The Interdisciplinary Chronic Kidney Disease Clinic

C H A P T E R

48 The Interdisciplinary Chronic Kidney Disease Clinic Carolyn A. Bauera, Jerry Yeeb and Ruth C. Campbellc a

Division of Nephrology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA, b Henry Ford Hospital, Division of Nephrology and Hypertension, Detroit, MI, USA, c Medical University of South Carolina, Department of Medicine/Division of Nephrology, Charleston, SC, USA

SCOPE OF THE PROBLEM Nephrology is currently engulfed in a maelstrom of factors, including the increasing prevalence of CKD, a complex patient population, the need to reduce progression to ESRD and improve RRT outcomes, and a shrinking nephrology workforce. These issues are forcing individual physicians and health-care systems to critically evaluate how care is delivered to this diverse patient population. Interdisciplinary care (IDC) in the form of the CKD clinic has emerged as an alternative to traditional nephrology care as one way to address these pressing issues. Such a clinic may address four fundamental and overarching aspects of the care of CKD patients: quality improvement, interdisciplinary care, risk factor management, and education (Figure 48.1). Statistics regarding CKD are well known. Twentysix million or approximately 13% of the US population has CKD. This number is increasing due to the increasing prevalence of diabetes, hypertension and obesity.1 Of primary importance to the practicing nephrologist is that 7.7% have CKD stage 3 and 0.47% have CKD stage 4.1 The lifetime risks of ESRD are 2.2%, 3.3%, 7.8 %, and 8.5% for white women, white men, black women, and black men, respectively.2 Added to this workforce challenge is the improved survival of ESRD patients,3 and the intrinsic complexity of this population. CKD with its multiple co-morbidities has substantial competing risk from cardiovascular mortality.4–7 Thirty-one percent of patients with CKD have diabetes, and that percentage rises progressively from 3.6% to 44.7 % during P. Kimmel & M. Rosenberg (Eds): Chronic Renal Disease. DOI: http://dx.doi.org/10.1016/B978-0-12-411602-3.00048-2

the transition from stage 1 to stage 4 CKD.5 This population carries a heavy cardiovascular burden. Twentyseven percent of stage 4 CKD patients have congestive heart failure, 30% have had a stroke and 36.5 % have coronary artery disease.5 The minority of these patients will reach ESRD while most will die of CVD.8 Beyond medical challenges, the CKD population is burdened with socioeconomic challenges including poverty9 and low health literacy,10 which may contribute to poor outcomes. Despite decades of awareness of the importance of permanent dialysis vascular access, almost 80% of newly initiated patients begin dialysis with a catheter.3 Early referral to a nephrologist is a necessary but not a sufficient requirement. A significant number of patients who are followed by a nephrologist before starting RRT will still start with a temporary access, and lack of education may be a part of this phenomenon.11,12

Quality improvement

Interdisciplinary care CKD clinics

Risk factor management

Education

FIGURE 48.1  CKD clinic aspects of care. Quality improvement, interdisciplinary care, risk factor management, and education of CKD patients require balanced integration.

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48.  The Interdisciplinary Chronic Kidney Disease Clinic

Educational information must also be delivered in a way that patients can understand and assimilate. Low health literacy affects rates of permanent vascular access placement in ESRD patients.13 These data suggest that traditional methods of education may not be optimal for maximizing dialysis readiness. In the face of this increasing workload and need for improved outcomes, nephrology is facing a workforce crisis with fewer fellowship applicants.14 There is no evidence that this trend will reverse in the immediate future. Identifying those who will care for this growing patient population is an important and urgent task. These issues have led to a critical appraisal of how care is being delivered and how outcomes (and which outcomes) are being followed at the individual level within health-care systems. Which groups of patients will benefit the most from intensive involvement from a shrinking pool of nephrologists versus usual care through their primary care physicians? What should constitute nephrology goals of care: management of complications of CKD, retarding progression to ESRD, preparation for ESRD, CVD mortality reduction, or all of these? How will this care be delivered and by whom? How will this care be delivered most effectively? What is the role of the primary care provider? What is the most cost-effective model? The CKD clinic/IDC model has emerged in response to many of these issues. While universal and welldefined in the management of ESRD, IDC in predialysis CKD and its delivery remains heterogeneous and is still being defined.

