GFR Implementation & CKD Program at Southern California Kaiser Permanente

1. GFR Implementation & CKD Program at Southern California Kaiser Permanente Peter Crooks, M.D. Physician Director, Renal Program Southern California Kaiser Permanente 4 October 2005

2. Kaiser PermanenteSouthern 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

3. Kaiser PermanenteSouthern 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

4. Kaiser PermanenteSouthern 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

5. K/DOQI CKD Staging Requires 2 or more GFR, 3 or more months apart GFR 90 60 30 15 If other markers kidney disease: proteinuria, hematuria, anatomic Complications Possible Complications Evident Renal Replacement 1 2 3 4 5 CKD Stage

6. 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

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

8. 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. 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]

9. Practical 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

10. GFR Table Example

11. 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.

12. MDRD GFR Estimate Lab Printout

13. Comparison with Cleveland Clinic

14. Inter-Laboratory Comparison Testing for Creatinine (mg/dL) This is data for 16 of 45 different lab sites in Southern California Kaiser.

15. CKD 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.

16. CKD Staging Algorithm Kaiser Permanente So California Proteinuria = macroscopic > 300 mg/day or random microalbumin >= 300 mcg/mg creatinine on 2 occasions DM means diagnosis of diabetes mellitus Estimate of 2 standard deviations below mean for age ~ GFR + 1/2 Age < 85

17. CKD Staging AlgorithmAll 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

18. Total adult population: 2,200,000

19. GFR >90 or no CR 60-89 30-59 15-29 NHANES III 64% 31% 4.3% 0.2% PERCENTAGES POPULATION • SCPMG • 68% • 27% • 3.4% • 0.17%

20. Modified Stage 3High-risk if GFR + ½ Age < 85 • Roughly divides Stage 3 Population in half • Of CKD stage 3 patients going to ESRD, most all are from high risk group

21. CKD Staging Results Kaiser Permanente So California CKD patients account for 21% of all CAD registry patients CKD patients account for 37% of all CHF registry patients

22. Primary care lab ordering for CKD Kaiser Permanente So California

23. Primary care actions for CKD Kaiser Permanente So California

24. Fax messages at point of careKaiser Permanente So California

25. CKD Care at KPSC - POINT (Internet)

27. Nephrology Referralis strongly encouraged for all patients with... • CKD 4 & 5 (GFR < 30) • unless other terminal disease/co-morbidity

28. For patients CKD 1-3,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%

29. AT LEAST ONE OUTPT. NEPHROLOGY VISIT 1998-2002 CKD 1 7% CKD 2 13% CKD 3 14% CKD 4 77% CKD 5 FUTURE RRT 94% WHO ARE KP NEPHROLOGISTS SEEING?

30. CKD Stage 4-5 (Pre-ESRD) DM requires Case Management

31. CKD EducationKaiser 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

33. Hospital Days, Nephrologist Visits& Modality EducationKaiser Permanente So CaliforniaCKD 4 & 5pre:4263 Patients

34. CKD 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

35. CVD Risk vs. GFR in ARICManjunath et al. J 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)

36. When you see this... Think this... HIGH CVD RISK

37. GFR Implementation & CKD Program at Southern California Kaiser Permanente Thank you! And over to SCPMG colleague, James Dudl, M.D.