- Email: [email protected]
Referral and Comanagement of the Patient With CKD
Referral and Comanagement of the Patient With CKD Garland Adam Campbell and Warren Kline Bolton CKD is a common condition with well-documented associated morbidity and mortality. Given the substantial disease burden of CKD and the cost of ESRD, interventions to delay progression and decrease comorbidity remain an important part of CKD care. Early referral to nephrologists has been shown to delay progression of CKD. Conversely, late referral has been associated with increased hospitalizations, higher mortality, and worsened secondary outcomes. Late referral to nephrology has been consequent to numerous factors, including the health care system, provider issues, and patient related factors. In addition to timely referral to nephrologists, the optimal modality to provide care for CKD patients has also been evaluated. Multidisciplinary clinics have shown significant improvements in other disease states. Data for the use of these clinics have shown benefit in mortality, progression, and laboratory markers of disease severity. However, studies supporting the use of multidisciplinary clinics in CKD have been mixed. Evidence-based guidelines from groups, including Renal Physicians Association and NKF, provide tools for management of CKD patients by both generalists and nephrologists. Through the use of guidelines, timely referral, and a multidisciplinary approach to care, the ability to provide effective and efficient care for CKD patients can be improved. We present a model to guide a multidisciplinary comanagement approach to providing care to patients with CKD. Q 2011 by the National Kidney Foundation, Inc. All rights reserved. Key Words: CKD, PCP
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KD is common in patients and carries a significant burden of disease. The number of patients with CKD defined as an eGFR ,60 ml/min/1.73 m2 is estimated at 8 to 13 million in recent studies assessing The National Health and Nutrition Examination Survey (NHANES) data.1-3 CKD is growing more prevalent with time.4-7 CKD is also associated with significant morbidity and mortality. Potential efforts to delay progression and improve outcomes include interventions such as early referral to nephrology, multidisciplinary care, and intervention in known or suspected progression factors. Not only is there a high financial cost of ESRD care but also the true ‘‘cost’’ of ESRD goes beyond the cost of therapy. Delaying progression to ESRD will likely impact patient morbidity and mortality as well as avoid reductions in quality of life that are associated with ESRD. These are all significant reasons why possible interventions to delay progression of CKD to ESRD are important. Medication interventions and collaborative care have been shown to delay progression in CKD patients.8-14 Despite clinical practice guidelines, implementation of appropriate measures and monitoring for CKD patients are often not present at the time of referral to a nephrologist. This emphasizes the importance of early referral to nephrology for patients with CKD. Multiple studies
From Division of Nephrology, University of Virginia Health Sciences Center, Charlottesville, VA. Address correspondence to Warren Kline Bolton, MD, Division of Nephrology, University of Virginia HS, P.O. Box 800133, Charlottesville, VA 22908. E-mail: [email protected] Ó 2011 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 doi:10.1053/j.ackd.2011.10.006
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have shown that progression of kidney disease and other secondary markers of comorbid conditions are delayed after referral to nephrology.15-17 Once patients have been referred to nephrology, there is some question as to the best way to provide care for these patients. Multidisciplinary clinics have been shown to be beneficial to patient care in multiple patient populations. Studies with CKD patients in regard to multidisciplinary clinics have been mixed.14
Impact of Multidisciplinary Care Multidisciplinary clinics and team approaches for health care have numerous potential benefits in providing care for patients requiring subspecialty care. The benefits have been shown in disease states, including diabetes, cardiology, rheumatology, and oncology.18 This has also been assessed in CKD patients. These studies have compared outcomes including survival and progression with dialysis. Data include both observational and randomized studies. The members of multidisciplinary teams vary based on the setting, but frequently include a combination of a nurse educator, physician, social worker, nutritionist, and pharmacist.18,19 Some early data did not show a benefit of MDC, which raised the question of interventional care or recommendation-based care. Harris and colleagues did not show benefit in either delay in progression of renal function or mortality.20 Several reviews and studies have suggested that a negative result was due in part to lack of implementation of recommendations.8 Other studies have had negative findings regarding MDC. Isbel and colleagues reviewed 200 patients randomized to standard care or MDC focused on vascular risk factors. Biochemical markers, such as low-density lipoprotein cholesterol and
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homocysteine as well as blood pressure, were improved in statistically significant improvement in control of lipids MDC. No effect was seen on vascular assessment, includand blood pressure in 9 months. The decrease in eGFR ing carotid intima-media thickness or brachial artery reacwas noted to be 3.6 mL/min/1.73 m2 in the 9 months preceding the study, compared with 0.32 mL/min/1.73 m2 tivity. The lack of effect on vascular complications may have in the 12 months of the study period. The algorithm been due to late referral to the MDC in this population, as was most helpful for patients with a decrease in eGFR 60% of patients were already on dialysis.21 Mortality effects have been seen in some follow-up of greater than 5 mL/min/1.73 m2 in the time preceding MDC studies. In one such study, Curtis and colleagues the study. This UK study benefited from the universal use compared standard nephrology care and MDC in cohorts of eGFR reporting in patient identification.11 In a study based out of 2 nephrology clinics in Taiwan, from both Canada and Italy. These patients were selected W Wu and colleagues evaluated patients randomized to for inclusion after already starting dialysis. To exclude MDC approaches with a patient education focus. {1586} late referral patients, those who had not seen a nephroloThese patients were selected based on referral to nephrolgist for at least 3 months were excluded from the study. ogy and randomization, not selected based on eGFR. The Short-term data showed an improvement in hemoglobin, educational component was developed using KDOQI albumin, and calcium. Long-term data showed a statistiguidelines. The use of MDC in this study showed a decally significant improvement in survival based on use of crease in progression to dialysis, mortality, and the comMDC. The only other factor associated with survival at posite of these endpoints. There was a standardized 12 months was age. A limitation of this study was that education plan in this study, which included the discusit was limited to patients who initiated dialysis, introducsion of dialysis modalities and vascular access planning. ing a survival bias to the study. There was also selection This study showed an increase in the number of patients bias present in this study, as it was not a randomized opting for peritoneal dialycontrolled trial.18 Also showing an effect on sis in the group receiving CLINICAL SUMMARY mortality, Hemmelgarn and MDC education. Patients CKD is an enormous and growing problem in the USA and colleagues compared a cohort choosing hemodialysis across the world. of elderly patients in Canada were less likely to initiate from database review. The with a catheter for access.23 Nephrologists and their immediate “teams” are unable to manage the volume of patients who have CKD. The use of MDCs to impatients found to be enrolled plement guidelines with in MDC were propensity Non-nephrologist providers have the skills to deal with improvement of outcomes score matched to patients many nephrology related issues, but the skill level and willingness to provide that care varies. has been shown to improve cared for outside of an cardiac risk.24 This effect of MDC. A decrease in mortal Early PCP referral to nephrology care teams with coimplementing guidelines, ity over the time of the study management of CKD