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Improving kidney health and awareness through community-based education

Improving kidney health and awareness through community-based education. Mary Bates, RN. Goal - Objective. Educate nephrology community about new Pre-ESRD classes and current pilot programs in the greater Houston area. At the end of this presentation the reader will be able to answer.

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Improving kidney health and awareness through community-based education

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  1. Improving kidney health and awareness through community-based education Mary Bates, RN

  2. Goal - Objective Educate nephrology community about new Pre-ESRD classes and current pilot programs in the greater Houston area

  3. At the end of this presentation the reader will be able to answer • Why Kidney Education is important in Chronic Kidney Disease or CKD • What is a community-based education program • What information is included in CKD education program • How does early CKD education program benefit patient outcomes and the physician’s practice • What patients say about early CKD education • How one can participate or set up a program

  4. Chronic Kidney Disease in the US • Over 20 Million Americans have some degree of renal insufficiency….1 in 8 people. • 20 million others are at risk • Hypertension & Diabetes are the leading causes of kidney failure • 23% of all Americans have hypertension • 16 million Americans have diabetes • Both are independent risk factors for cardiovascular disease

  5. Knowledge is Power…for us and our patients. To educate patients is the highest form of care we can give. It empowers our patients to make changes big and small to improve their health and quality of life. It empowers them with control and information to feel more relaxed in an anxiety producing situation of CKD transition to ESRD. CKD EDUCATION

  6. Projection for ESRD Population USRDS ADR 2008

  7. Incidence by Race 2008

  8. African Americans Develop ESRD at a Younger Age

  9. New Conditions of Coverage • ESRD Medicare Reform • Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 – MIPPA) • CKD education is recognized by CMS • Reimbursement to nephrologists who provide chronic kidney disease education • Physicians Must Educate CKD Patients on: • Kidney disease • Access choices and issues • ESRD Treatment options • Physician performance is based on • Influenze vaccine • Blood Pressure control • Referral for an AV fistula • Laboratory values – Ca, PO4, PTH, Lipid profile *Best physicians educate on much more.

  10. Why Educate? • Why…Educate? And When? The earlier the better….Start education by stage 2 or 3 to have the biggest impact. • One reason is we must. The new cfc regulations are requiring pt education on kidney disease, treatment options, accesses. I don’t think this man had his “Save my vessels” class information or he would not allow anyone to stick him up and down both arms. • Another reason: It is smart use of patients time and energy. Pts who use this information stay healthier longer and start dialysis in a better place both physically and mentally. If they come to us healthier – they start healthier in ESRD with better Outcomes, more choices and better quality of life. • They make better choices: more open to dialysis options when starting dialysis not an emergency. When pt education is done ahead of starting dialysis Home dialysis is chosen more often.

  11. What is community-based education? • Patient education program that includes: • Multidisciplinary coaching program • Stage-specific education • Easy education referral process • Follow-up with patients and physicians • Sessions are free for patients and guests

  12. Location Location Location Find a comfortable location and time.

  13. Location The course does not need to be held in Maui, although it would be nice. A church down the street with a large conference room works fine. Experience with renal treatment options training reveaed we would gain more patients in a non-medical location. And our participants have reinforced that concept. The Houston Community-based CKD program sponsored by DaVita, known as EMPOWER, has had nearly 200 pts/family/friends The patient feedback is very positive

  14. What is Community-Based Education?Multidisciplinary Coaching Multidisciplinary coaching program • Inform patients about their kidney health • Improve quality of life • Preserve renal function • Help patients identify the best treatment choice for their lifestyle • Tools to organize and track their health care • Health Diary

  15. Multidisciplinary education • Multidisciplinary coaching program can make a difference. • A nurse, a dietitian and a social worker attend each class to present the information and answer questions. • The goal is help patients learn as much as they can about kidney health. • Informed patients are less anxious and more equipped to effectively follow their treatment plan, preserve renal function and improve their quality of life. • CKD education helps patients to identify the best treatment choice for their lifestyle and reinforce early fistula placement.

  16. Benefits of early intervention and education • Delay or prevent the worsening of cardiovascular disease, hypertension and diabetes • Delay or prevent the progression to chronic kidney disease • Improve outcomes if kidney replacement therapy ever becomes necessary • Psychologically prepare one for kidney disease • Reduce health care costs • Keep people employed and out of the hospital

  17. Tools Provided • An initial postcard and quarterly e-newsletters • Valuable tools from a well-regarded website, http://davita.com • GFR calculator and tracker • 500 CKD recipes • DaVita Diet Helper • CKD videos • More. • The health diary is a tool given to each CKD patient and is designed to help organize and track their health care. We recommend that patients utilize their Health Diary for all provider visits to maintain continuity of care.

