GFR Implementation & CKD Program GFR Implementation & CKD Program at Southern California Kaiser at Southern California Kaiser

Permanente Permanente

Peter Crooks, M.D.Physician Director, Renal Program

Southern California Kaiser Permanente4 October 2005

Kaiser PermanenteKaiser PermanenteSouthern California StructureSouthern California Structure

• 3 legally independent entities– Kaiser Health Plan (non-profit)– Kaiser Foundation (np - owns facilities)– Southern California Permanente

Medical Group (for profit)

• Kaiser pays SCPMG PMPM• SCPMG financially responsible

for Medical Care, including care at non-Kaiser Facilities

• Some risk sharing for good or poor financial outcomes

Kaiser PermanenteKaiser PermanenteSouthern California (KPSC)Southern California (KPSC)

• 3,100,000 Members– 90,000 CKD 1-5, 4500 ESRD

• 3300 Full-time Physicians– 58 Nephrologists

• 12 Geographic Areas– Bakersfield to San Diego

• 11 Medical Centers• 100+ Medical Offices• 1200 per diem Physicians• 30,000 Employees

Kaiser PermanenteKaiser PermanenteSouthern California StructureSouthern California Structure

• Impact of Structure– Linkage of payer and provider

• All in it together

– Drives integration of services• Full-service Medical Centers/Hospitals• Pharmacy & DME• Lab & Imaging• Consultative Services

– Drives internalization of care– Drives information sharing & QI– Drives proactive care

• Disease & population management

90 60 30 15GFR

CKD Stage

1 2 3 4 5

Renal Replacement

ComplicationsEvident

ComplicationsPossible

If other markers kidney disease: proteinuria, hematuria, anatomic

K/DOQI CKD StagingK/DOQI CKD StagingRequires 2 or more GFR, 3 or more months apartRequires 2 or more GFR, 3 or more months apart

Why use an Estimated GFR?Why use an Estimated GFR?

• Medical evidence (EBG)– Intervention can reduce ESRD and reduce CVD

• Permits Identification– PCP recognition of CKD– Permits patient to learn of condition, become

educated and take action

• Permits Staging/Stratification– Stage-specific intervention

Why use MDRD equation 7?Why use MDRD equation 7?

• Compromise of accuracy & ease of use– Doesn’t require urine– Only 4 variables

• Serum creatinine level, age, gender, black or non-black race

• Good fit with data at lower GFR• Hope for better equation in future

Equation 7:GFR = 170 x [Pcr]-0.999 x [Age]-0.176 x [0.762 female] x [1.180 black race] x [SUN]-0.170 x [Alb]+0.318

Modified Equation 7:GFR = 186 x [Pcr]-1. 154 x [Age]-0.203 x [0.742 female] x [1.212 black race]

A More Accurate Method To Estimate Glomerular Filtration Rate from Serum Creatinine: A New Prediction Equation, AS. Levey, et al;Ann Intern Med. 1999;130:461-470.

Practical Implementation IssuesPractical Implementation Issues

• Apply only to age > 18• If not provided by lab, GFR calculation not easy• Report normal values as ‘> 90’• Race is often not available in IT systems

– Report both B & NB result, clinician interprets

• GFR requires interpretation– Acute vs. chronic renal insufficiency– Age-adjusted interpretation

• Stage 2 in elderly• Stage 3: GFR + 1/2AGE < 85 ? higher risk

• Accuracy of serum creatinine measurement

GFR Table ExampleGFR Table Example

MDRD GFR Estimate Lab Printout

John Doe MR# 1234567 Creatinine 2.0 mg/dL

GFR estimate non-Black race: 60 ml/min/1.73 m2 body surface area Black race: 73 ml/min/1.73 m2 body surface area

This estimate of renal function assumes a steady-state and is not useful if the renal function is changing rapidly.

GFR >90 is normal. GFR 60-89 may be normal for age >70.

Age: 48 years Gender: Female Race: Non-Black

NAME TEST, FEMALE MR# 000000000006 WED – 12/02/02 10:35ACC NO 300521670 - 1 COLL DT/TM 12/02/02 10:35 ORD MD TEST, TEST****************************** DISPLAY RESULTS ******************************* PROCEDURE RESULT ABN REF-RANGE / UNITS

CREAT-SER 0.8 0.6-1.1 MG/DL GFR ESTIMATE 81 mL/min Result is normalized to 1.73 m2 body surface area. This estimate of renal function assumes a steady-state and is not useful if the renal function is changing rapidly.

