IV)every 3 months for Stage IV)

Goal intact PTH levelsGoal intact PTH levels

-Stage III:-Stage III: 35-70 pmol/L35-70 pmol/L

-Stage IV:-Stage IV: 70-110 pmol/L70-110 pmol/L

-Stage V:-Stage V: 150-300 pmol/L150-300 pmol/L

CKD Clinic: Guidelines for Bone CKD Clinic: Guidelines for Bone Metabolism and DiseaseMetabolism and Disease

Stages III-IV: Serum phosphate levels maintained Stages III-IV: Serum phosphate levels maintained between 2.7-4.6 mg/dlbetween 2.7-4.6 mg/dl

Restrict dietary phosphate to 800-1000 mg/day if Restrict dietary phosphate to 800-1000 mg/day if above targetabove target

If diet cannot control phosphate levels, calcium If diet cannot control phosphate levels, calcium containing phosphate binders are effective in containing phosphate binders are effective in lowering phosphate levels as initial binder therapy. lowering phosphate levels as initial binder therapy. Non-calcium, non-aluminum phosphate binders can Non-calcium, non-aluminum phosphate binders can be usedbe used

CKD Clinic: Guidelines for Bone CKD Clinic: Guidelines for Bone Metabolism and DiseaseMetabolism and Disease

In CKD stages III and IV, therapy with an active oral In CKD stages III and IV, therapy with an active oral Vitamin D sterol (calcitriol, alfacalcidol or Vitamin D sterol (calcitriol, alfacalcidol or doxercalciferol) is indicated when serum levels of doxercalciferol) is indicated when serum levels of 25(OH)-vitamin D are >30 ng/ml, and plasma levels 25(OH)-vitamin D are >30 ng/ml, and plasma levels of intact PTH are above target levelsof intact PTH are above target levels

Follow intact PTH every 3 months when on Vitamin Follow intact PTH every 3 months when on Vitamin D sterol. Back off dosage if PTH below target to D sterol. Back off dosage if PTH below target to avoid adynamic bone diseaseavoid adynamic bone disease

CKD Clinic: Guidelines for Bone CKD Clinic: Guidelines for Bone Metabolism and DiseaseMetabolism and Disease

Measure serum total COMeasure serum total CO22 every 12 months in every 12 months in CKD, Stage III and every 3 months in CKD, CKD, Stage III and every 3 months in CKD, Stage IVStage IV

In CKD patients, maintain total COIn CKD patients, maintain total CO22 > 21 > 21 mEq/L with supplemental alkali salts, if mEq/L with supplemental alkali salts, if necessarynecessary

CKD Clinic: Control of HTNCKD Clinic: Control of HTN

Strict BP control slows the progression of Strict BP control slows the progression of chronic kidney diseasechronic kidney disease

BP control reduces cardiovascular morbidity BP control reduces cardiovascular morbidity and mortalityand mortality

BP control is a major component of the CKD BP control is a major component of the CKD ClinicClinic

CKD Clinic: Control of HTNCKD Clinic: Control of HTNPopulationPopulation BP GoalBP Goal Pharmacological Pharmacological

TherapyTherapy

GeneralGeneral <140/90<140/90 Beta blockers, Beta blockers, diureticsdiuretics

CKD Stages I-IV CKD Stages I-IV with with

proteinuria/DMproteinuria/DM

<125/75<125/75 ACE, ARB, ACE, ARB, diureticsdiuretics

CKD Stages I-IV CKD Stages I-IV without without

proteinuriaproteinuria

<135/85<135/85 ACE, ARB, ACE, ARB, diureticsdiuretics

CKD Clinic: Anemia ManagementCKD Clinic: Anemia Management

Based on KDOQI, 2006Based on KDOQI, 2006

Maintain Hgb values between 11-13 g/dl using Maintain Hgb values between 11-13 g/dl using ESA agentsESA agents

Begin testing at all stages of CKDBegin testing at all stages of CKD

CKD Clinic: Anemia ManagementCKD Clinic: Anemia Management

Monthly monitoring of Hgb in ESA treated Monthly monitoring of Hgb in ESA treated patientspatients

