Advances in Chronic Kidney Disease

Quality in CKD: The 3 “Cs”

Jerry Yee — 2011-11-01

In this issue of Advances in Chronic Kidney Disease, we find its essence in the cover illustration—an idealized, but not unrealistic, interdigitating conceptualization of the multiplicity of interactions of clinical CKD care between nephrologist and primary care physician (PCP), with the patient juxtaposed between them. The Co-Editors of this issue, Drs. Rebecca J. Schmidt and Bethany S. Pellegrino, in conjunction with their contributing authors, present a series of papers that portrays the colors of CKD that continually confront and challenge PCPs and kidney physicians in their efforts to deliver quality care. But, what is the formula for ensuring the quality of CKD care?

Collegiality and CKD

Rebecca J. Schmidt, Bethany Pellegrino — 2011-11-01

Not so long ago, respected textbooks of nephrology classified renal failure as an “either-or” entity, and patients were diagnosed with renal failure that was “acute” or “chronic.” Chronic renal failure referred to all that was not “acute,” and spawned the gamut of renal function, including ESRD, the Medicare diagnosis designated to those requiring renal replacement therapy (RRT). Doctors of dialysis patients spent much time providing chronic dialysis-related care, except when running to extinguish a clinical fire related to the now rarely witnessed state of uremia. Primary care physicians left the dialysis care to nephrologists. When uncovered before the onset of symptoms, chronic renal failure was monitored for progression of renal functional decline to a level thought worthy of dialysis. Less fortunate was the patient whose chronic renal failure was “acutely” discovered during the presentation of pulmonary edema or hemodynamically significant hyperkalemia. The polarity represented by these terms did little justice to the wide spectrum of renal function that fell under the heading of “chronic,” despite the fact that all chronic renal failure is not necessarily ESRD, and vice versa.

Why Work Together? Developing Effective Comanagement Strategies for the Care of Patients With CKD

Beth Pellegrino, Rebecca J. Schmidt — 2011-11-01

The ever-growing population of patients with CKD has prompted an increasing emphasis on earlier identification and proactive management by primary care providers. The provision of effective CKD care will necessitate a collegial relationship between the primary care providers and nephrologists exists. In this paper, barriers to the development of this working relationship, potential solutions within existing practice patterns, and newer ideas for effective communication will be explored.

Complications of Progression of CKD

Min Yang, Chester H. Fox, Joseph Vassalotti, Michael Choi — 2011-11-01

CKD is a complex comorbid condition with multiple manifestations. It is closely linked with cardiovascular disease and has a very high mortality rate. Currently, it consumes 28% of Medicare expenditures. Complications of CKD include hypertension, diabetes, dyslipidemia, cardiovascular disease, anemia, and bone and mineral disorders. It is underrecognized and underdiagnosed in primary care offices. There is strong evidence that controlling blood pressure, blood glucose, and use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in albuminuric patients, as well as referral to the nephrologist when glomerular filtration rate is <30 mL/min/1.73 m2, is associated with lower mortality, better access to kidney transplantation, improved management of comorbidities, and less frequent use of catheters for dialysis and to lower mortality.

Improving Blood Pressure Control Among Adults With CKD and Diabetes: Provider-Focused Quality Improvement Using Electronic Health Records

Bernadette Thomas — 2011-11-01

Current evidence demonstrates poor provider knowledge and compliance to clinical practice guidelines (CPGs) for CKD screening, blood pressure (BP) goals specific to people with diabetes mellitus (DM) and CKD, and underutilization or incorrect drug selection for antihypertensive therapy. This 12-week provider-focused quality improvement project sought to (1) increase primary care provider (PCP) adherence to CPG in the treatment and control of BP among adults with CKD and DM by using electronic health records (EHRs) and patient-level feedback (scorecards); (2) increase PCP delivery of basic CKD patient education by using EHR-based decision support; and (3) assess whether electronic decision support and scorecards changed provider behavior. The project included 46 PCPs, physicians, and nurse practitioners, in a statewide federally qualified health center that operates 12 comprehensive primary care sites in Connecticut. There were 6781 DM visits, among 3137 unique, racially diverse patients. There was a statistically significant increase in CKD screening, diagnosis, and use of angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker. There was a statistically, but not clinically, significant increase in CKD basic education and ancillary service provider use when the provider was aware of the diagnosis or used EHR enhancements. EHR decision support and real-time provider feedback are necessary but not sufficient to improve uptake of CPG and to change PCP behavior.

Geriatric Nephrology: A Paradigm Shift in the Approach to Renal Replacement Therapy

Derrick L. Latos, Jessica Lucas — 2011-11-01

The population of elderly individuals diagnosed with CKD continues to grow. Many have multiple comorbid conditions that will impact life expectancy as well as decisions about whether to pursue renal replacement therapy. Nephrologists are uniquely positioned to assist their patients and caregivers in this regard and spend considerable time counseling them about the benefits and risks associated with dialysis therapy. This article presents an overview of many of the issues facing nephrologists, and provides tools to assist busy clinicians in helping their elderly patients in deciding whether to consider dialysis or intensive, nondialysis care.