GFR >=90 is normal; GFR 60-89 is mildly reduced; GFR 30-59 is moderately reduced; GFR 15-29 is severely reduced; GFR <15 is kidney failure. Many elderly patients may have mildly and even moderately reduced GFR due to aging.------------------------------------------PRINT OVERRIDE DESTINATION PSN6 ----CMD: | PF=FWD BA=BACK ACCNO PP=PRTLAS Y Y/N

OT=OTHER PRINTER ID RR=RETURN MM=MASTER

MDRD GFR Estimate Lab Printout

Comparison with Comparison with Cleveland ClinicCleveland Clinic

Serum Creatinine (mg/dL)Cleveland Clinic result 0.9 1.4 2.9 3.4

Kaiser Labs Mean 0.9 1.4 2.7 3.3

Kaiser Labs Minimum 0.7 1.1 2.5 3.0

Kaiser Labs Maximum 1.0 1.5 2.9 3.6

Stan. Dev. 0.07 0.08 0.08 0.12

C.V. 8.1% 6.2% 3.0% 3.5%

% within + or - 15% of Cleveland 93% 98% 100% 100%

Inter-Laboratory Comparison Inter-Laboratory Comparison Testing for Creatinine (mg/dL)Testing for Creatinine (mg/dL)

Laboratory Location Inst. Result

Orange Main CX7 1.3Orange Main LX20 1.3Bakersfield Stockdale CX9 1.3Baldwin Park Main CX7 1.3Baldwin Park Main LX20 1.4Baldwin Park Montebello CX3 1.4Baldwin Park San Dimas Clinic CX3 1.4Bellflow er Imperial Clinic CX7 1.4Bellflow er Main CX3 1.3Bellflow er Main LX20 #1 1.4Bellflow er Main LX20 #2 1.4Fontana Indian Hills Clinic CX3 1.5Fontana Loma Linda Clinic CX7 1.4Fontana Main LX20 #1 1.3Fontana Main LX20 #2 1.3Fontana Mob CX9 1.5

This is data for 16 of 45 different lab sites in Southern California Kaiser.

CKD Staging AlgorithmCKD Staging Algorithm• To automate CKD staging , need algorithm

– Compare recent GFR to GFR 3+ mos prior

– ‘Lock in’ CKD Stage until two GFR >3 mos apart are both out of range in same direction

• q3mo GFR: 31, 35 (Stage 3), 29, 34, 26, 31, 22, 26 (Stage 4)

– Lag behind current GFR and provides ‘baseline’

– Urine ignored if GFR > 60• If GFR < 60, must decide urine and anatomic criteria (not simple)

• Need more than one abnormal urine result

• Focus on protein, ignore hematuria, etc.

CKD Staging Algorithm CKD Staging Algorithm Kaiser Permanente So California Kaiser Permanente So California

GFR Range

Chronicity CKD Marker >90 60-89 30-59 15-29 <15

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Unknown(1 or more GFR

< 3 months apart)

Chronicity UnknownStage 2

Chronicity UnknownStage 3

Chronicity UnknownStage 4

Chronicity UnknownStage 5

GFR Reduced> 3 months

Marker absent or not

neededNormal

Chronically Reduced GFR

Stage 2

Low-risk CKDStage 3

GFR + 1/2 age > 85

CKDStage 4

(Marker not need)

CKDStage 5

(Marker not need)

Proteinuria or other modifier

CKDStage 1

(proteinuria)

CKDStage 2

(proteinuria)

High-risk CKDStage 3 (Modified)

proteinuria, DM or

GFR + 1/2 age < 85

Proteinuria = macroscopic > 300 mg/day or random microalbumin >= 300 mcg/mg creatinine on 2 occasionsDM means diagnosis of diabetes mellitusEstimate of 2 standard deviations below mean for age ~ GFR + 1/2 Age < 85

CKD Staging AlgorithmCKD Staging AlgorithmAll Possible OutcomesAll Possible Outcomes

• Not determined - no serum creatinine available– At Risk - age > 65, HTN, DM, Family History

• No CKD - 1 or more serum creatinine available, GFR > 90, U/A OK• Chronically Reduced GFR stage 2