ESA doses should be decreased, not ESA doses should be decreased, not necessarily held when a downward trend in necessarily held when a downward trend in Hgb is neededHgb is needed

Details in the next presentationDetails in the next presentation

CKD Clinic: Anemia ManagementCKD Clinic: Anemia Management

Iron testing every month at initiation of ESA treatmentIron testing every month at initiation of ESA treatment Iron testing every 3 months during stable ESA Iron testing every 3 months during stable ESA

treatmenttreatment Sufficient iron should be administered to maintain the Sufficient iron should be administered to maintain the

following indices of Fe statusfollowing indices of Fe status-Serum ferritin > 100 ng/ml-Serum ferritin > 100 ng/ml-TSAT > 20 %-TSAT > 20 %-Discontinue IV Fe is ferritin > 500 ng/ml-Discontinue IV Fe is ferritin > 500 ng/ml

CKD Clinic: Risk Reduction for CKD Clinic: Risk Reduction for Cardiovascular DiseaseCardiovascular Disease

Blood pressure controlBlood pressure control Smoking cessationSmoking cessation Encourage physical activity (> 30 minutes of Encourage physical activity (> 30 minutes of

moderate-intensity physical activity on most days of moderate-intensity physical activity on most days of the week)the week)

Anemia managementAnemia management Phosphate, calcium, intact PTH managementPhosphate, calcium, intact PTH management Dyslipidemia managementDyslipidemia management

CKD Clinic: Dyslipidemia CKD Clinic: Dyslipidemia ManagementManagement

Measure LDL, HDL, triglycerides (fasting)Measure LDL, HDL, triglycerides (fasting)

Correct with diet, physical activity, and smoking/EtOH reductionCorrect with diet, physical activity, and smoking/EtOH reduction

Use pharmacological agents if above measures fail to achieve target levelsUse pharmacological agents if above measures fail to achieve target levels

-Triglycerides > 500 mg/dl, triglyceride lowering agent-Triglycerides > 500 mg/dl, triglyceride lowering agent

-LDL > 70 mg/dl, ? Use of low dose statin-LDL > 70 mg/dl, ? Use of low dose statin

-LDL > 100 mg/dl, low dose statin-LDL > 100 mg/dl, low dose statin

-LDL > 130 mg/dl, high dose statin-LDL > 130 mg/dl, high dose statin

-LDL< 100 mg/dl, fasting triglycerides > 200 mg/dl, non-HDL -LDL< 100 mg/dl, fasting triglycerides > 200 mg/dl, non-HDL cholesterol > 130 mg/dl, consider statin therapycholesterol > 130 mg/dl, consider statin therapy

CKD Clinic: Vascular AccessCKD Clinic: Vascular Access

By Stage IV, patients are educated on dialysis By Stage IV, patients are educated on dialysis modalities and should be able to make a modalities and should be able to make a decision concerning dialysis typedecision concerning dialysis type

For those who choose hemodialysis, vascular For those who choose hemodialysis, vascular access is placed by Stage IV. access is placed by Stage IV. Fistulas are the Fistulas are the access of choice!access of choice!

Fistula Prevalence Rates in ESRD: Fistula Prevalence Rates in ESRD: Network 11 DataNetwork 11 Data

05

101520253035404550

Oct '03 Oct '04 Oct '05 Dec '06 Mar '07

Network 11USA

Fistula Prevalence by State: Fistula Prevalence by State: Network 11 Data March 2007Network 11 Data March 2007

Minnesota:Minnesota: 45.0 %45.0 % Wisconsin:Wisconsin: 46.3 %46.3 % North Dakota:North Dakota: 51.4 %51.4 % South Dakota:South Dakota: 51.4 %51.4 % Michigan:Michigan: 40.3 %40.3 %

Fistula First Project Goals for ESRDFistula First Project Goals for ESRD

K/DOQI: AVF placement rates of > 65 % for K/DOQI: AVF placement rates of > 65 % for prevalent patientsprevalent patients

CMS: 66 % AVF prevalent use nationally by CMS: 66 % AVF prevalent use nationally by June 2009June 2009