DEFINITION OF CKD CLINIC: MODELS OF INTERDISCIPLINARY CARE There is not a single definition of interdisciplinary care (IDC) in CKD. IDC implies that health-care providers of different disciplines (physicians, advanced practice professionals [APPs, formerly known as physician extenders or mid-level providers], pharmacists, social workers and dietitians) collaboratively, cohesively and synergistically work and communicate together as a team to provide care for patients. The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines specify that IDC nephrology care should encompass dietary counseling, education and counseling regarding different RRT modalities, transplantation options, vascular access surgery, and ethical, psychological and social care.15 Financial restraints of the provider(s) and patient(s) may limit the ability to offer all of these services to patients. Additionally, not all insurance providers in the US provide reimbursement for IDC care. On a practical level, it is important for a nephrology practice to prioritize what outcomes require improvement

the most, and to identify those services most urgently needed by its patient population, and then to expand the scope of the clinic as feasible. To do this, the CKD clinic team needs to be able to monitor changes in outcomes for quality improvement processes in order to maximize patient benefits. CKD education is a primary goal for many clinics. Other common goals of CKD clinics are to manage the complications of CKD such as hypertension, anemia, mineral and bone disorders, and acidosis according to guidelines established by KDIGO. The rationale for choosing these guidelines is that they represent the goals of care targeted to slow progression and ameliorate uremic symptoms. Frequently, an APP manages patients by following a protocol to achieve guideline benchmarks with the collaboration of a nephrologist. Eighty-three percent of APPs associated with nephrology practices in the US report working in CKD or anemia management clinics.16 There are supportive data from other chronic disease states that an advance practitioner, protocol driven model can be effective in disease management.17 One challenge of this approach, particularly when working with a large group of nephrologists, is to obtain consensus on which guidelines will be implemented by the APP for an individual patient. Some CKD clinics may run parallel to a nephrology clinic, with patients alternating between CKD clinic visits and general nephrology visits. The IDC clinic and the referring nephrologist should be seen as a team and not as a group of competing providers. This issue can be managed by clear communication of the treatment plan by the nephrologist in the patient chart, or a request for a verbal “checkout” when the patient is in the CKD clinic. A third structural component to consider is who is referring the patients to the clinic. Some clinics incorporate a nephrology evaluation into the CKD clinic and may take referrals directly from primary care physicians.18 Some CKD clinics may offer only education or protocol driven management of CKD, and may not accept a referral from a primary care physician. A primary care physician may refer a patient to a CKD clinic and be unaware that the intervention may not provide a nephrology evaluation of the cause of CKD. This underscores the importance of clearly defining the goals of the CKD clinic. While the variety of clinic structures makes it difficult to study outcomes and efficacy of CKD clinics, it reflects that the needs and resources of nephrology practices vary widely and that a “one size fits all” approach may not be practical. However, most approaches should provide coordinated and engaged patient-centered care that directly and forcefully addresses the patient’s requirement for meaningful CKD education, the transition to RRT, and targets and monitors major CKD complications as applicable (Table 48.1).

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Goals of Treatment for a CKD Clinic

TABLE 48.1  Principal Goals of an Interdisciplinary Care CKD Clinic Goal

Comment

Coordination of care

Collaborative engagement/ partnership with primary care physicians and specialists

Determination of CKD progression risk and rate

Estimation of GFR decline; proteinuria determination(s)

Mitigate CKD complications and cardiovascular risk

Blood pressure; mineral and bone disorders; metabolic acidosis; anemia; lipids

CKD education

Multiple component/personnel utilization; MIPPA

Transition to ESRD

Discussion of prognosis; RRT modality/option planning; transplant and vascular access evaluations

Abbreviations: CKD: chronic kidney disease, ESRD: end-stage renal disease, GFR: glomerular filtration rate, RRT: renal replacement therapy, MIPPA: Medicare Improvement of Patients and Providers Act.

