New Guidelines in Kidney Disease Impact on Diabetes Care

1
New Guidelines in Kidney DiseaseImpact on
Diabetes Care

• Dr. Adeera Levin
• University of British Columbia
• Vancouver Canada

2
Objectives

• The Burden of Illness
• BC estimates of kidney disease
• Consequences of Kidney Disease
• New BC guidelines patients at risk
• Relevance to diabetic care

3
Key messages

• Estimates of GFR improve the interpretation of
  creatinine and allow assessment of kidney
  function
• Values lt 60 ml/min require
• Evaluation and treatment of co-morbidities
• Serial evaluation over time
• Patients with kidney disease are at high risk for
  cardiovascular disease more than dialysis
• Maximize CVD risk management
• Assess etiology of KD, attempt to slow
  progression
• Define targets and attempt to achieve

4
The Problem

• Chronic Kidney Disease is an epidemic worldwide
• Growth 6-8 per annum of dialysis patients
• Accumulating data re possibility of delaying the
  progression of kidney disease, using multiple
  drug and behaviour intervention therapies.
• Under-recognition at earlier stages of kidney
  dysfunction persists
• Late referral
• Lost opportunities for improved patient outcomes
•  

5
Solution to Epidemic of Dialysis and Silence

• Improve identification of CKD at earlier stages
• Collaborative approaches to identification,care
  and evaluation of strategies for CKD

6
How to diagnose kidney disease

• Serum creatinine is a poor marker
• Estimates of kidney function ( GFR) are better
  predictors of outcome
• Examination of the urine is important
• High risk populations should be screened

7
Definition of Chronic Kidney Disease

• Structural or functional abnormalities of the
  kidneys for gt3 months, as manifested by either
• 1. Kidney damage, with or without decreased GFR,
  as defined by
• pathologic abnormalities
• markers of kidney damage, including abnormalities
  in the composition of the blood or urine or
  abnormalities in imaging tests
• 2. GFR lt60 ml/min/1.73 m2, with or without kidney
  damage.

8
Why estimate kidney function?

• Creatinine is a poor marker of kidney function
• Estimates of GFR or creatinine clearance are
  better predictors of outcome
• Glomerular filtration rate or creatinine
  clearance approximate true function
• The equation based GFR which appears on BC lab
  tests relies on data which is easily obtained
  from the computer system
• All equations are ESTIMATES

9
SERUM CREATININE
Differences in muscular mass
Cr 135 umol/L
GFR 100ml/min
GFR 50ml/min
10
NKF Proposed Classification of CKD

• New nomenclature staging will improve
  communication
• Clinical care
• Research initiatives
• Public awareness/ education
• Increase awareness of need for prevention
• Primary, secondary and tertiary

AJKD Feb 2002
11
Why Classify Severity as the Level of GFR?

• GFR is accepted as the best overall measure of
  kidney function in health and disease
• Providers and patients are familiar with the
  concept that the kidney is like a filter.
• GFR translates well into percentage of Kidney
  function making communication with patients
  relatively simple

12
Chronic Kidney Disease - Stages
Adapted from Am J Kidney Dis 2002 39 (2, Suppl.
1) S46-S75
13
Conservative Estimates Prevalence of CKD in
Canada (gt20 y of age) 1.3million- 2.5 million
Adapted from Am J Kidney Dis 2002 39 (2, Suppl.
1) S17-S31 and using CORR data and Pop data
14
CKDEstimated Burden 2004
15
Multiple Complications of CKDimpact on outcomes

• Hypertension and cardiovascular disease
• Nutrition
• Anemia
• Abnormalities of Mineral metabolism
• calcium, phosphate, iPTH
• Quality of Life/ Physical well being

16
Case Mrs. LC

• 60 yo woman , wt 60 kg
• Diabetes, and HTN x 10 years
• Reason for referral Renal dysfunction
• Physical Examination
• BP 140/90 , femoral bruit, decreased PP
• Meds
• HCZ 25 mg OD
• Insulin

17
Laboratory History

• 1995 1996 1997
  1998
• sCr umol/L 80 100 120
  160
• E GFR 62 49 40
  31
• Stage 2-3 3
  3 3-4
• Rate of decline (ml/min/yr) -
  13 9 9
• Continued progression 10ml/min dialysis in 2.5
  3 years
• Hgb g/L 120 116 108 99
• work up for anemia started, no cause
  identified