patients affords a solution to providing quality care for the increasing CKD population. such as those detailed in (3.5 years) was seen in the coKDOQI and KDIGO, may hort of MDC patients combe able to provide similar pared with controls. No benefits in CKD patients. In focusing on guideline impledifference was seen in hospitalization rate, either for allmentation, Thanamayooran and colleagues evaluated the cause or cardiovascular events (defined as acute myocarability of an MDC to meet guideline goals.25 This study dial infarction, congestive heart failure, cerebrovascular evaluated over 300 patients in a retrospective cohort duraccident, and transient ischemic attack). There was a trend ing 10 years in MDC. This study was able to document an to significance in cardiovascular hospitalization.22 Bayliss and colleagues assessed the rate of decrease in improvement in blood pressure control and metabolic glomerular filtration rate (GFR) in MDC patients. The pamarkers. There was also an increase in the number of patients in the MDC historical cohort had a slower rate of tients choosing peritoneal dialysis as a modality for renal decline in GFR in unadjusted and adjusted analysis. No replacement therapy (RRT). Unfortunately, despite use of effect was seen on blood pressure, low-density lipoproa multidisciplinary approach, guideline targets were not tein, or HbA1c by MDC care.14 This would suggest an inmet in a significant number of patients. Examples of this dependent effect on renal function outside of any effect include 40% of patients not receiving renin-angiotensin on diabetic or hypertensive control. blockade, 30% of stage 5 CKD patients with hemoglobin Using a focus on patient education as part of an below 100 g/L, and half of stage 5 CKD patients with hyalgorithm-based approach to MDC, Richards and colperphosphatemia.25 Other studies have shown different benefits of MDC in leagues evaluated 483 patients in a UK cohort of CKD CKD patients. These benefits have included laboratory management. The algorithm used in this study focused parameters, vascular access parameters, and increased on patient education, but also included dietary managepatient usage of peritoneal dialysis as a modality of ment, medication adjustment, and optimization of cliniRRT.23 Goldstein and colleagues showed improvement cal management. This study was able to demonstrate
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in laboratory parameters, including albumin, hemoglobin, and mineral metabolism with MDC. This study also showed an increase in the number of patients initiating dialysis with a mature arteriovenous fistula.26 Yeoh and colleagues confirmed a decrease in the use of temporary catheters at initiation of dialysis.27 Given the substantial benefits of autologous access over catheter based access, this highlights an important potential benefit of MDC. The implementation and intended patient benefits of Fistula First and Renal Physicians Association (RPA) initiatives, which promote increasing incidence of fistula in our dialysis population, would likely benefit from increased use of MDC. The Goldstein prospective cohort study also showed an increase in the number of patients initiating peritoneal dialysis compared with controls. One negative finding noted in this study was that a significant number of patients did not meet KDOQI goals. No effect was seen on mortality in this study.26 A negative finding in several MDC studies was an inability to meet guideline goals.25,26 Although this has been argued as a negative finding, it should be noted that although guidelines were not universally met in these studies, there was an improvement in the percentage of patients meeting goals in both studies. In reviewing and assessing the impact of MDC, it has been difficult to determine what factors are responsible for the impact seen in several studies of MDCs. Data can be extrapolated from other studies to show the benefit of specific parts of MDC. The Modification of Diet in Renal Disease study demonstrated a potential benefit of intensive diet management on progression of CKD although the results during the trial approached, but did not reach, significance.9 Dietician activity in MCD can provide this for patients. Modification of Diet in Renal Disease and other trials such as REIN and RENAAL have also shown the benefit of intensive blood pressure monitoring and control. An MDC can help provide the close monitoring through physician-directed activity of associated providers.8 MDC does require a significant amount of infrastructure, and part of the improvement in patient outcomes may be due to the increase of clinic contact time for patients with chronic disease. Studies that have shown a positive impact of MDC suggest an economic benefit of up to $4000 per patient partly because of a decrease in emergent dialysis starts and fewer days spent in the hospital during the first month on dialysis. The estimated cost of MDC included approximately $1800 per patient year, with the expectation of 8 clinic visits per year. That estimate does not include medication costs, laboratory tests, and physician fees.28 That said, the delay in progression to ESRD seen in some MDC studies could have an offsetting financial effect. Previous studies have suggested only a 10% decrease in progression to ESRD could create a savings of $9 billion over a period of 10 years in the United States.10,11,29
In summary, although the data have been mixed, evidence from multiple different types of studies suggests a medical, societal, and financial benefit of MDC of patients with CKD. Patient education, one of the key components of MDC, has been shown in several settings to be influential in improving patient outcomes. Further studies, including randomized controlled trials, need to be performed to show conclusive benefit of MDCs in nephrology.
Referral Timing Numerous studies have looked at the effects of referral to nephrology on patient outcomes. These studies have generally shown a benefit to referral to nephrology, especially early referral. There have been extensive studies on the characteristics leading to late referral. These studies have also examined ways to increase appropriate referrals to nephrology.4,30-32 When assessing these data, different definitions of ‘‘late referral’’ have been used. This has been based at times on months before dialysis, ranging from 1 to 6 months.27 As this is retrospective, it is less beneficial in advising appropriate referral timing. Guidelines such as KDOQI have recommended referral in stage 4 CKD (eGFR ,30), possibly earlier.27-29 Even with these recommendations, available literature varies on its definition when assessing data. Jones and colleagues performed an observational study of over 700 patients and compared the rate of decline eGFR in the 5 years before and after referral to a nephrology clinic. Overall, before referral, there was a 5.4 mL/min/1.73 m2/y decline in function, which decreased to a 0.35 mL/min/1.73 m2/y after referral. In this study, 84% of patients had a decline of .1 mL/min/1.73 m2/y before referral, and 55% had a decline of ,1 mL/min/ 1.73 m2/y after referral. In those referred with a more rapid decline in eGFR, over half of these patients showed an improvement in their rate of decline of renal function.15 Some of the benefits of early referral that have been shown in the literature include a decrease in hospitalizations and mortality at 1 year. Hospitalizations were noted to be significantly increased from 13.5 6 2.2 days to 25.3 6 3.8 days for patients with late referral in a metaanalysis of 8 studies. The 1-year mortality was also higher in late referrals (29%-13%), with a risk ratio of 2.08 (1.31-3.31).4 There is also an increase in the frequency of CKD secondary complications in patients who are referred late to nephrology. These include anemia, poor nutrition, and uremic complications.4,33 A retrospective study of 1057 hemodialysis patients in France showed a decrease in hemoglobin for patients with follow-up of less than 6 months when compared with populations with followup of 6 to 35, 36 to 71, and greater than 72 months.33