  18. TOOLS FOR BETTER CARE

  19. Health Diary Resource for the patients • Patient information • Healthcare phone numbers • History and Physical • Medication list • Lab work • Diabetes and Hypertension • Glossary

  20. The health diary • Both the patients and the doctors really like this diary. • Not only is it a great resource but it gives the patients a central location to keep their valuable health information. • They just ask for copies and file it away. • When they go to any health professional, they have it. • Even with Hurricane Ike – pick it up and go. • The doctors like it when they can see all the information. • Best from patients is the questions to ask the doctor. • Reminds them of the importance of the medication, BP or lab results.

  21. What stage am I? This is the question most patients ask. We review kidney function and the stages of kidney disease. We review how this calculation works and that is based on both kidneys. We discuss that the stages are generally progressive but that patients can impact or slow the progression of kidney disease with diet, medications and healthy behaviors. Patients need to be informed and ask lots of questions of their health care team and physicians. • Stage 1 – GFR ≥ 90 cc/min/1.73m2 • Kidney Damage with normal or high GFR • Stage 2 – GFR – 60 to 89 cc/min/1.73m2 • Kidney Damage with mildly decreased GFR • Stage 3 – GFR – 30 to 59 cc/min/1.73m2 • Moderate decreased GFR • Stage 4 – GFR – 15 to 29 cc/min/1.73m2 • Severely decreased GFR • Stage 5 – GFR - < 15 cc/min/1.73m2 • Kidney failure NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

  22. Glomerular filtration rate • The serum creatinine by itself is a very POOR way to assess kidney disease. • It does not take into account variation in muscle mass, nutritional status or body habitus • GFR measures how well your kidneys filter waste products, which tells your doctor how well your kidneys are working. • In 2002, the National Kidney Foundation began recommending the use of GFR instead of just serum creatinine for a more accurate measurement of kidney function. • GFR is calculated from your blood creatinine, age, race and gender. From AAKP Healthline, 2009 – Stephen Z. Fadem

  23. Assessment of kidney disease • Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD), but in following its progress. • Although there are various ways to do this, the simplest is the MDRD GFR (glomerular filtration rate) which can be calculated using a patient’s age, race, gender and a laboratory test, known as the serum creatinine. The muscles are in a constant state of being broken down and being repaired. • The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day. • While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors mentioned above necessary. • This equation was derived from a large study published in 1994 that looked at how the modification of dietary protein would affect renal disease – hence Modification of Diet in Renal Disease (MDRD). • This study required a very accurate measurement of kidney function. The investigators noticed the mathematical relationships between the accurately measured GFR, age, race, creatinine and gender, and derived the MDRD study equations still in use today. • It is also referred to as the eGFR. This GFR is used to determine what stage of kidney disease one has, stages 1 and 2 being very mild, with GFRs above 60 ml/min. • When the GFR is greater than 60, other markers of kidney function such as an abnormal urine or abnormal ultrasound are necessary for making the diagnosis. When the GFR is less than 60 for greater than three months, it indicates the presence of CKD. • Once the GFR is calculated, and repeated in 3 months we also need to look at other markers of Kidney disease. While this is necessary if the GFR is > 60, we also recommend testing for markers strongly in everyone since it helps us reverse the reversible and get a better diagnosis. Markers include the renal ultrasound and the urinalysis. • Although the calculation involves some complicated math tricks, it was programmed for the Internet shortly after it was discovered, and is on the Web at www.mdrd.com. • The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators. • Many laboratories routinely report the MDRD GFR along with the serum creatinine value. As more and more laboratories standardize their serum creatinine measurements to the National Institute of Standards, the equation will change slightly, but that change is also programmed and available at www.mdrd.com. • When using the program, simply key in your serum creatinine, age, race and gender and your GFR value will appear. The site will also calculate your kidney disease stage. It is important that you personally keep track of your serum creatinine and GFR values. From AAKP Healthline, 2009 – Stephen Z. Fadem

  24. You have heard about Cystatin C • Serum creatinine has a drawback in the measurement of glomerular filtration rate (GFR) in that it may vary according to muscle mass. • Cystatin C is a 13 kilodalton protein that is filtered by the glomerulus and reabsorbed and metabolized by tubular cells. The amount that is excreted into the urine is negligible. Its production is very steady, and not dependent on muscle mass. • It has been proposed as an alternate marker for estimating GFR by Dr. Joe Coresh. • An elevated serum cystatin C level may indicate a worse cardiovascular risk in patients with the metabolic syndrome. (18456039) . • The literature is emerging, and showing that it has benefit as a marker. Here are two formulae that might be useful in demonstrating the relationships between serum creatinine and serum cystatin C • The serum cystatin C calculation is found at http://touchcalc.com • Joe Coresh recommends averaging the Cystatin C and the MDRD GFR

  25. Clinical evaluation of patients at increased risk for CKD • All Patients • Measurement of blood pressure • Serum creatinine to estimate GFR • Protein to creatinine or albumin to creatinine ratio in first AM or random untimed spot urine specimen • Examination of the urine sediment or dipstick for red blood cells and white blood cells