WHO WILL BENEFIT FROM INTERDISCIPLINARY CARE Who is the optimal patient for nephrology-based IDC? Given the sheer number of CKD patients in the US, it would be impossible for all of them to be followed by a nephrology IDC team. Patients at the highest risk of progression to ESRD or patients who have complications of CKD that need specialized management (such as anemia) are logical populations to target. The 2012 KDIGO CKD guidelines suggest that patients with progressive CKD be treated in an IDC setting, but do not specify a GFR cutoff.15 An accurate identification of this population is required. Models have been developed to help estimate the risk of progression to ESRD.19 Tangri et al. described a model that uses age, sex, eGFR, urine albumin-to-creatinine ratio, calcium, phosphorus, albumin and bicarbonate to predict risk of progression.20 A web-based calculator is available, as well as a smart-phone app.21 The following key CKD progression factors help to identify the population for IDC.

Proteinuria One of the challenges of the 2002 K/DOQI19 guidelines was the heterogeneity of the risk of progression, particularly for stage 3 CKD patients.15 This issue has been extensively addressed in the 2012 KDIGO guidelines. Proteinuria remains a powerful predictor of progression in both diabetic and non-diabetic patients.22–24 The presence and degree of proteinuria as an independent risk factor is now included in the staging guidelines, throughout the range of GFR. The

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guidelines recommend that patients with an albuminto-creatinine ratio >300 mg/g or protein-to-creatinine ratio >500 mg/g be referred to a nephrologist.

Rate of Change in GFR The slope of the rate of loss of GFR helps identify those patients who are at higher risk for progression to ESRD. The 2012 KDIGO guidelines define rapid progression as loss of GFR by greater than 5 mL/min/1.73 m2 or by 25% per year.15 This patient population may warrant more aggressive modification of risk factors, and education for RRT, including transplant. An absolute level of GFR for access placement is not specified in the 2012 KDIGO guidelines. However, it is recommended that patients are referred for access planning when it is anticipated that they have more than 10% risk of starting RRT within one year.

Age Age is a non-modifiable risk factor but is an important consideration, particularly for early referral for CKD education. In 2010, 24.8% of incident ESRD patients were over 75 years of age.3 Elderly patients benefit from starting dialysis with a permanent access.25 However, there is minimal survival benefit from dialysis for patients over the age of 80 years with multiple comorbidities26 or improvement of performance status of nursing home residents.27 A thoughtful discussion of RRT, including the option of supportive, non-dialytic care is fundamental.15 There are a number of other potentially modifiable factors that contribute to progression including the underlying disease, poorly controlled diabetes, poorly controlled hypertension, hyperlipidemia and smoking history. Management of some of these factors such as hypertension, hyperlipidemia, glycemic control and smoking may significantly overlap with primary care provider approaches. A Canadian study comparing a nephrology IDC model to care by a primary care physician failed to show a difference in loss of GFR.28 A criticism of this study is that the participants were at low risk for progression at baseline, suggesting that a low-risk population may not benefit from nephrology IDC care. As the primary care medical home model develops, nephrologists may find that they better serve CKD patients with a low risk of progression as a “medical neighbor” rather than assuming primary management of risk factors.

GOALS OF TREATMENT FOR A CKD CLINIC The ultimate goals of a CKD clinic are to improve morbidity and mortality of patients with CKD. CKD

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clinics use an IDC approach to educate and improve the health of this susceptible population. Clinics should institute treatment protocols based on recent national and international guidelines for CKD like those guidelines published by the National Kidney Foundation, the Kidney Disease Outcomes Quality Initiative (KDOQI) and the international guidelines, the Kidney Disease Improving Global Outcomes (KDIGO).15,19 Treatment protocols should also integrate findings of large RCTs to provide the best practices for this high-risk population. To reach these goals, CKD clinics need to focus on managing CVD risks, implementing practices to retard the progression of CKD, and transitioning patients safely from CKD to ESRD. Underlying causes of CKD such as diabetes and hypertension should be controlled. Complications of CKD including metabolic bone derangements, anemia, electrolyte disturbances and fluid imbalance must be diagnosed and treated. Given the immunosuppressive nature of advancing CKD, vaccines against influenza viruses, streptococcal pneumonia, and hepatitis B should be administered.29,30