– GFR 60-89 3+ mos, urine/anatomy normal• Chronicity Unknown Reduced GFR 2 -5

– low GFR not meeting 3+ mo criteria• CKD Stage 1 • CKD Stage 2 • CKD Stage 3 High-risk ESRD/Low-risk ESRD• CKD Stage 4 • CKD Stage 5 Future renal replacement/No future renal replacement • CKD Stage 5 Hemodialysis• CKD Stage 5 Peritoneal Dialysis• CKD Stage 5 Transplant

– CKD substage 1-5

52CKD 5 TXP 4

142CKD 5 TXP 4

594CKD 5 TXP 3

282CKD 5 TXP 2

52CKD 5 TXP 1

336CKD 5 PD

2,959CKD 5 HEMO

479CKD 5 FUTURE RRT

3,281CKD 4

56,900CKD 3 High-risk & Low-risk

11,942CKD 2

10,707CKD 1

73CHRONICITY UNKNOWN 5

276CHRONICITY UNKNOWN 4

16,326CHRONICITY UNKNOWN 3

218,032CHRONICITY UNKNOWN 2

320,628CHRONICLLY REDUCED 2

542,469NO CKD WITH CREATININE

992,752NO CKD NO CREATININE

PatientsStage

Total adult population:

2,200,000

PERCENTAGES POPULATIONPERCENTAGES POPULATION

GFRGFR >>90 or no CR90 or no CR

60-8960-89

30-5930-59

15-2915-29

• NHANES III• 64%• 31%• 4.3%• 0.2%

• SCPMG• 68%• 27%• 3.4%• 0.17%

Modified Stage 3Modified Stage 3 High-risk if GFR + ½ Age < 85High-risk if GFR + ½ Age < 85

Stage 3 GFR Age GFR + ½ age

31 70 62 (high risk)

45 80 95 (low risk)

55 40 75 (high risk)

Roughly divides Stage 3 Population in half

Of CKD stage 3 patients going to ESRD, most all are from high risk group

CKD Staging Results CKD Staging Results Kaiser Permanente So CaliforniaKaiser Permanente So California

CKD 1 CKD 2

CKD 3 mod CKD 4

CKD 5 PRE TXP Dialysis

5,293 6,761 40,408 4,120 539 1,345 3,373

IN CAD registry 9% 24% 28% 38% 33% 21% 45%IN CHF registry 3% 12% 14% 25% 21% 6% 26%

CKD patients account for 21% of all CAD registry patients

CKD patients account for 37% of all CHF registry patients

CKD Stage Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

GFRNormal &

CKD marker 90Mild decrease

& CKDmarker

60Moderatedecrease 30

Severedecrease 15

Kidney failureNot ondialysis

PRIMARY CARE LAB STUDIES FOR CKDSerum creatinine yearly yearly 6-12 mos 3-6 mos 1-3 mosUrinalysis yearly yearly yearly yearly yearlyRandom microalbumin for proteinquantitation

yearly1 yearly1 yearly1 yearly1 yearly1

24-hour urine no no no per nephrol. per nephrol.Check potassium selected2 selected2 selected2 yes yesRenal ultrasound selected3 selected3 yes4 yes4 yes4

Screen for anemia no no yes yes yesScreen for lipid disorders yes yes yes yes yesScreen for hign PTH, highphosphorus, low calcium

no yes yes yes yes

Screen for decreased albuminand malnutrition

if nephrotic if nephrotic yes yes yes

Primary care lab ordering for CKDPrimary care lab ordering for CKDKaiser Permanente So California

Primary care actions for CKDPrimary care actions for CKDKaiser Permanente So California

GFRNormal &

CKD marker 90Mild decrease

& CKDmarker

60Moderatedecrease 30

Severedecrease 15

Kidney failureNot ondialysis

PRIMARY CARE ACTIONS FOR CKDNephrology referral selected5 selected5 selected5 yes yesOptimize BP & DM control yes yes yes yes yesPatient awareness of CKD &Kidney Class

yes yes yes yes yes

Smoking cessation yes yes yes yes yesACEI or ARB if DM withmicroalbumuria or non-DM withproteinuria

yes yes yes yes yes

ACEI or ARB if hypertensive? yes yes yes yes yesLipid treatment to LDL goal < 100 yes yes yes yes yesAnemia Work-upNephrology EPO Clinic

no-

no-

Hgb <12.06

Hgb < 11.0Hgb <12.06

Hgb < 11.0Hgb <12.06

Hgb < 11.0Hepatitis B immunization no no yes yes7 yes7

Pneumovax yes yes yes yes yes

Fax messages at point of careFax messages at point of careKaiser Permanente So California

• Consider Nephrology referral (Near ESRD) – Stage 4 & 5 patients who are not ESRD who have never had anSCPMG nephrologist appointment or who have not had a nephrology appointment in the last year.