  26. Stage-Specific Education Taking Control of Kidney Disease Living with Stage 3 and Early Stage 4 CKDFocus on preserving renal function • Normal Kidney functions / Kidney Disease • Control of co-morbidities / Diabetes / HTN • Diet and medication • Heart healthy behaviors • Preserving veins • Insurance questions • Questions to ask physician

  27. Treatment of CKD • Treat the underlying disease • Treat associated problems • Slowing the loss of kidney function • Prevent heart disease • Reduce complications • Preparation for dialysis/transplantation • Kidney transplant or dialysis NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

  28. Definition of Chronic Kidney Disease • Chronic kidney disease is defined as either kidney damage or GFR < 60 cc/min/1.73m2 for ≥ 3 months. • Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

  29. Clinical Practice Guidelines for Management of Hypertension in CKD

  30. Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD

  31. Stages 1 and 2: Preventing Heart Disease in CKD • Traditional cv risk factors • Non traditional risk factors

  32. How Can You Protect Yourself Against Heart Disease And High Blood Pressure? • Get regular medical checkups • Control your blood pressure • Monitor your blood pressure weekly • Check your cholesterol regularly – watch saturated fats and fructose • Watch your diet - SALT • Regular doctor visits • Blood pressure - 130/80 • It make take several medications • Don’t smoke • If you choose to drink, do so in moderation • Exercise regularly • Manage stress

  33. Traditional Risk Factors • Smoking • Cholesterol • Obesity • Family History

  34. Non Traditional Risk Factors • Inflammation • Mineral-bone disorder • Anemia

  35. ACEs and ARBs • These drugs are critical to care starting in Stage 1 and 2 • ACES and ARBs have a compound effect on blocking the renin-angiotensin system. • The goal is to lower the blood pressure to 120 mm Hg and to titrate proteinuria. • Contraindications include allergy and bilateral renal artery stenosis • Potassium levels should be monitored closely when patients are on ACES or ARBS • (Beta blockers, NSAIDS, ACES and ARBS can raise serum potassium)

  36. Blood Pressure Is Poorly Controlled in Patients With CKD

  37. Inflammation • Associated with CKD • Atherosclerosis • Vascular calcification • Statins not helpful in CKD5 • CRP not diagnostic • MIA

  38. Exercise And Kidney Care • Talk to your doctor about starting an exercise program that’s right for you. • Exercise can help you improve physical functioning and emotional well-being, increase physical stamina, improve blood pressure and reduce the risk of heart disease, lower cholesterol, help you sleep better and control body weight. • Incorporating consistent aerobic exercise, even taking a 20-minute walk, can help especially if your CKD is a result of hypertension or diabetes.

  39. Watch meds and therapies Here are some examples: • Avoid Metformin in Stage 3 and beyond • Contrast media – • Nephrogenic sclerosing fibrosis may occur with an MRI due to galadinium contrast – so procedure should be done without this contrast agent • Iodine can be nephrotoxic – and patients should be well hydrated pre procedure • NSAIDS should not be given to kidney patients

  40. Diet • Sodium - 100 mmoles • Lipids - pre dialysis • Carbohydrates - Diabetes • Proteins - MDRD Trial • Potassium - watch because of ARBs and ACE inhibitors

  41. Nutritional Tips For Healthy Kidneys • In order to help maintain healthy kidneys it is important to eat properly • Keep track of daily calories • Limit total fat • Watch high fructose corn syrup • Watch excess proteins and phosphorus - Monitor the amount of protein eaten • You may need to watch potassium - Learn about potassium • Your dietitian can help you with recipes that fit your needs • Control salt intake • Take care of your bones – exercise and take vitamin D • Be sure to get enough iron • Watch fluid intake • Understand your nutritional plan

  42. Stage 3 – Medical Focus • CKD MBD – Metabolic bone disease • Acidosis - Bicarbonate • Anemia – Erythropoietin Class reinforces bone and heart healthy diet.

  43. Stage 3 • a. Cardiovascular risks and therapy – stay the course • b. Preparation: 1. Anemia 2. Acidosis 3. Blood pressure/ACEs and ARBS 4. Inflammation 5. Diet 6. Modality choice 7. Access preparation • c. Modalities of therapy

  44. Preparation • Anemia • Acidosis • Blood pressure - ACES & ARBS • Inflammation • Diet • Modality Choice • Access Preparation

  45. Anemia in CKD • Anemia management with EPO since 1990s - • Keep Hct < 42 • N Eng J Med 339:584-90, 1998 • Keep hgb 10 - 12 • CHOIR • N Eng J Med 355:2071-2084, 2006. • 34% worse when hgb target is 13.5 than 11.2 • CREATE • N Eng J Med 355:2084-2098, 2006 • 22% worse when hgb is 13-15 than 10.5-11.5 • Check Iron levels and correct first • EPO can be given in the office - monitor blood work

  46. EPO RBC RBC PRECURSOR

  47. Acidosis • Increased protein catabolism of amino acids • Inhibition of protein synthesis can cause a low albumin • Accelerates renal osteodystrophy • Modulates vitamin D and parathyroid hormone levels • Evokes insulin resistance

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