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Individual studies as well as a larger meta-analysis have shown a significant decrease in albumin in patients with late referral.4,33,34 Preparation for RRT is also facilitated by early referral. Vascular access planning and RRT preparation are also important components of CKD care. Patients with early referral are more likely to initiate dialysis with an autologous access; they are also more likely to choose peritoneal dialysis. Late referral to nephrology also has an impact on RRT choice relating to transplantation. Patients referred to nephrology earlier in their CKD course have a greater possibility to avoid dialysis with preemptive transplantation.4,35 Literature documenting the benefits of early referral has unfortunately not been successful in increasing the rate of early referral. A recent review of the literature documents that 25% to 50% of patients are either referred with already advanced CKD or not referred to nephrology before the need for dialysis.16 Causes of late referral to nephrology have been categorized into several factors such as health care system– related, provider-related, and patient-related factors.16,17,36 Unfortunately, there are no substantial data regarding possible interventions to reduce late referral. Further examination of potential causes may provide insight into further investigation and interventions of late referral. Health care system effects on referral have also been assessed. Medicare populations are often used as a baseline for comparisons. Arora and colleagues showed an increase in late referral in health care maintenance organization patients that was 5 fold compared with Medicare patients.37 Patients in the Veterans Health Administration (VHA) system who used both VA and Medicare-based services were less likely to be referred late to nephrology compared with patients who used only Medicare services. Although patients were less likely to have late referrals if they used VA resources, a third of the patients in the cohort did not receive predialysis nephrologist care.16,38 Provider factors have also been assessed in referral patterns. A retrospective study of US incident dialysis patients compared referral times relating to the training background of the patient’s primary care physician (PCP). Patients with a PCP trained in internal medicine were referred significantly later than patients with a PCP trained in family practice or another general provider.39 This was confirmed in several European studies.16 These individual studies and follow-up reviews have suggested that training disparities and customary clinical practice play a role in this finding. The effect of provider knowledge on referral patterns and timing has been looked at with several survey studies. One study from 2006 showed that 60% of surveyed PCPs were not familiar with KDOQI guidelines and that 31% did not base their referral on stage of CKD.16,36 Another study from Boulware and colleagues included
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nephrologists acting as PCPs. When compared with nephrologists, other general providers were substantially less likely to recognize CKD.40 More recently, trained providers were more aware of a CKD diagnosis, as noted by a study of 479 internal medicine residents: the study showed that 90% would refer CKD stage 4 patients to a nephrologist. Although trained providers were more likely to acknowledge and refer a stage 4 CKD patient, 33% of the providers in the same study were unaware of clinical practice guidelines (KDOQI).41 The difficulty in trying to assess provider perceptions of referral to nephrologists is that most literature is older. The most recent study with interviews with 10 PCPs cited problematic communication, insufficient access, and difficulty with coordinating care. A review of late-referral etiologies included lack of appreciation of benefits of nephrology care in early CKD,42 benefits of adequate pre-ESRD care,36 benefits of early referral,43 severity of disease,30 and the relation of creatinine and eGFR.16 Some literature has cited negative attitudes regarding the role of nephrologists in patient care being limited to dialysis care and technical aspects relating to dialysis.16,30,42,43 The effect on reporting of eGFR to referral was assessed by Hemmelgarn, reviewing a cohort of 1,135,968 patients in Canada.44 Following a 3-month transition of reporting of eGFR with standard laboratory values, referrals of patients with CKD stage 3 or less increased by 17.5 visits per 10,000 CKD patients per month. This represented a 68.4% increase from baseline before the reporting of eGFR. This finding persisted at 2 years, although it had decreased to an increase of 13.3 visits. These numbers were more significant when assessing patients with eGFR ,30 mL/min/1.73 m2, with referrals increasing by 134.4 visits per 10,000 CKD patients per month. This effect for patients with CKD stage 4 and 5 was most pronounced for women. Other factors that were noted to be associated with increased referral included age (46-65 years, 86 years, and older), diabetes, hypertension, and presence of comorbidities. The main limitation of this study was inclusion of individual readings of eGFR, which may falsely classify patients with AKI as having CKD (sustained decrease in eGFR for more than 3 months).44 Patient factors have also been noted regarding late referral. Numerous studies have cited advanced age, most commonly considered greater than 75, as being associated with late referral. NonCaucasian patients also have been shown to be referred later than Caucasian patients in some studies. Other studies have been mixed on this ethnicity-based finding. Although socioeconomic status has not clearly been linked to late referral, lack of health insurance and unemployment has been shown to affect referral. Presence of comorbid illnesses and gender has not been consistently linked to referrals. Potential interventions to reduce the incidence of late referral have not been significantly assessed. The
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literature on interventions has mainly focused on providers, with only one study addressing patient factors. A study performed through Kaiser Permanente allowed use of their electronic record to decrease some potential barriers to referral.45 Nephrologists in this study were allowed access to data showing patients meeting criteria for CKD. Further, study nephrologists were given the opportunity to prompt generalists to initiate the referral process. A study performed in the United Kingdom allowed electronic-only consultation for patients with mild CKD.4-6 Patient-based interventions have been performed with multicenter randomized trials using psychoeducation interventions. Interventions included education about function and diseases of the kidneys, nutrition, options for RRT, and social activities to promote self-care. These Canadian studies were found to extend time before initiation of dialysis. It was also noted that these interventions extended survival by a median of 8 months after initiation of dialysis.12-13
Comanagement Model for the Care of Patients With CKD Extensive evidence-based clinical practice guidelines from the NKF and the RPA have delineated target goals for therapy of patients with CKD. These goals are directed to both slowing the progression rate of CKD and
decreasing the cumulative comorbidities. It is obvious that the comorbidities present at the onset of dialysis have their origins within CKD, as emphasized by the increasing morbidity and mortality that are directly related to CKD. These treatment goals are listed in Figure 1.47 The specific targets are described in the RPA clinical practice guidelines48,49 and multiple NKF guidelines. Tools to facilitate their implementation are available for PCPs and nephrologists alike: http://www.renalmd.org/RPAAdvanced-CKD-Patient-Management-Toolkit/. Many of the interventional therapeutic regimes to slow progression of CKD and decrease comorbidity should be applied to the general population as part of good general medicine care. Optimization of CKD care requires a collaborative effort of many providers in a multidisciplinary treatment model.50-52 We describe this as a triangle in discussions of care with patients. The patients themselves represent the apex of the triangle, the PCP team is another corner in the triangle, and the nephrologist and the nephrology team represent the third corner of the triangle. We have previously described the members of the nephrology team.52 Each of these individuals plays a pivotal role in optimal therapy of the patient to minimize the risk of progression to ESRD and the comorbid conditions associated with CKD and ESRD. Many individuals need to be involved in this collaborative pattern, including physicians, nutritionists, social services, mid-level providers, the
Figure 1. Optimal CKD care. Reprinted by permission of the publisher from Bolton WK, Owen WF: Preparing the patient for renal replacement therapy, The Chronic Kidney Disease Series Postgraduate Medicine, 111(6), 97-108. Copyright 2002 by JTE Multimedia.