Patient Education Pre-dialysis education is the most studied aspect of IDC in nephrology. Pre-dialysis education is associated with increased selection of home dialysis modalities, improved permanent access placement and reduced mortality.11,12,31 Even a one-day intervention has been shown to have significant benefits.31,32 In 2010, under the Medicare Improvement of Patients and Providers Act (MIPPA), Medicare began to reimburse for CKD education provided by a physician, APP or clinical nurse specialist for Medicare recipients with CKD stage 4 or 5. Up to six sessions of education are reimbursed, and may be delivered either as a class or on an individual basis in the outpatient setting.33 The classes must cover management of comorbidities, prevention of uremic complications, and options for RRT (including hemodialysis (HD), peritoneal dialysis (PD), home therapies, access options and transplantation). A recent survey of US nephrology practices found that 60% offered a CKD education class, and that an advanced practitioner delivered 87% of the classes.34 The educational materials for these classes were either developed locally, originated from the National Kidney Foundation (NKF) CKD education series “Your Treatment, Your Choice,” or represented a hybrid of local and NKF materials. An important consideration in CKD education programs is the impact of health literacy. Low health literacy, or how well a patient understands and assimilates information to make decisions regarding his or her health, is common in the US and among CKD patients.35 It is associated with increased mortality on dialysis36 and with lower referral rates for

transplantation.37 These data support the need to assess patients’ understanding of the education that they have been given. An advantage of the NKF “Your Treatment, Your Choice” program is that it provides outcome assessment tools to help determine whether class participants found the information understandable and helpful. While the MIPPA benefit only applies to outpatient CKD education for most settings, CKD education may also be delivered effectively in the hospital. Rioux et  al. described a program of CKD education for hospitalized patients who needed to start dialysis acutely. Their intervention resulted in 31% of patients choosing a home dialysis modality prior to hospital discharge.38

Cardiovascular Risk Management Patients with CKD have an extremely high burden of CVD4 and patients with stage 3 or 4 CKD are more likely to die of CVD than progress to ESRD.8 The risk of death compared to the progression to ESRD becomes even more pronounced in the expanding elderly CKD population.39 Beyond preparation for ESRD, the goal of the CKD clinic is to improve patients’ cardiovascular health and decrease the incidence of heart attacks, strokes and congestive heart failure. Traditional risk factors for CVD such as increasing age, hypertension, diabetes, and hyperlipidemia are highly prevalent in the CKD population.40 In addition, other non-traditional risk factors for CVD have been identified in patients with CKD, including anemia,41,42 fluid overload, vascular calcifications, inflammation, malnutrition and increased oxidative stress.43,44 Albuminuria, even when not associated with diabetes, is associated with higher incidence of cardiovascular events.45,46 CKD clinics need to focus on interventions for modifiable risk factors for CVD. Smoking is associated with CVD and observational data suggest that smoking may influence the progression of renal disease. Therefore, smoking cessation should be addressed with each patient.47,48 Aspirin therapy likely confers cardiovascular protection in this high-risk population. A post hoc analysis of a large RCT demonstrated aspirin decreased mortality and major cardiac events in patients with diastolic hypertension and eGFR <45 mL/ min/1.73 m2 albeit with the caveat of potential bleeding risks.49 Aggressive lipid lowering therapy in pre-ESRD CKD patients has been shown in both a post hoc analysis of a large RCT and a RCT in patients with CKD to improve cardiovascular outcomes.50,51 International treatment guidelines now recommend that all pre-ESRD CKD patients over 50 years old be started on a statin as well as those patients less than 50 who are at high risk for coronary artery disease or stroke.52 Hypertension control in CKD is extremely important to decrease risk of heart attacks, strokes and heart failure.53 The CKD interdisciplinary staff encourage patients to modify their

VIII.  THERAPEUTIC CONSIDERATIONS

Goals of Treatment for a CKD Clinic

lifestyle behaviors, follow healthy diets, lose weight, and to engage in exercise.