18
What do we know ?
19
CVD /or Diabetes
Adverse outcomes
CKD
20
Cardiovascular Mortality in the General
Population (NCHS) and in ESRD Treated by Dialysis
(USRDS)
Annual mortality ()
100
Dialysis
10
General population
1
0.1
Male
Female
0.01
Black
White
2534
4554
6574
?85
3544
5564
7584
Age (years)
21
Hospitalizations CKD is expensive, longer
lengths of stayCanada 99/00 CIHI / CORR

• Adm Total Days Mean LOS
• All Acute 3.3 million 27 million
  4.8- 16.4
• Total CKD 67,000 908,000 9.6 -15.2
• 2 3
• Est Costs CKD - 1,363,270,500
• (assume 1500/dy)
• Excludes Dialysis , ? Complete Dx CKD,
  therefore Underestimate

22
The costs of CKD are higher if you have DM or
heart disease Dialysis pts have longest
hospitalizations CIHI / CORR

• Adm Mean LOS
• DM, No CKD 265,442 5.6- 13.2 days
• DM CKD 7,532 10.8-14.9 days
• Cardiac No CKD 623,736 6.4-11.8 days
• Cardiac CKD 15,503 9.1-15.5 days
• Hospitalizations diagnostic codeDM Cardiac
  Disease, with and without CKD Canada 99/00

23
In patients at risk, 25-40 have GFR lt60ml/min
International Survey of 20,000 pt charts in non
nephrology offices N 7000 se creatinine
available for calculations Levin et al ISN,
2003
24
Kidney Disease

• Prevalent in identifiable groups
• Aging (gt 60)
• Diabetes
• Hypertension/Cardiovascular disease (CVD)
• Specific ethnic groups Aboriginals, African
  Americans, Asians
• Family history of KD

25
Consequences of the SilenceContributors to the
Epidemic

• Late referral
• High risk patients
• Who are high risk patients?
• Who is being referred to nephrology care?
• Where are the high risk groups receiving care?

26
International survey of referral patterns Nov
2001 N 930 pts, 13 countries
People are referred late to nephrologists
Pts

• 55 of patients lt30 ml/min
• 80 of patients lt60 ml/min

lt15 15-30 30-60
60-90 gt90
Calculated GFR (ml/min
Levin et al , ISN 2003
27
Most specialists refer late
60
Calculated GFR (ml/min)

lt15
6089
1529
?90
3059
40
60 of patients under care of specialists for
more than 1 year
20
General practice
0
Cardiology
Endocrinology
Other
Diabetology
213
92
10
26
192
165
Levin et al ISN, 2003 submitted Lancet
?2 91.02, df20, plt0.001
28
Consequences of late referral

• Costly to /for patient
• Not able to avoid dialysis
• missing the chance of therapies
• Delay progression of kidney disease
• Prevent/ protect against cardiovascular disease
• no adequate preparation for RRT
• Costly for society
• longer hospitalisation
• vascular access procedures
• selection of dialysis modality/ pre-emptive
  transplant

Jungers NDT 2002 17 1371
29
Provincial Strategies to Reduce the Burden

• Public awareness
• Professional education
• Policy Influence
• Care Delivery Systems
• Research
• Basic, clinical, and outcome based

30
Northern Region
Interior Region
Vancouver Coastal Region
Vancouver Island Region
Fraser Region
31
Baseline information British ColumbiaHow are we
doing?

• Hi risk Population survey
• Patients alive/ registered 1993- 2001
• CVD, HTN or Diabetes
• Age and gender
• N 669,000
• Over age 60 419,000
• Serum creatinine within last 2 years
• 40

• Incident dialysis pts 2001
• 40 diabetics
• Incident diabetic dialysis pts
• 40 had referral to nephrology lt 3 mo prior to
  dialysis start

Unpublished data, Ministry of Health, BC
32
Prevalence of High Risk groups BC2002-03 Cohort
( 4 million pop)
N 607,821
Excludes anyone with diagnosis of CKD
344,506
53,820
67,602
21,255
34,370
6,805
79,463
33
High risk groups are not well screened for
CKDData British Columbia 2002/03 cohort
years
34
High risk groups are undertreatedData British
Columbia 2002/03 cohort
years
35
Even those in highest risk groups DM /- CVD
and HTN are undertreatedData British Columbia
2002/03 cohort
years
36
CKD Provincial strategy