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Figure 2. Kidney care recommendations.
transplant team, the surgical team, and many others. Many of the goals and targets recommended for CKD patients can be accomplished by PCPs and are part of good general preventive care medicine. As patients progress toward later stages of CKD, increasing involvement of the nephrology team is required to address the specific disease complications associated with progressive kidney disease. Figure 2 describes the interrelationship between the PCP and the nephrologist. The degree to which the PCP and the patient wish for nephrologist involvement will depend on the comfort level of both the PCP and the patient as well as the nephrology team to provide timely and thorough care. Different PCPs and nephrologists have different reflection points for referral and comanagement. Some nephrologists prefer to provide a large degree of preventative care to patients in late stage III progressing into stage IV and V, whereas others prefer to see patients in stage IV or V only. Many PCPs are comfortable in referring patients with stage IV or stage V disease to the nephrologist, desiring to implement the various interventions and guidelines for CKD themselves rather than by the nephrology team. Yet others prefer a broader spectrum of care and intervention by nephrologists. The point at which the shift in care occurs from the PCPs to the nephrology team is represented in Figure 2 by the shading from dark to light and vice versa. Specific indications obviously occur for stones, proteinuria, hematuria, etc. As progressive stages of CKD develop, patient education, selection of RRT modalities, access placement, and institution of RRT are the purview of the nephrologist and the nephrology team.
Recommendations in the Figure also include clinical follow-up intervals and interaction between the PCP and the nephrologist. In our own practice, we recommend that patients in late stage III with a GFR of ,45 mL/min be referred to a nephrologist for collaborative care of the patient, with more frequent visits as CKD progresses. Communication is a critical element in this model, as are mutual trust and respect for the rest of the care team. Indeed, it is our recommendation that our dialysis patients maintain their relationship with their PCP for non–ESRD-related issues, problems, preventive care, maintenance evaluation and treatment, and other medical issues that are more correlated within the demands of a general medical practice. This comanagement model might be described as a ‘‘flexible’’ or ‘‘floating’’ model, as it depends on the individualized care-preference level of the patient, PCP, and the nephrology team in the care of the patients. It is the goal of a strong and positive collaborative interaction in the care of patients with CKD to provide an approach that places the patient as the center of care decisions. The mutual goal of collaborative care includes slowing disease progression and decreasing comorbidities of CKD. Different models are now being considered to accomplish similar goals including, but not limited to, accountable care organizations and pay-forperformance models. Presently, the future structure of these organizations is poorly defined. The collaborative practice model—which involves the PCP, the nephrologist, and the patient in a mutually agreeable, trusting, communicating triangle—seems to us to provide
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optimal therapy for patients with CKD, optimal utilization of resources, and expertise of the core providers. With this model, patients benefit from a multidisciplinary approach of the general medical practice as well as the special expertise of nephrology. Patients in this model will simultaneously take advantage of the benefits of early referral to nephrology. We firmly believe that the preponderance of evidence supports comanagement of the CKD patient to improve patient care outcomes and quality of life as well as to render the most efficient, effective, and cost-effective treatment for our many patients with CKD.
Acknowledgment The authors appreciate the secretarial assistance of Anita Jacobson.
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15. Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced CKD. Nephrol Dial Transplant. 2006;21:2133-2143. 16. Fisher M, Ahya S, Gordon E. Interventions to reduce late referrals to nephrologists. AJ Neph. 2011;33:60-69. 17. Jungers P. Late referral: Loss of chance for the patient, loss of money for society. Nephrol Dial Transplant. 2002:371-375. 18. Curtis BM, Ravani P, Malberti F. The short and long term impact of multidisciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant. 2005;20:147-154. 19. Curtis BM, Barrett BJ, Djurdjev O, Singer J, Levin A. Evaluation and treatment of CKD patients before and at their first nephrologist encounter in Canada. AJKD. 2007;50:733-742. 20. Harris LE, Luft FC, Rudy DW, Kesterson JG, Tierney WM. Effects of multidisciplinary case management in patients with chronic renal insufficiency. The American Journal of Medicine. 1998;105:464-471. 21. Isbel NM, Haluska B, Johnson DW, Beller E, Hawley C, Marwick TH. Increased targeting of cardiovascular risk factors in patients with CKD does not improve atheroma burden or cardiovascular function. Am Heart J. 2006;151:745-753. 22. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association between multidisciplinary care and survival for elderly patients with CKD. JASN. 2007;18:993-999. 23. Wu I-W, Wang S-Y, Hsu K-H, et al. Multidisciplinary predialysis education decreased the incidence of dialysis and reduces mortality-a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant. 2009;24:3426-3433. 24. Snyder JJ, Collins AJ. Association of preventive health care with atherosclerotic heart disease and mortality in CKD. Journal of American Society of Nephrology. 2009;20:1614-1622. 25. Thanamayooran S, Rose C, Hirsch DJ. Effectiveness of a multidisciplinary kidney disease clinic in achieving treatment guideline targets. Nephrol Dial Transplant. 2005;20:2385-2393. 26. Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. Am J Kidney Dis. 2004;44:706-714. 27. Yeoh HH, Tiquia HS, Abcar AC, Rasgon SA, Idroos ML, Daneshvari SF. Impact of pre-dialysis care on clinical outcomes. Hemodialysis International. 2003;7:338-341. 28. Rocco M. Disease managment program for CKD patients: The potential and pitfalls. AJKD. 2009;53:s56-63. 29. Clinical Practice Guidelines for Chronic Kidney Disease. Evaluation, classification, and stratification. American Journal of Kidney Diseases. 2002;39:S1-S1000. 30. Lameire N, Wauters JP, Teruel JLG, Biesen WV, Vanholder R. An update on the referral pattern of patients with end stage renal disease. Kidney Int. 2002:27-34. 31. Obrador GT, Pereira BJ. Early referral to the nephrologist and timely initiation of renal replacement therapy: A paradigm shift in management of patients with chronic renal failure. Am J Kidney Dis. 2000;31:398-417. 32. Jungers P, Zingraff G, Albouze G, et al. Late referral to maintenance dialysis: Detrimental consequences. Nephrol Dial Transplant. 1993;8:1089-1093. 33. Jungers P, Massey ZA, Nguyen-Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved longterm survival of dialysis patients. Nephrol Dial Transplant. 2001;16: 2357-2364. 34. Khan SS, Xue JL, Kazmi WH, et al. Does predialysis nephrology care influence patient survival after the initiation of dialysis? Kidney Int. 2005;67:1038-1046. 35. Huisman RM. The deadly risk of late referral. Nephrol Dial Transplant. 2004;19:2175-2180. 36. Navaneethan S, Kandula P, Jeevanantham V, Nally JVJR, Liebman SE. Referral patterns of primary care physicians for CKD in general population and geriatric patients. Clin Nephrol. 2010;73:260-267.