Progression of CKD Unfortunately, few therapies are proven to delay progression from CKD to ESRD. Consequently, CKD clinics must assertively address interventions that slow the decline of renal function. Control of hypertension, especially with ACEIs or ARBs, in diabetics and non-diabetics retards the progression of CKD23,54–57 and decreases the incidence of cardiovascular events.58 ACEI and ARB treatment also decreases proteinuria, which is both a risk factor for the development of CVD and advancing CKD.59 There are conflicting guidelines on the appropriate level of blood pressure control in CKD patients based on recent literature. The international KDIGO guidelines for patients with CKD recommended a blood pressure target less than 130/80  mm  Hg for those patients with albuminuria and less than 140/90 for those patients without.60 In contrast, the Joint National Committee 8 (JNC 8) blood pressure guidelines recommend a target blood pressure of less than 140/90 in all CKD patients between 18 to 70 years of age.61 These differences and the literature that support them has sparked much debate in the nephrology community.25,62–65 Other interventions that may slow the decay in kidney function include the treatment of metabolic acidosis, avoiding nephrotoxins and effective patient education. Treatment of acidosis with bicarbonate may attenuate renal damage in remnant nephrons.66 Small RCTs suggest that bicarbonate therapy may improve eGFR and decrease risk of ESRD.67,68 CKD clinics educate patients to avoid nephrotoxins, particularly non-steroidal antiinflammatory drugs, and ensure that all medications are appropriately dosed based on a patient’s eGFR. Education may also play a role in delaying ESRD. One randomized study of advanced CKD patients revealed that a single education session with nurse follow-up was associated with delay in the initiation of RRT by approximately 3 months.69

Preparation for ESRD Patients with advanced CKD must be safely transitioned to ESRD. The CKD clinic should provide action plans for initiating dialysis, coordinate listings for renal transplantation and define goals of care for patients who may or may not desire or benefit from these modalities. Education, in both individual and group sessions, is fundamental to this process. Patients must understand the different options for RRT. Patients must make preparations for kidney failure before the onset of symptomatic uremia. Learning about the risks

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and benefits of PD, in-center and home HD and transplantation facilitates informed decision-making by patients and their families that best accommodates patients’ desires and circumstances. Patients who are independent, enjoy travel and have adequate supply space may opt for peritoneal or home HD. RRT modalities may change over the course of a patient’s lifetime. Preparation for dialysis should occur simultaneously to evaluation for transplantation. The modality for RRT should be established at least 6 months to 1 year prior to the development of ESRD. This allows for timely fistula placement and for the work-up required prior to transplantation. Patient knowledge about the signs and symptoms of kidney failure will aid the physician in establishing when to initiate dialysis.

Hemodialysis A planned transition to HD should result in improved health for patients and reduced costs. CKD clinics aim to impact the high morbidity and mortality associated with the commencement of HD. Mortality peaks in the first few months after dialysis initiation. The highest risk of death was in the second month after initiation of HD, and the mortality rate was 43.5% in 2009 (435 deaths/1000 lives at risk).3 According to the Dialysis Outcomes and Practice Patterns Study (DOPPS), a large international cohort, the mortality rate in the first 120 days after starting HD was 33% in the US, significantly greater than in most other countries.70 Some risk factors identified with early mortality in HD were older age, HD catheter use, hypoalbuminemia, congestive heart failure, and lack of pre-dialysis care.71,72 Dietitians in an IDC care model work with patients to prevent, diagnose and address malnutrition. Patients are evaluated for extracellular fluid overload and treated with both medications and salt and water restrictions. CKD clinics should coordinate the timely placement of arteriovenous fistulas (AVFs), the preferred vascular access, to limit the need for insertion of HD catheters. Patients beginning dialysis with an HD catheter have a significantly increased risk of death compared to patients who began dialysis with an AVF.73,74 Current guidelines recommend consideration of AVF construction when the risk of dialysis is anticipated to be greater than 10% within one year.19 The current eGFR, its rate of loss with time and magnitude of albuminuria can help determine those patients at greatest risk for progression.11,21 Collaborative partnership with a vascular surgeon with high-level expertise in AVF construction is instrumental for the establishment of well-functioning AVFs in suitable individuals. Unfortunately, not all patients are candidates for AVF given underlying arterial or venous insufficiency. Accordingly, patients must