• The Solution
• Identify patients with CKD early in course
• Reduce potential for mis-interpretation of common
  tests
• Identify key elements to successful strategy for
  early identification and care
• Collaboration
• Cooperation
• Education
• Data Collection

37
Provincial CKD Initiative

• Multi-faceted Strategy (led by MOHS CDM and
  BCPRA)
• standardization of lab testing
• new clinical practice guideline for physicians
• new patient registry to help identify and track
  patients at all stages
• patient self-management support
• development of best practice networks
• Detailed info at www.healthservices.gov.bc.ca/cdm/

38
Collaboration Interdisciplinary

• MOH/ CDM group
• PRA/PHSA
• BC Association of Laboratory Physicians,
• CEQAL Lab standardization
• Health care professionals
• GPs, Internists, Cardiologists,Endocrinologists,
  Nephrologists
• Nurses, social workers, dieticians, and
  pharmacists
• GPAC
• Guidelines and protocols committee
• Kidney Foundation
• Patient representatives

39
Clinical Practice Guideline

• Dispels belief that little can be done to slow or
  prevent onset of ESRD
• 7 recommendations for investigation management
  (at-risk and diagnosed)
• Care objectives to gt appropriate, evidence-
  based care
• Patient flow sheet
• Physician resource list

40
Clinical Practice GuidelineRecommendations

• Screen high-risk populations
• Evaluate patient with abnormal screening test
  results (determine stage)
• Determine cause of kidney disease
• Identify care objectives (e.g. bp, diabetes,
  weight/nutrition, cardiovascular risk, GFR and
  urine testing, psychosocial health etc.)
• Support patient self-management
• Meet care objectives
• Refer
• when unable to determine cause or meet objectives

41
Interventions to delay progression

• Guideline recommendations concordant wit other
  publications
• Life style changes ( smoking)
• Blood pressure control lt 130/80
• ACE inhibitors
• Protein restriction
• Patient involvement in care

Pennell JP. Am J Med 2001 111 559 568 2004
MOH websitemspprotocols
42
Definable Target treatments

• Blood pressure lt 125/ 75 (130/80)
• Proteinuria lt 1 gm/day
• Use of ACEi /- ARB
• Average 4 BP meds per pt to achieve goals
• Calcium, phosphate, iPTH Normal values
• Use of vitamin D supplements, calcium and
  phosphate binders
• Nutrition
• HCO3 N, Albumin N
• Sequential measurement of kidney function
• Predict progression education preparation

43
Patient Materials

• Clinical guideline includes
• Patient flow sheets
• Guide for Patients on managing health
• Patient log sheet to track key info, including
  medication use
• MOHS CDM website includes range of patient
  information on CKD and links to self-management
  resources

44
Care Goals of CKD Programs
CKD
Adapted from Pennell JP. Am J Med 2001 111 559
- 568
45
Integrated Strategies BC Early identification

• Integrated strategy ( MOH, MDs, Lab, patients)
• Laboratory reporting of estimated GFR
• Standardized creatinine measurements against gold
  standard
• Automatic reporting of GFR
• Guideline for identification and care
• Physician directed guidelines interpretation and
  management
• Patient log
• Education strategy
• Web based patient and MD education
• CDM Tool kit
• Questionnaire
• Health Outcomes Research

46
Proposed Impact of strategy

• Overall
• Reduce the number of pts with identifiable
  diseases who are referred late
• I.e. diabetics with late referral should be
  reduced
• Improved interpretation of serum creatinine
• Timely referral to nephrology
• Reduced unknown burden

• Measurable outcomes
• New knowledge
• of high risk populations with CKD
• Outcomes of pts depending on services accessed
• MD knowledge/ impact of formal education
  strategies
• Reduction in rates of progression to dialysis
• Cost savings
• Costs of screening high risk vs benefits

47
Co-Management of Pts with CKD
General Internist
General Practitioner
At increased risk
Severe?Kidney function
Mild ?Kidneyfunction
Moderate ?Kidneyfunction
Kidneyfailure
Kidneydamage
120 90 60 30 15
Endocrinology
Cardiology
Nephrology Team
Other specialties
48
Conclusions

• CKD is a major public health problem
• Mild CKD is associated with worse outcomes
• Diabetics constitute a high risk group
• All Diabetics should be screened for KD
• Monitor eGFR and MA
• Achieve target BP and elimination/reduction of MA
• Use of ACEi/ ARB clear
• Collaborative care