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37. Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol. 1999;10:1281-1286. 38. Fischer M, Stroupe K, Kaufman J, et al. Pre-dialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services. Am J Manag Care. 2010;16:e57-66. 39. Navaneethan SD, Aloudate S, Singh S. A systemtic review of patient and health system characteristics associated with late referral in CKD. BMC Nephrology. 2009:3. 40. Boulware L, Troll M, Jaar B, Myers D, Powe N. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis. 2006;48:192-204. 41. Agrawal V, Ghosh A, Barnes M, McCullough P. Perception of indications for nephrology referral among internal medicine residents: a national online survey. CJSAN. 2009;4:323-328. 42. Wauters J, Lameire N, Davidson A, Ritz E. Why patients with progressing kidney disease are referred late to the nephrologist; on causes and proposals for improvement. Nephrol Dial Transplant. 2005;20:490-496. 43. Eadington D. Delayed referral for dialysis. Nephrol Dial Transplant. 1996:2125-2126. 44. Hammelgarn B, Zhang J, Manns BJ, et al. Nephrology visits and health care resource use before and after reporting estimated glomerular filteration rate. JAMA. 2010;303:1151-1158.
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45. Lee B, Forbes K. The role of specialists in managing health of populations with chronic illness: the example of chronic kidney disease. British Medical Journal. 2009;339:b2395. 46. Mondry A, Zhu A, Loh M, Vo T, Hahn K. Active collaboration with primary care providers increases specialist referral in chronic renal disease. BMC Nephrology. 2004;5:16. 47. Bolton WK, Kliger AS. Chronic renal insufficiency: current understandings and their implications. Am J Kidney Dis. 2000;36: S4-S12. 48. Renal Physicians Association. Clinical Practice Guideline: Appropriate patient preparation for renal replacement therapy. Guideline Number 3. Renal Physicians Association Guideline. 2002. 49. Bolton WK. Renal Physicians Association Clinical Practice Guideline: Appropriate patient preparation for renal replacement therapy. Clinical Practice Guideline Number 3. J Am Soc of Nephrol. 2003;14:1406-1410. 50. Bolton WK. The role of the nephrologist in ESRD/pre-ESRD care: A collaborative approach. J Am Soc Nephrol. 1998;9:S90-S95. 51. Bolton WK, Owen WF Jr. Preparing the kidney failure patient for renal replacement therapy. Teamwork optimizes outcomes. Postgraduate Medicine. 2002;111:97-108. 52. Bolton WK. Nephrology nurse practitioners in a collaborative care model. Am J Kidney Dis. 1998;31:786-793.
C
KD is common in patients and carries a significant burden of disease. The number of patients with CKD defined as an eGFR ,60 ml/min/1.73 m2 is estimated at 8 to 13 million in recent studies assessing The National Health and Nutrition Examination Survey (NHANES) data.1-3 CKD is growing more prevalent with time.4-7 CKD is also associated with significant morbidity and mortality. Potential efforts to delay progression and improve outcomes include interventions such as early referral to nephrology, multidisciplinary care, and intervention in known or suspected progression factors. Not only is there a high financial cost of ESRD care but also the true ‘‘cost’’ of ESRD goes beyond the cost of therapy. Delaying progression to ESRD will likely impact patient morbidity and mortality as well as avoid reductions in quality of life that are associated with ESRD. These are all significant reasons why possible interventions to delay progression of CKD to ESRD are important. Medication interventions and collaborative care have been shown to delay progression in CKD patients.8-14 Despite clinical practice guidelines, implementation of appropriate measures and monitoring for CKD patients are often not present at the time of referral to a nephrologist. This emphasizes the importance of early referral to nephrology for patients with CKD. Multiple studies
From Division of Nephrology, University of Virginia Health Sciences Center, Charlottesville, VA. Address correspondence to Warren Kline Bolton, MD, Division of Nephrology, University of Virginia HS, P.O. Box 800133, Charlottesville, VA 22908. E-mail: [email protected] Ó 2011 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 doi:10.1053/j.ackd.2011.10.006
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have shown that progression of kidney disease and other secondary markers of comorbid conditions are delayed after referral to nephrology.15-17 Once patients have been referred to nephrology, there is some question as to the best way to provide care for these patients. Multidisciplinary clinics have been shown to be beneficial to patient care in multiple patient populations. Studies with CKD patients in regard to multidisciplinary clinics have been mixed.14
Impact of Multidisciplinary Care Multidisciplinary clinics and team approaches for health care have numerous potential benefits in providing care for patients requiring subspecialty care. The benefits have been shown in disease states, including diabetes, cardiology, rheumatology, and oncology.18 This has also been assessed in CKD patients. These studies have compared outcomes including survival and progression with dialysis. Data include both observational and randomized studies. The members of multidisciplinary teams vary based on the setting, but frequently include a combination of a nurse educator, physician, social worker, nutritionist, and pharmacist.18,19 Some early data did not show a benefit of MDC, which raised the question of interventional care or recommendation-based care. Harris and colleagues did not show benefit in either delay in progression of renal function or mortality.20 Several reviews and studies have suggested that a negative result was due in part to lack of implementation of recommendations.8 Other studies have had negative findings regarding MDC. Isbel and colleagues reviewed 200 patients randomized to standard care or MDC focused on vascular risk factors. Biochemical markers, such as low-density lipoprotein cholesterol and
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homocysteine as well as blood pressure, were improved in statistically significant improvement in control of lipids MDC. No effect was seen on vascular assessment, includand blood pressure in 9 months. The decrease in eGFR ing carotid intima-media thickness or brachial artery reacwas noted to be 3.6 mL/min/1.73 m2 in the 9 months preceding the study, compared with 0.32 mL/min/1.73 m2 tivity. The lack of effect on vascular complications may have in the 12 months of the study period. The algorithm been due to late referral to the MDC in this population, as was most helpful for patients with a decrease in eGFR 60% of patients were already on dialysis.21 Mortality effects have been seen in some follow-up of greater than 5 mL/min/1.73 m2 in the time preceding MDC studies. In one such study, Curtis and colleagues the study. This UK study benefited from the universal use compared standard nephrology care and MDC in cohorts of eGFR reporting in patient identification.11 In a study based out of 2 nephrology clinics in Taiwan, from both Canada and Italy. These patients were selected W Wu and colleagues evaluated patients randomized to for inclusion after already starting dialysis. To exclude MDC approaches with a patient education focus. {1586} late referral patients, those who had not seen a nephroloThese patients were selected based on referral to nephrolgist for at least 3 months were excluded from the study. ogy and randomization, not selected based on eGFR. The Short-term data showed an improvement in hemoglobin, educational