christopher keller, md director of clinical operations boise kidney and hypertension institute rpa...
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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