By: Dr. Jay Ginsberg, MD, MMM, Chief Medical Officer, DCC, Inc.
Beverly Brown, RNC, ANP Director of Medical Management, DCC, Inc.
Applause for Dr. Jeffrey Berns recent Medscape editorial on NKF initiatives for 2015 (“We Can Do Better” With CKD and ESRD Patients. Medscape. Aug 29, 2014)! These initiatives are an important step in facilitating positive changes in the way CKD (Chronic Kidney Disease) is managed in the U.S.
Historically, providers have managed the comorbid conditions associated with CKD, while CKD smolders in the background, hence named the “silent disease”. Most people are asymptomatic and are not told they have CKD until the late stages when they are facing dialysis. In a national study done with patients on dialysis, more than 55% indicated they were not told they had CKD until they reached end stages.(1)
We can do better. Many CKD programs only initiate management in late stages (4/5/ESRD). At risk individuals need to be identified while they are still in the early stages, when it is possible to bend the CKD progression curve to delay ESRD and dialysis for month, years, or forever. Providing early education; close monitoring of metrics; coordination of care among pro-viders; and assuring “best practices” regimens paralleling NFK Guidelines can help delay the progression of renal disease for many people.
Dr. Berns alluded to the high number of patients in the U.S. who start dialysis with a dangerous central catheter vs a fistula or PD. The USRDS 2012 Report indicates 91% of dialysis patients in the US are on in center programs. The vast majority of these, over 80%, start emergently with a hospitalization; inpatient placement of a neck catheter and inpatient dialysis. Patients dialyzing on central catheters have a 53% higher mortality rate in the first year; a 38% higher risk of cardiovascular event; and double the infection rate of patients dialyzing on other modalities.(4)This is a costly way to start dialysis, for both the pa-tient and the health plan.
We can and MUST do better! The primary goal of intervention should be to prolong the need for dialysis by months or years, but if progression does occur, the plan should be for an orderly, planned transition from late stage disease to dialysis, with elective placements of fistulas and PD catheters, and when appropriate, early referral for transplant. Education about symp-toms and signs of progressive disease and all dialysis options are essential to this goal. Patients need to make well informed decisions about the quality of life they expect to have when they face dialysis.
We can do better with transplant referrals. Renal transplant is the treatment of choice for patients with advanced CKD and ESRD. (2) A study using USRDS data on nearly 230,000 patients found that the annual death rate was significantly lower in those transplanted than in those on the waiting list (3.8 versus 6.3/100 patient years)(5) But few patients are told about trans-plant options by their providers prior to beginning dialysis, and only a small percent are told after onset of dialysis. Pre-emptive transplant and paired donor transplants have increased in popularity in recent years and have proven to be a viable option for many people. But they must be educated well ahead of ESRD as it takes time to muster donors and to be evaluated at a Center of Excellence program. Also, since cadaveric transplant is limited to a few thousand annually, patients must un-derstand the importance of listing early and dual listing.
Another area where we can do better is the coordination of care among providers. Lack of coordination between providers can lead to hospital days that could have been avoided. Medication change is one area of concern when multiple specialists are involved. Often there is no communication, or the communication is slow to reach the intended recipient. Frequently the nurse case managers have a better overall picture than an individual provider and are able to step into the role of care coordi-nator. Whether it is to oversee the entire treatment plan or question the rationale when something seems inappropriate, having a nurse coach or case manager helps ensure patients receive optimum care and insurers get good value for their expenditures.
ESRD is a deadly disease, and we need to do better at detection of CKD and prevention of ESRD. Studies indicate that screening for CKD is cost effective (3) and leads to timely education of patients, often empowering them to do something about changing the outcome. For many, this is the “wake up call” that spurs them into action for a better lifestyle and im-proved compliance all around. Well informed patients can do better!
(1) Plantinge, Boulware,Coresh et all.Patient Awareness of Chronic Kidney Disease;trends and predictors.Archives Internal Medicine:2008;168(20);2268-2275.
(2) 2014 OPTN Minority affairs Committee report, Educational Guidance on Patient referral to Kidney Transplantation.
(3) Komeda et. Al. American Journal of Kidney Disease 2014; 63(5):789-97
(4) Kavani, Palmer et all; Association Between Hemodialysis Access Type and Clinical Outcomes; A Systematic review. Journal of American Society of Nephrology 2013;Feb 24(3) 465-73
(5) Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK
Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999; 341(23):1725.