component was developed using KDOQI albumin, and calcium. Long-term data showed a statistiguidelines. The use of MDC in this study showed a decally significant improvement in survival based on use of crease in progression to dialysis, mortality, and the comMDC. The only other factor associated with survival at posite of these endpoints. There was a standardized 12 months was age. A limitation of this study was that education plan in this study, which included the discusit was limited to patients who initiated dialysis, introducsion of dialysis modalities and vascular access planning. ing a survival bias to the study. There was also selection This study showed an increase in the number of patients bias present in this study, as it was not a randomized opting for peritoneal dialycontrolled trial.18 Also showing an effect on sis in the group receiving CLINICAL SUMMARY mortality, Hemmelgarn and MDC education. Patients CKD is an enormous and growing problem in the USA and colleagues compared a cohort choosing hemodialysis across the world. of elderly patients in Canada were less likely to initiate from database review. The with a catheter for access.23 Nephrologists and their immediate “teams” are unable to manage the volume of patients who have CKD. The use of MDCs to impatients found to be enrolled plement guidelines with in MDC were propensity Non-nephrologist providers have the skills to deal with improvement of outcomes score matched to patients many nephrology related issues, but the skill level and willingness to provide that care varies. has been shown to improve cared for outside of an cardiac risk.24 This effect of MDC. A decrease in mortal Early PCP referral to nephrology care teams with coimplementing guidelines, ity over the time of the study management of CKD patients affords a solution to providing quality care for the increasing CKD population. such as those detailed in (3.5 years) was seen in the coKDOQI and KDIGO, may hort of MDC patients combe able to provide similar pared with controls. No benefits in CKD patients. In focusing on guideline impledifference was seen in hospitalization rate, either for allmentation, Thanamayooran and colleagues evaluated the cause or cardiovascular events (defined as acute myocarability of an MDC to meet guideline goals.25 This study dial infarction, congestive heart failure, cerebrovascular evaluated over 300 patients in a retrospective cohort duraccident, and transient ischemic attack). There was a trend ing 10 years in MDC. This study was able to document an to significance in cardiovascular hospitalization.22 Bayliss and colleagues assessed the rate of decrease in improvement in blood pressure control and metabolic glomerular filtration rate (GFR) in MDC patients. The pamarkers. There was also an increase in the number of patients in the MDC historical cohort had a slower rate of tients choosing peritoneal dialysis as a modality for renal decline in GFR in unadjusted and adjusted analysis. No replacement therapy (RRT). Unfortunately, despite use of effect was seen on blood pressure, low-density lipoproa multidisciplinary approach, guideline targets were not tein, or HbA1c by MDC care.14 This would suggest an inmet in a significant number of patients. Examples of this dependent effect on renal function outside of any effect include 40% of patients not receiving renin-angiotensin on diabetic or hypertensive control. blockade, 30% of stage 5 CKD patients with hemoglobin Using a focus on patient education as part of an below 100 g/L, and half of stage 5 CKD patients with hyalgorithm-based approach to MDC, Richards and colperphosphatemia.25 Other studies have shown different benefits of MDC in leagues evaluated 483 patients in a UK cohort of CKD CKD patients. These benefits have included laboratory management. The algorithm used in this study focused parameters, vascular access parameters, and increased on patient education, but also included dietary managepatient usage of peritoneal dialysis as a modality of ment, medication adjustment, and optimization of cliniRRT.23 Goldstein and colleagues showed improvement cal management. This study was able to demonstrate
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in laboratory parameters, including albumin, hemoglobin, and mineral metabolism with MDC. This study also showed an increase in the number of patients initiating dialysis with a mature arteriovenous fistula.26 Yeoh and colleagues confirmed a decrease in the use of temporary catheters at initiation of dialysis.27 Given the substantial benefits of autologous access over catheter based access, this highlights an important potential benefit of MDC. The implementation and intended patient benefits of Fistula First and Renal Physicians Association (RPA) initiatives, which promote increasing incidence of fistula in our dialysis population, would likely benefit from increased use of MDC. The Goldstein prospective cohort study also showed an increase in the number of patients initiating peritoneal dialysis compared with controls. One negative finding noted in this study was that a significant number of patients did not meet KDOQI goals. No effect was seen on mortality in this study.26 A negative finding in several MDC studies was an inability to meet guideline goals.25,26 Although this has been argued as a negative finding, it should be noted that although guidelines were not universally met in these studies, there was an improvement in the percentage of patients meeting goals in both studies. In reviewing and assessing the impact of MDC, it has been difficult to determine what factors are responsible for the impact seen in several studies of MDCs. Data can be extrapolated from other studies to show the benefit of specific parts of MDC. The Modification of Diet in Renal Disease study demonstrated a potential benefit of intensive diet management on progression of CKD although the results during the trial approached, but did not reach, significance.9 Dietician activity in MCD can provide this for patients. Modification of Diet in Renal Disease and other trials such as REIN and RENAAL have also shown the benefit of intensive blood pressure monitoring and control. An MDC can help provide the close monitoring through physician-directed activity of associated providers.8 MDC does require a significant amount of infrastructure, and part of the improvement in patient outcomes may be due to the increase of clinic contact time for patients with chronic disease. Studies that have shown a positive impact of MDC suggest an economic benefit of up to $4000 per patient partly because of a decrease in emergent dialysis starts and fewer days spent in the hospital during the first month on dialysis. The estimated cost of MDC included approximately $1800 per patient year, with the expectation of 8 clinic visits per year. That estimate does not include medication costs, laboratory tests, and physician fees.28 That said, the delay in progression to ESRD seen in some MDC studies could have an offsetting financial effect. Previous studies have suggested only a 10% decrease in progression to ESRD could create a savings of $9 billion over a period of 10 years in the United States.10,11,29
In summary, although the data have been mixed, evidence from multiple different types of studies suggests a medical, societal, and financial benefit of MDC of patients with CKD. Patient education, one of the key components of MDC, has been shown in several settings to be influential in improving patient outcomes. Further studies, including randomized controlled trials, need to be performed to show conclusive benefit of MDCs in nephrology.