CKD Clinic: Vascular Access CKD Clinic: Vascular Access PlacementPlacement

Establish good working relationship with access surgeon who Establish good working relationship with access surgeon who is skilled in placing fistulasis skilled in placing fistulas

Surgeon should be equipped to do all types of fistula Surgeon should be equipped to do all types of fistula placements including basilic fistulae with transpositionplacements including basilic fistulae with transposition

Coordinate pre-op eval with surgeon in terms of vein mapping, Coordinate pre-op eval with surgeon in terms of vein mapping, appointments, etc.appointments, etc.

Begin vascular access flow sheet in CKD clinic concerning Begin vascular access flow sheet in CKD clinic concerning evaluation of vasculature, placement of fistulae, maturation, evaluation of vasculature, placement of fistulae, maturation, and complications. This flow sheet will be transitioned to the and complications. This flow sheet will be transitioned to the ESRD chart once dialysis beginsESRD chart once dialysis begins

CKD Program: QA/QICKD Program: QA/QI

Are we doing what we say we’re Are we doing what we say we’re doing?doing?

Major component of CKD programMajor component of CKD program

CKD Program: Elements of QA/QICKD Program: Elements of QA/QI

Anemia ManagementAnemia Management: % patients with Hgb>11 g/dl: % patients with Hgb>11 g/dl Bone Disease and RxBone Disease and Rx: % patients with P< 4.6 mg/dl, intact : % patients with P< 4.6 mg/dl, intact

PTH between 70-110 pmol/L, total COPTH between 70-110 pmol/L, total CO22 >22 mEq/L >22 mEq/L Vascular AccessVascular Access: Incidence rates of fistulae in patients : Incidence rates of fistulae in patients

beginning dialysisbeginning dialysis ImmunizationsImmunizations: % patients completing Hep B, influenza, : % patients completing Hep B, influenza,

pneumovax, tetanuspneumovax, tetanus HypertensionHypertension: % patients with BP in goal range: % patients with BP in goal range Risk ReductionRisk Reduction: % patients with LDL < 100 mg/dl: % patients with LDL < 100 mg/dl

CKD Clinic Approach vs. Standard CKD Clinic Approach vs. Standard Nephrologist CareNephrologist Care

Study by Curtis, et.al. (Nephrol Dial Transplant, Study by Curtis, et.al. (Nephrol Dial Transplant, 2005), compared patients with CKD with longer than 2005), compared patients with CKD with longer than 3 months exposure to nephrology care who were part 3 months exposure to nephrology care who were part of a CKD Clinic approach vs. standard nephrology of a CKD Clinic approach vs. standard nephrology carecare

The CKD Clinic patients had significantly higher The CKD Clinic patients had significantly higher Hgb and Alb levels at the commencement of dialysis Hgb and Alb levels at the commencement of dialysis compared to standard nephrology care patients. compared to standard nephrology care patients. Survival was significantly better in the CKD Clinic Survival was significantly better in the CKD Clinic patients than the standard nephrology care patientspatients than the standard nephrology care patients

QA/QI: Midwest Nephrology QA/QI: Midwest Nephrology ExperienceExperience

Anemia ClinicAnemia Clinic

Average Hgb: 11.5 g/dlAverage Hgb: 11.5 g/dl

% patients with Hgb >11 g/dl: 83 % (n = 208)% patients with Hgb >11 g/dl: 83 % (n = 208)

QA/QI: Midwest Nephrology QA/QI: Midwest Nephrology ExperienceExperience

Vascular Access PlacementVascular Access Placement

CKD Clinic: CKD Clinic: 58.6 % had AVF placed 58.6 % had AVF placed by start of dialysisby start of dialysis

Standard Neph Care:Standard Neph Care: 13.3 % had AVF placed 13.3 % had AVF placed by start of dialysisby start of dialysis

CKD Program: Educational ResourceCKD Program: Educational Resource

Provide education on CKD to:Provide education on CKD to:

