Christopher Keller, MDDirector of Clinical Operations

Boise Kidney and Hypertension Institute

RPA 2011 Annual MeetingFriday, March 18, 2011

Disclosure of Conflict of Interest

Name of Faculty or Presenter

Reported Financial Relationship

Christopher Keller, MD

Consulting Fees

Genzyme Corporation

Affymax, AMAG

Study Investigator for Research

Cytochroma, Fibrogen, Pfizer, Takeda, Boehringer Ingelheim, Johnson & Johnson, Abbott, Amgen, Advanced Renal Technologies

Christopher Keller, MDDirector of Clinical Operations

Boise Kidney and Hypertension Institute

RPA 2011 Annual MeetingFriday, March 18, 2011

What are the issues?What are the issues?Primary care providers (PCPs) often defer referrals until

very advanced stages of CKD25-50% of all ESRD patients never saw a nephrologist until

3 months or less before onset of dialysisReasons for not referring: advanced age, comorbidities,

and perceived patient nonadherence to therapy

Fischer MJ et al., Am J Nephrol 2011;33:60-69Navaneethan et al., Clin Nephrol 2010;73:260-267

What are the issues?What are the issues?Nephrologists are spending more time focused on CKD

progression and less time on non-nephrology concernsThe use of a multidisciplinary team (MDT) to manage stage

3-4 CKD patients may slow progression of CKD and may improve outcomes at the start of dialysis

Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub

Slowing CKD progression with an MDT Slowing CKD progression with an MDT

Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub

Curtis et al. Nephrol Dial Transplant 2005;20:147

Kaplan-Meyer survival after starting dialysis therapy

Mortality benefit with an MDTMortality benefit with an MDT

Open the black box…Open the black box…PCPs must play a critical role in the multidisciplinary

teamRPA ToolKit website: http

://www.renalmd.org/toolkit-form/

Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343

How do we involve primary providers?How do we involve primary providers?Step 1: Identify your goals for co-management

Preferences for timing of referralsStep 2: Open communication lines with primary

providersAsk them directly about their co-management interestsLet them know that you are willing to answer questions

Tonelli M et al., Ann Intern Med 2011;154:12-21

How do we involve primary providers?How do we involve primary providers?Step 3: Communicate regularly with primary providers

Ensure timely, effective communication with the PCPs every visit

Track referrals and identify providers that do not refer early; devote resources for education

Electronic record systems and note templates make it easier

1) CKD--The current eGFR is [] ml/min. Chronic kidney disease is due to 2) Anemia --goal Hgb is 10 -12. Goal ferritin is > 100 and tsat is > 20. 3) HTN--goal BP is < 140/9 0. 4) Acidosis --goal serum bicarbonate is 22. 5) Vitamin D --goal 25-OH vitamin D is > 30. 6) Ca/Phos --goal Ca is 8.5 to 9.5 and goal phos is < 5; goal PTH is < 100. 7) Nutrition --goal albumin is 4.0. 8) Dyslipidemia--goal LDL is < 100 and triglycerides < 500. 9) Dialysis education --Dialysis and transplant options have been discussed. 10) Vascular access --the patient has been advised to protect the non -dominant arm for dialysis. Thanks for allowing the patient to participate in the Conductor Clinic, our clinic program dedicated to the protection of renal function in patients with late stag e CKD. Conductor labs 1 week before next visit: 1 month / 3 month / 6 month

Boise Kidney model: DocumentationBoise Kidney model: Documentation

ConclusionsConclusionsThe complexity and breath of nephrology management

has been a barrier to PCP communicationMultidisciplinary care of advanced CKD patients may

slow CKD progression and reduce mortality in CKD patients

Communication with PCPs is required to:Optimize early referralsPermit nephrologists more time and energy to focus on

prevention of ESRD