Referral Timing Numerous studies have looked at the effects of referral to nephrology on patient outcomes. These studies have generally shown a benefit to referral to nephrology, especially early referral. There have been extensive studies on the characteristics leading to late referral. These studies have also examined ways to increase appropriate referrals to nephrology.4,30-32 When assessing these data, different definitions of ‘‘late referral’’ have been used. This has been based at times on months before dialysis, ranging from 1 to 6 months.27 As this is retrospective, it is less beneficial in advising appropriate referral timing. Guidelines such as KDOQI have recommended referral in stage 4 CKD (eGFR ,30), possibly earlier.27-29 Even with these recommendations, available literature varies on its definition when assessing data. Jones and colleagues performed an observational study of over 700 patients and compared the rate of decline eGFR in the 5 years before and after referral to a nephrology clinic. Overall, before referral, there was a 5.4 mL/min/1.73 m2/y decline in function, which decreased to a 0.35 mL/min/1.73 m2/y after referral. In this study, 84% of patients had a decline of .1 mL/min/1.73 m2/y before referral, and 55% had a decline of ,1 mL/min/ 1.73 m2/y after referral. In those referred with a more rapid decline in eGFR, over half of these patients showed an improvement in their rate of decline of renal function.15 Some of the benefits of early referral that have been shown in the literature include a decrease in hospitalizations and mortality at 1 year. Hospitalizations were noted to be significantly increased from 13.5 6 2.2 days to 25.3 6 3.8 days for patients with late referral in a metaanalysis of 8 studies. The 1-year mortality was also higher in late referrals (29%-13%), with a risk ratio of 2.08 (1.31-3.31).4 There is also an increase in the frequency of CKD secondary complications in patients who are referred late to nephrology. These include anemia, poor nutrition, and uremic complications.4,33 A retrospective study of 1057 hemodialysis patients in France showed a decrease in hemoglobin for patients with follow-up of less than 6 months when compared with populations with followup of 6 to 35, 36 to 71, and greater than 72 months.33
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Individual studies as well as a larger meta-analysis have shown a significant decrease in albumin in patients with late referral.4,33,34 Preparation for RRT is also facilitated by early referral. Vascular access planning and RRT preparation are also important components of CKD care. Patients with early referral are more likely to initiate dialysis with an autologous access; they are also more likely to choose peritoneal dialysis. Late referral to nephrology also has an impact on RRT choice relating to transplantation. Patients referred to nephrology earlier in their CKD course have a greater possibility to avoid dialysis with preemptive transplantation.4,35 Literature documenting the benefits of early referral has unfortunately not been successful in increasing the rate of early referral. A recent review of the literature documents that 25% to 50% of patients are either referred with already advanced CKD or not referred to nephrology before the need for dialysis.16 Causes of late referral to nephrology have been categorized into several factors such as health care system– related, provider-related, and patient-related factors.16,17,36 Unfortunately, there are no substantial data regarding possible interventions to reduce late referral. Further examination of potential causes may provide insight into further investigation and interventions of late referral. Health care system effects on referral have also been assessed. Medicare populations are often used as a baseline for comparisons. Arora and colleagues showed an increase in late referral in health care maintenance organization patients that was 5 fold compared with Medicare patients.37 Patients in the Veterans Health Administration (VHA) system who used both VA and Medicare-based services were less likely to be referred late to nephrology compared with patients who used only Medicare services. Although patients were less likely to have late referrals if they used VA resources, a third of the patients in the cohort did not receive predialysis nephrologist care.16,38 Provider factors have also been assessed in referral patterns. A retrospective study of US incident dialysis patients compared referral times relating to the training background of the patient’s primary care physician (PCP). Patients with a PCP trained in internal medicine were referred significantly later than patients with a PCP trained in family practice or another general provider.39 This was confirmed in several European studies.16 These individual studies and follow-up reviews have suggested that training disparities and customary clinical practice play a role in this finding. The effect of provider knowledge on referral patterns and timing has been looked at with several survey studies. One study from 2006 showed that 60% of surveyed PCPs were not familiar with KDOQI guidelines and that 31% did not base their referral on stage of CKD.16,36 Another study from Boulware and colleagues included
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nephrologists acting as PCPs. When compared with nephrologists, other general providers were substantially less likely to recognize CKD.40 More recently, trained providers were more aware of a CKD diagnosis, as noted by a study of 479 internal medicine residents: the study showed that 90% would refer CKD stage 4 patients to a nephrologist. Although trained providers were more likely to acknowledge and refer a stage 4 CKD patient, 33% of the providers in the same study were unaware of clinical practice guidelines (KDOQI).41 The difficulty in trying to assess provider perceptions of referral to nephrologists is that most literature is older. The most recent study with interviews with 10 PCPs cited problematic communication, insufficient access, and difficulty with coordinating care. A review of late-referral etiologies included lack of appreciation of benefits of nephrology care in early CKD,42 benefits of adequate pre-ESRD care,36 benefits of early referral,43 severity of disease,30 and the relation of creatinine and eGFR.16 Some literature has cited negative attitudes regarding the role of nephrologists in patient care being limited to dialysis care and technical aspects relating to dialysis.16,30,42,43 The effect on reporting of eGFR to referral was assessed by Hemmelgarn, reviewing a cohort of 1,135,968 patients in Canada.44 Following a 3-month transition of reporting of eGFR with standard laboratory values, referrals of patients with CKD stage 3 or less increased by 17.5 visits per 10,000 CKD patients per month. This represented a 68.4% increase from baseline before the reporting of eGFR. This finding persisted at 2 years, although it had decreased to an increase of 13.3 visits. These numbers were more significant when assessing patients with eGFR ,30 mL/min/1.73 m2, with referrals increasing by 134.4 visits per 10,000 CKD patients per month. This effect for patients with CKD stage 4 and 5 was most pronounced for women. Other factors that were noted to be associated with increased referral included age (46-65 years, 86 years, and older), diabetes, hypertension, and presence of comorbidities. The main limitation of this study was inclusion of individual readings of eGFR, which may falsely classify patients with AKI as having CKD (sustained decrease in eGFR for more than 3 months).44 Patient factors have also been noted regarding late referral. Numerous studies have cited advanced age, most commonly considered greater than 75, as being associated with late referral. NonCaucasian patients also have been shown to be referred later than Caucasian patients in some studies. Other studies have been mixed on this ethnicity-based finding. Although socioeconomic status has not clearly been linked to late referral, lack of health insurance and unemployment has been shown to affect referral. Presence of comorbid illnesses and gender has not been consistently linked to referrals. Potential interventions to reduce the incidence of late referral have not been significantly assessed. The
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literature on interventions has mainly focused on providers, with only one study addressing patient factors. A study performed through Kaiser Permanente allowed use of their electronic record to decrease some potential barriers to referral.45 Nephrologists in this study were allowed access to data showing patients meeting criteria for CKD. Further, study nephrologists were given the opportunity to prompt generalists to initiate the referral process. A study performed in the United Kingdom allowed electronic-only consultation for patients with mild CKD.4-6 Patient-based interventions have been performed with multicenter randomized trials using psychoeducation interventions. Interventions included education about function and diseases of the kidneys, nutrition, options for RRT, and social activities to promote self-care. These Canadian studies were found to extend time before initiation of dialysis. It was also noted that these interventions extended survival by a median of 8 months after initiation of dialysis.12-13
Comanagement Model for the Care of Patients With CKD Extensive evidence-based clinical practice guidelines from the NKF and the RPA have delineated target goals for therapy of patients with CKD. These goals are directed to both slowing the progression rate of CKD and
decreasing the cumulative comorbidities. It is obvious that the comorbidities present at the onset of dialysis have their origins within CKD, as emphasized by the increasing morbidity and mortality that are directly related to CKD. These treatment goals are listed in Figure 1.47 The specific targets are described in the RPA clinical practice guidelines48,49 and multiple NKF guidelines. Tools to facilitate their implementation are available for PCPs and nephrologists alike: http://www.renalmd.org/RPAAdvanced-CKD-Patient-Management-Toolkit/. Many of the interventional therapeutic regimes to slow progression of CKD and decrease comorbidity should be applied to the general population as part of good general medicine care. Optimization of CKD care requires a collaborative effort of many providers in a multidisciplinary treatment model.50-52 We describe this as a triangle in discussions of care with patients. The patients themselves represent the apex of the triangle, the PCP team is another corner in the triangle, and the nephrologist and the nephrology team represent the third corner of the triangle. We have previously described the members of the nephrology team.52 Each of these individuals plays a pivotal role in optimal therapy of the patient to minimize the risk of progression to ESRD and the comorbid conditions associated with CKD and ESRD. Many individuals need to be involved in this collaborative pattern, including physicians, nutritionists, social services, mid-level providers, the
Figure 1. Optimal CKD care. Reprinted by permission of the publisher from Bolton WK, Owen WF: Preparing the patient for renal replacement therapy, The Chronic Kidney Disease Series Postgraduate Medicine, 111(6), 97-108. Copyright 2002 by JTE Multimedia.