Primary Care physiciansPrimary Care physicians Insurance Companies, HMO’s, PPO’s etc.Insurance Companies, HMO’s, PPO’s etc.Healthcare systems, laboratoriesHealthcare systems, laboratoriesPatients, familiesPatients, families

CKD Program: Educational Resource CKD Program: Educational Resource for PCP’sfor PCP’s

Study by Lea, et.al. (AJKD, 2006), found that up to Study by Lea, et.al. (AJKD, 2006), found that up to 34.4 % of PCP respondents did not recognize all risk 34.4 % of PCP respondents did not recognize all risk factors for CKD (race, diabetes, hypertension, family factors for CKD (race, diabetes, hypertension, family history, etc.)history, etc.)

Use of grand rounds, noon-time talks at PCP clinics, Use of grand rounds, noon-time talks at PCP clinics, night-time dinner talks to present CKD managementnight-time dinner talks to present CKD management

Provide “CKD packet” to PCP’s reviewing early Provide “CKD packet” to PCP’s reviewing early referral, management, and creatinine clearance referral, management, and creatinine clearance calculatorscalculators

CKD Program: Educational Resource CKD Program: Educational Resource to Healthcare Systems, Laboratoriesto Healthcare Systems, Laboratories

Report creatinine clearance and Stage of Report creatinine clearance and Stage of CKD with all serum creatinine levelsCKD with all serum creatinine levels

Bring attention to early CKD and referralBring attention to early CKD and referral

CKD Program: Liaison with Dialysis CKD Program: Liaison with Dialysis FacilitiesFacilities

Provide smooth transition for patient from Provide smooth transition for patient from CKD Clinic to the Dialysis FacilityCKD Clinic to the Dialysis Facility

Transition important patient information Transition important patient information including vascular access flow sheet, including vascular access flow sheet, medication list, immunization record, and medication list, immunization record, and kidney transplant work-upkidney transplant work-up

CKD Program: Financial IssuesCKD Program: Financial Issues

Medicare reimburses NP at 80 % of MD Medicare reimburses NP at 80 % of MD chargescharges

Commercial insurance reimburses NP at Commercial insurance reimburses NP at 100 % of MD charges100 % of MD charges

To optimize reimbursement, Midwest To optimize reimbursement, Midwest Nephrology incorporated the anemia clinic Nephrology incorporated the anemia clinic into the CKD clinic under the direction of the into the CKD clinic under the direction of the NPNP

CKD Program: Midwest Nephrology, CKD Program: Midwest Nephrology, MilwaukeeMilwaukee

One full time NP (7/1/05-6/30/06). We One full time NP (7/1/05-6/30/06). We hired a second NPhired a second NP

The anemia clinic (aranesp) had about The anemia clinic (aranesp) had about 164 patients between 7/1/05-12/31/05 and 164 patients between 7/1/05-12/31/05 and about 208 patients from 1/1/06-6/30/06about 208 patients from 1/1/06-6/30/06

CKD Program: Midwest Nephrology, CKD Program: Midwest Nephrology, MilwaukeeMilwaukee

Expenses: NP salary and benefits, aranesp Expenses: NP salary and benefits, aranesp purchase, overheadpurchase, overhead

Revenue: Pharmaceutical, administration fee, Revenue: Pharmaceutical, administration fee, Hemacue fee, CKD Clinic appointment feeHemacue fee, CKD Clinic appointment fee

CKD Program: Midwest Nephrology, CKD Program: Midwest Nephrology, MilwaukeeMilwaukee

CKD portion of the Clinic revenue was 82 % of the CKD portion of the Clinic revenue was 82 % of the NP’s salary and about 66 % of NP’s salary and NP’s salary and about 66 % of NP’s salary and benefitsbenefits

With the addition of the aranesp clinic to the CKD With the addition of the aranesp clinic to the CKD program, the net profit after all expenses was program, the net profit after all expenses was $271,328 for the 6 months 1/1/06-6/30/06$271,328 for the 6 months 1/1/06-6/30/06

Linking anemia clinic to the CKD program is key to Linking anemia clinic to the CKD program is key to ongoing solvency of the complete programongoing solvency of the complete program