Referral and Comanagement of the Patient With CKD

Garland Adam Campbell, Warren Kline Bolton — 2011-11-01

CKD is a common condition with well-documented associated morbidity and mortality. Given the substantial disease burden of CKD and the cost of ESRD, interventions to delay progression and decrease comorbidity remain an important part of CKD care. Early referral to nephrologists has been shown to delay progression of CKD. Conversely, late referral has been associated with increased hospitalizations, higher mortality, and worsened secondary outcomes. Late referral to nephrology has been consequent to numerous factors, including the health care system, provider issues, and patient related factors. In addition to timely referral to nephrologists, the optimal modality to provide care for CKD patients has also been evaluated. Multidisciplinary clinics have shown significant improvements in other disease states. Data for the use of these clinics have shown benefit in mortality, progression, and laboratory markers of disease severity. However, studies supporting the use of multidisciplinary clinics in CKD have been mixed. Evidence-based guidelines from groups, including Renal Physicians Association and NKF, provide tools for management of CKD patients by both generalists and nephrologists. Through the use of guidelines, timely referral, and a multidisciplinary approach to care, the ability to provide effective and efficient care for CKD patients can be improved. We present a model to guide a multidisciplinary comanagement approach to providing care to patients with CKD.

Peritoneal Dialysis Versus Hemodialysis: Risks, Benefits, and Access Issues

Ramapriya Sinnakirouchenan, Jean L. Holley — 2011-11-01

Peritoneal dialysis (PD) and hemodialysis (HD) are dialysis options for end-stage renal disease patients in whom preemptive kidney transplantation is not possible. The selection of PD or HD will usually be based on patient motivation, desire, geographic distance from an HD unit, physician and/or nurse bias, and patient education. Unfortunately, many patients are not educated on PD before beginning dialysis. Most studies show that the relative risk of death in patients on in-center HD versus PD changes over time with a lower risk on PD, especially in the first 3 months of dialysis. The survival advantage of PD continues for 1.5-2 years but, over time, the risk of death with PD equals or becomes greater than with in-center HD, depending on patient factors. Thus, PD survival is best at the start of dialysis. Patient satisfaction may be higher with PD, and PD costs are significantly lower than HD costs. The new reimbursement system, including bundling of dialysis services, may lead to an increase in the number of incident patients on PD. The high technique failure of PD persists, despite significant reductions in peritonitis rates. Infection also continues to be an important cause of mortality and morbidity among HD patients, especially those using a central venous catheter as HD access. Nephrologists’ efforts should be focused on educating themselves and their patients about the opportunities for home modality therapies and reducing the reliance on central venous catheter for long-term HD access.

Transplantation and the Primary Care Physician

Rita L. McGill, Tina Y. Ko — 2011-11-01

Increasing appreciation of the survival benefits of kidney transplantation, compared with chronic dialysis, has resulted in more patients with kidney disease being referred and receiving organs. The evolving disparity between a rapidly increasing pool of candidates and a smaller pool of available donors has created new issues for the physicians who care for kidney patients and their potential living donors. This article outlines current efforts to address the growing number of patients who await transplantation, including relaxation of traditional donation criteria, maximization of living donation, and donation schemas that permit incompatible donor–recipient pairs to participate through paired donation and transplantation chains. New ethical issues faced by donors and recipients are discussed. Surgical advances that reduce the morbidity of donors are also described, as is the role of the primary physician in medical issues of both donors and recipients.

From CKD to ESRD: A Tale of Two Transitions

Robert Jan Kossmann — 2011-11-01

Transitions in levels of health offer important opportunities to affect patient outcomes. The transition from CKD to ESRD and dialysis dependence is costly in personal, social, and economic terms. This paper reviews these costs and offers resources that can be used by physicians and medical teams to help patients and their families weather the challenges of this process.

The “No Dialysis” Option

Fliss E.M. Murtagh, Lewis M. Cohen, Michael J. Germain — 2011-11-01

Increasing numbers of patients are starting dialysis who have limited prognoses for 6-month survival. The presence of multiple comorbidities, aging, and frailty contributes to this phenomenon. The rate of dialysis withdrawal has been accelerating over the past decade, and this calls into question the condition of patients who are initiating dialysis. One option is to consider and discuss the “no dialysis” option with patients and family. Patients need to be identified who may benefit from this option, and their medical management needs to be reviewed.

The Patient-Centered Medical Home and the Nephrologist

Lawrence S. Weisberg — 2011-11-01

The patient-centered medical home (PCMH) is a model of practice that has been proposed to address the many ills of our current health care delivery and financing systems. At its heart is a primary care practice that provides comprehensive, coordinated, high-quality, personalized care. Integral to the success of the PCMH model is a “neighborhood” of specialists who subscribe to the principles of the PCMH. Nephrologists will have an opportunity to practice within this framework, either as the PCMH itself or, more likely, as “neighbors” to the “home.” The effective and enthusiastic participation of nephrologists and other specialists will depend on the details of the model, not the least important of which is the financial structure. Dozens of demonstration projects around the country are currently testing the model. If the PCMH model proves to be workable and is widely adopted, nephrologists could be uniquely positioned to participate, given our long experience providing coordinated care for complex patients in a quality-conscious environment.

Masthead

2011-11-01

Editorial Board