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Figure 2. Kidney care recommendations.
transplant team, the surgical team, and many others. Many of the goals and targets recommended for CKD patients can be accomplished by PCPs and are part of good general preventive care medicine. As patients progress toward later stages of CKD, increasing involvement of the nephrology team is required to address the specific disease complications associated with progressive kidney disease. Figure 2 describes the interrelationship between the PCP and the nephrologist. The degree to which the PCP and the patient wish for nephrologist involvement will depend on the comfort level of both the PCP and the patient as well as the nephrology team to provide timely and thorough care. Different PCPs and nephrologists have different reflection points for referral and comanagement. Some nephrologists prefer to provide a large degree of preventative care to patients in late stage III progressing into stage IV and V, whereas others prefer to see patients in stage IV or V only. Many PCPs are comfortable in referring patients with stage IV or stage V disease to the nephrologist, desiring to implement the various interventions and guidelines for CKD themselves rather than by the nephrology team. Yet others prefer a broader spectrum of care and intervention by nephrologists. The point at which the shift in care occurs from the PCPs to the nephrology team is represented in Figure 2 by the shading from dark to light and vice versa. Specific indications obviously occur for stones, proteinuria, hematuria, etc. As progressive stages of CKD develop, patient education, selection of RRT modalities, access placement, and institution of RRT are the purview of the nephrologist and the nephrology team.
Recommendations in the Figure also include clinical follow-up intervals and interaction between the PCP and the nephrologist. In our own practice, we recommend that patients in late stage III with a GFR of ,45 mL/min be referred to a nephrologist for collaborative care of the patient, with more frequent visits as CKD progresses. Communication is a critical element in this model, as are mutual trust and respect for the rest of the care team. Indeed, it is our recommendation that our dialysis patients maintain their relationship with their PCP for non–ESRD-related issues, problems, preventive care, maintenance evaluation and treatment, and other medical issues that are more correlated within the demands of a general medical practice. This comanagement model might be described as a ‘‘flexible’’ or ‘‘floating’’ model, as it depends on the individualized care-preference level of the patient, PCP, and the nephrology team in the care of the patients. It is the goal of a strong and positive collaborative interaction in the care of patients with CKD to provide an approach that places the patient as the center of care decisions. The mutual goal of collaborative care includes slowing disease progression and decreasing comorbidities of CKD. Different models are now being considered to accomplish similar goals including, but not limited to, accountable care organizations and pay-forperformance models. Presently, the future structure of these organizations is poorly defined. The collaborative practice model—which involves the PCP, the nephrologist, and the patient in a mutually agreeable, trusting, communicating triangle—seems to us to provide
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optimal therapy for patients with CKD, optimal utilization of resources, and expertise of the core providers. With this model, patients benefit from a multidisciplinary approach of the general medical practice as well as the special expertise of nephrology. Patients in this model will simultaneously take advantage of the benefits of early referral to nephrology. We firmly believe that the preponderance of evidence supports comanagement of the CKD patient to improve patient care outcomes and quality of life as well as to render the most efficient, effective, and cost-effective treatment for our many patients with CKD.
Acknowledgment The authors appreciate the secretarial assistance of Anita Jacobson.
References 1. Jones CA, McQuillan G, Kusek JW, et al. Serum creatinine levels in the US population: Third national health and nutrition examination survey. Am J Kidney Dis. 200;32:992-999. 2. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. Journal of the Amercian Medical Association. 2007;298:2038-2047. 3. Snyder JJ, Foley RN, Collins AJ. Prevalence of CKD in the United States: A sensitivity analysis using the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Am J Kidney Dis. 2009;53:218-228. 4. Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with CKD referred late to nephrologists: A meta-analysis. Am J Med. 2007;120:1063-1070. 5. U.S. Renal Data Systems: USRDS 2010 Annual Data Report. National Institute of Diabetes and Digestive and Kidney Diseases. 2011. 6. Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients with end-stage renal disease in the United States to the year of 2010. JASN. 2001:2753-2758. 7. Gilbertson DT, Liu J, Xue JL, et al. Projecting the number of patients with end-stage renal disease in the United States to the Year 2015. Journal of American Society of Nephrology. 2005;16:3736-3741. 8. Komenda P, Levin A. Analysis of cardiovascular disease and kidney outcomes in multidisciplinary chronic kidney disease clinic; complex disease requires complex care models. Current Opinion in Nephrology & Hypertension. 2006:61-66. 9. Klahr S, Levey AS, Beck GJ. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. N Engl J Med. 1994;330:877-884. 10. Trivedi HS, Pang MM, Campbell A, Saab P. Slowing the progression of chronic renal failure: Economic benefits and patients’ perspectives. Am J Kidney Dis. 2002;39:721-729. 11. Richards N, Whitfield M, O’Donoghue D. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filteration rate (eGFR) reporting, improves patient outcomes. Nephrol Dial Transplant. 2008;23:549-555. 12. Devins G, Mendelssohn DC, Barre P, Binik YM. Predialysis psychoeducational intervention and coping styles influence time to dialysis in CKD. AJKD. 2003;42:693-703. 13. Devins GM, Mendelssohn DC, Barre Pe, Taub K, Binik YM. Predialysis psychoeducational intervention extends survival in CKD: A 20 year follow up. AJKD. 2005;46:1088-1098. 14. Bayliss EA, Bhardwaja B, Ross C, Beck A, Lanese DM. Multidisciplinary team care may slow the rate of decline in renal function. CJSAN. 2011:704-710.
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