• Suggest Nephrology return (Near ESRD) –Stage 4 & 5 patients who are not ESRD, who have seen an SCPMGnephrologist but have not been seen in the last 100 days.

• Obtain creatinine level – Last GFR (based on creatinine level) was seriously reduced from prior value; need todetermine if kidney function has returned to baseline or is truly worsening.

• Obtain hemoglobin level – Stage 3-5 without a hemoglobin level in last 12 months (it is important to identify andaggressively treat renal anemia).

• Angiotensin converting enzyme inhibitors (ACE) – Suggested starting dose for renoprotection (persistentproteinuria) and/or CV risk reduction.

• Statin cholesterol-lowering medications – Suggested starting dose if LDL > 100.

CKD Care at KPSC - POINT (Internet)

• CKD 4 & 5 (GFR < 30)– unless other terminal disease/co-morbidity

Nephrology ReferralNephrology Referralis strongly encouraged for all is strongly encouraged for all

patients with...patients with...

For patients CKD 1-3,For patients CKD 1-3,consider Nephrology referral if consider Nephrology referral if

….….• Proteinuria > 1000 mg/day

• ~random microalbumin 1000• especially if persists despite control of DM, HTN,

and use ACE I/ARB

• Clarification of CKD diagnosis• Very difficult to control Blood Pressure• Suspected EPO-deficiency anemia• Unexplained acute fall GFR > 25-50%

WHO ARE KP WHO ARE KP NEPHROLOGISTS SEEING?NEPHROLOGISTS SEEING?

AT LEAST ONE OUTPT. NEPHROLOGY VISIT 1998-2002

94%CKD 5 FUTURE RRT

77%CKD 4

14%CKD 3

13% CKD 2

7%CKD 1

CKD EducationCKD Education

Kaiser Permanente So California

• Education: defined Classes– Kidney Class: any CKD Stage– Choices Class: Stage 4-5pre

• Group Visits• Individual Counseling

– Social Worker, Care Manager, Nutritionist

Selec ted New Indicators for Vario us CKD S tag es Prior to Renal Replacement

49%

66%

74%

82%85%

72%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CKD 1-5pre

CKD 1-5pre

CKD 1-5pre

CKD 1-5pre

CKD 3-5pre CKD 4-5pre CKD 4-5pre

Ha ving Quantitative Urine Pro tein

Appro pria te ACEI o r ARB

Rx fo r prote inuria

Having LDL Cho les tero l in 12

mo s .

LDL > 10 0 and Lipid Rx in 12

mos .

Having Hemo g lo bin > 11

S ee n by Nephro log is t in 12

mo s .

Pre dialys is Educatio n

Pro g ram

Hospital Days, Nephrologist VisitsHospital Days, Nephrologist Visits& Modality Education& Modality Education

Kaiser Permanente So California

CKD 4 & 5pre:CKD 4 & 5pre: 4263 Patients4263 Patients

CKD 4&5Hospital Days

per patient per year

Pats. % Pats. %2.3 3,081 72% 1,116 26%

CKD 4&5Seen by

Nephrologistin last 12 months

CKD 4&5Attended Choices (Modality) Class

CKD and CVDCKD and CVD

• CKD patients = highest CVD risk category• CVD risk factors accelerate CKD• CKD uniquely exacerbates CVD• Most CKD patients die of CVD before ESRD• Majority of new ESRD patients have CVD• CKD need treatment for CVD risk reduction

CVD Risk vs. GFR in ARICCVD Risk vs. GFR in ARICManjunath et al. Manjunath et al. J Am Coll Cardiol 2003; 41: 47–55J Am Coll Cardiol 2003; 41: 47–55

GFR 15-59 (n=444), adj RR 1.38 (1.02, 1.87)GFR 60-89 (n=7,665), adj RR 1.16 (1.00, 1.34) 10 ml/min lower GFR, adj RR 1.05 (1.02, 1.09)

When you see this...When you see this...

Think this...Think this...

HIGH CVD RISK

GFR Implementation & GFR Implementation & CKD Program at Southern CKD Program at Southern

California Kaiser PermanenteCalifornia Kaiser Permanente

Thank you!Thank you!

And over to SCPMG colleague,And over to SCPMG colleague,

James Dudl, M.D.James Dudl, M.D.