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48.  The Interdisciplinary Chronic Kidney Disease Clinic

appreciate that 40% of AVFs may either fail or require additional maturation procedures, in order to ensure a functioning access prior to dialysis.75 Starting HD in the hospital is costly. Interdisciplinary CKD programs can arrange for dialysis units to accept patients without the need for hospitalization. CKD clinic members can ensure that testing and records are accurate and complete and that a dialysis center is ready to accept patients in a timely fashion. In brief, outpatient dialysis starts are better and more cost-effective for patients, and the prevailing health-care system promotes this approach.

life’s end. A discussion of an individual’s prognosis and the risks and benefits of dialysis and transplantation should be provided to each patient to ensure informed decision-making regarding dialysis initiation if progression to ESRD is likely. In addition, patients can state their future wishes regarding the timing of withdrawal from dialysis. Planning ahead benefits patients’ families who will understand their loved ones’ wishes before reaching kidney failure. For patients who decide on medical management at stage 5 CKD – the “no dialysis” option – IDC programs should continue to provide services that facilitate patient overall wellness and comfort.

Peritoneal Dialysis

Anemia of CKD

Patients interested in peritoneal dialysis (PD) should meet with a PD nurse and receive education before deciding which RRT modality to pursue. The IDC team should determine whether the patient’s living environment has adequate space to perform the mandatory sterile procedures and store supplies. Team members must continually evaluate patient symptoms, signs and laboratory studies to determine the timing of PD and coordinate with an experienced surgeon for PD catheter placement. The patient should be accepted into a PD unit in order to initiate training following catheter insertion. Family members should be encouraged to learn about the process and assist the patient.

As CKD advances, many patients develop anemia of CKD. Previously, CKD clinics were often centered about administration of erythropoietin-stimulating agents (ESAs) for treatment of anemia. However, the use and insurance coverage of these drugs has greatly decreased because the TREAT,81 CHOIR,82 and CREATE83 trials did not demonstrate benefits of hemoglobin (Hb) normalization. The FDA issued “black box” warnings concerning thrombosis and cancer growth associated with these drugs and required that providers distribute a medication guide (risk evaluation and mitigation strategies) to every patient receiving a new prescription.84 Presently, treatment of anemia is reimbursed when the Hb declines to less than 10 g/dL, and the patient should be iron replete at the time of ESA initiation. All anemic patients must be screened for iron deficiency, which should be treated with intravenous or oral iron compounds. Also, appropriate evaluations for occult blood loss must be performed before ESA administration. The FDA only recommends ESAs to prevent blood transfusions, especially in patients who are transplant candidates, to mitigate the possibility of allosensitization.84 When CKD programs initiate ESAs, they need to carefully monitor patients to ensure their hemoglobin levels do not rise too rapidly or exceed 11 g/dL.84

Transplantation Transplantation offers the best survival advantage for ESRD patients. Transplantation prior to starting RRT is associated with improved patient and kidney allograft survival.76–78 The CKD clinic should educate patients about transplantation, assist in transplant evaluation referrals and facilitate discussions between patients and their families regarding live kidney donation. The median wait time for a deceased donor kidney in the US is approximately four years79 and varies by region of the country. Patients should be wait-listed at eGFRs less than 20 mL/min/1.73 m2, to accrue waiting time before initiating RRT, potentially decreasing the duration of dialytic care.

Advanced Care Planning The high risk of mortality and of decreased functional status in association with ESRD in the elderly28,80 warrants advanced care planning as part of the services provided by CKD clinics. In the US, 20% of patients who died in the initial 120 days after starting dialysis stopped treatment.70 Clarifying patients’ wishes prior to ESRD may decrease aggressive and costly measures that are not in the best interests of patients who are at

Metabolic Bone Disease CKD is often complicated by metabolic bone disease. CKD patients often have deranged calcium levels, elevated phosphate and parathyroid hormone levels and vitamin D deficiency. IDC programs for CKD should employ guidelines to treat these disorders.

Underlying Disorders CKD clinic staff must coordinate with primary care providers to ensure that the underlying causes of CKD, such as diabetes and hypertension, are addressed and treated. Effective communication with PCPs is

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Economics of CKD Clinics

paramount to ensure that all providers recognize their specific responsibilities when treating these diseases.

CKD CLINICS IMPROVE OUTCOMES Interdisciplinary CKD clinics employ patient education, nutrition counseling and guideline-driven care to treat patients with advancing CKD. The prevailing literature suggests these programs may decrease hospitalizations, improve arteriovenous access placement before initiation of RRT, improve mortality rates before and after reaching ESRD, and are cost-effective. CKD clinics aim to improve CVD risk and decrease mortality using an IDC approach, patient education and guideline-driven care. Snyder and Collins found that the greater number of preventive measures employed per year, including two S[Cr] measurements, a lipid measurement, an A1c test, calcium, phosphate and parathyroid hormone levels, and administration of influenza vaccination, significantly decreased the risk of atherosclerotic heart disease in a high-risk Medicare cohort.85 Hemmelgarn et al. showed an improved mortality risk in a pre-dialysis cohort who had IDC care compared with a propensity-matched control.86 A prospective cohort study in Taiwan also demonstrated decreased mortality for those patients who had access to IDC care.87 Two other cohort studies support that exposure to IDC care decreased mortality rates after dialysis initiation.88,89 Fresenius Medical Care North America, a large dialysis organization, established that patients who underwent a pre-dialysis educational program were significantly more likely to choose PD as their RRT, begin HD with an AVF or arteriovenous graft (AVG) and were less likely to die within the first 90 days following onset of dialysis.90 However, not all data support that IDC intervention can decrease CVD or mortality risk. A randomized trial of 788 Dutch patients with eGFRs ranging from 20 to 70 mL/min/1.73 m2 compared intensive nurse practitioner support to standard nephrologist care and determined a decrease in the CVD risk factors of high blood pressure, LDL cholesterol, anemia and proteinuria.91 Despite these risk factor reductions, no differences in the primary composite outcome of myocardial infarction, stroke or cardiovascular death were discovered. Yet, this study had several limitations. The nephrologists providing the standard care were informed of the study and reminded of the current CKD guidelines, thereby inducing contamination bias. Also, the trial had fewer than expected events and may have been underpowered to demonstrate a significant outcome. Despite the non-significant cardiovascular outcomes, the nurse practitioner CKD intervention of this Dutch study showed a significant renal benefit in extended follow-up. In the nurse practitioner arm there was

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a 20% decrease of the incidence of the composite outcomes of death, ESRD and 50% increase in creatinine.92 This study also showed slowed eGFR decline in the intervention group. Use of education, IDC teams, and guideline-driven care have also been shown to increase the use of arteriovenous accesses and decrease hospitalization rates. Cohort studies performed in California, Taiwan and Canada showed that patients exposed to IDC care had significantly decreased hospitalizations and more AVFs.33,93,94 A single-center study associated guideline-driven care by APPs with improved functioning, permanent vascular accesses and decreased hospitalizations 12 months after dialysis initiation.95 As illustrated in the Dutch randomized study discussed previously, CKD education and IDC care may also decrease the progression to ESRD. A randomized trial demonstrated that a single 90-minute education session along with follow-up phone calls significantly delayed dialysis initiation by approximately 3 months in patients expected to start dialysis within 6 to 18 months.69 A program in England determined that patients with eGFRs less than 30 mL/min/1.73 m2 who had access to a nurse, patient education, medication management and nutrition counseling had a decreased rate of the fall of eGFR, with the greatest benefit in those patients with rapidly progressive CKD.96 In early CKD, there are conflicting data on the efficacy of IDC care. In a large health maintenance organization population, a study found a slower eGFR decline in those patients who were enrolled in IDC care compared with historical controls.97 However, a Canadian RCT found no significant impact on GFR decline by adding a nurse-coordinated model in patients with slowly progressive CKD (eGFR 25 to 60 mL/min/1.73 m2).29 Conflicting randomized trials on the renal benefit of IDC care warrant continued study.

ECONOMICS OF CKD CLINICS CKD clinics are often composed of a variety of different providers, including but not limited to advanced nurse practitioners, physician assistants, dietitians, nurses, social workers, pharmacists and administrative staff. Each CKD clinic is set up differently, contingent on budgeting and office space. Funding for CKD clinics may vary greatly in different countries depending on the resources of the national health-care system and the extent of health-care privatization. In the US, advancedpractice providers can bill most insurance companies directly, however, other members of the team may not be reimbursed by the standard fee-for-service model. Dietitians are reimbursed by Medicare for stage 4 CKD patients, but may not be covered by other insurance

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48.  The Interdisciplinary Chronic Kidney Disease Clinic

companies. There is an MIPPA benefit from Medicare for six education classes, if these classes are taught by a physician, an advanced practice provider or clinical nurse specialist. A social worker can bill insurance companies only if providing counseling for a DSM-V diagnosis. Nursing staff can charge for administration of injectables and vaccines. Pharmacist services are not reimbursable. Enhanced administrative personnel are required to coordinate all the providers and educational services. Financial constraints may make it difficult for nephrologists to provide an IDC model of CKD to their patients. Grants, awards, donations or alternative sources of funding are often required, which often limits CKD clinics in the US to large academic institutions. The creation of accountable care organizations, which are groups of health-care providers that assume responsibility for the quality, cost-effectiveness and general health-care of specified US Medicare beneficiaries, may be an important source of funding for these IDC initiatives. Data which reveal cost savings with implementation of CKD clinics will encourage such organizations to fund an IDC model. Increased outpatient dialysis starts, and greater AVF and PD selection rates can help persuade funders that CKD clinics are cost-effective and sustainable. In 2007, the average inpatient cost for the first month of dialysis in the US was $9846 per Medicare member, and $22,841 per employer group health plan member.98 This cost could be greatly reduced by increasing outpatient dialysis starts. Increased AVF rates will also lower the expense associated with ESRD. AVFs were associated with approximately $3000 lower vascular access-related expenses compared to HD catheters.98,99 Patients with AVFs compared to those with HD catheters had a lower total per person per year cost at $64,701 and $90,110, respectively.98 Increasing the rate of PD as the initial modality for ESRD is also cost-effective. According to the United States Renal Data System, the total yearly expenditure per patient in 2010 for HD was $87,561 compared to $66,751 for PD, a saving of over $20,000 per patient per year.3 Despite the increased costs of an IDC team, a study in Taiwan found a saving of $1200 in patients beginning dialysis.94 The cost savings to be gained through an improved transition to ESRD likely outweighs the greater costs of an IDC team.

CONCLUSION The CKD clinic has emerged as an interdisciplinary care model that encompasses patient education, medical management of CKD complications and progression risk factors and quality improvement. The CKD clinic team may include physicians, advanced practice providers, nurses, dietitians, pharmacists and social

workers. Team structure and clinic goals should be tailored to local practice needs. Common goals include CKD education, RRT planning and treatment of complications of CKD based on national/international guidelines. Data suggests that CKD clinics improve CKD and RRT education and lead to greater rates of home dialysis and permanent access placement. Long-term studies are needed to determine if CKD clinics provide a beneficial effect on preserving kidney function. Financing CKD clinics remains problematic as many insurers do not pay for IDC services. The long-term viability of the CKD clinic model may ultimately depend on demonstrating effectiveness and a reduction in overall patient care costs.

Acknowledgments The authors express their sincere gratitude to Ms. Stephanie Stebens, MLIS, for her expert manuscript and bibliographical contributions.

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