The National Kidney Foundation’s
Kidney Early Evaluation ProgramTM
“The Greater New York Experience”
Ellen H. Yoshiuchi, MPS
Division Program Director
National Kidney Foundation
Serving Greater New York
Program Objectives
• Describe the goal of the Kidney Early
Evaluation Program (KEEP) and it’s relation to
CKD as a public health problem.
• List KEEP criteria and rationale for each
function to assist in identifying individuals at
risk for CKD and in providing appropriate early
treatment options to minimize co-morbidities.
• Explain KEEP’s impact and its role in the CKD
awareness initiative to help improve patient
outcomes.
Declaration of Disclosure
• It is the policy of the National Kidney Foundation to
ensure balance, independence, objectivity, and
scientific rigor in all CME/CE activities. Any
individuals who have control over CME content are
required to disclose to learners any relevant financial
relationship(s) they may have with commercial
interests supporting this activity or whose products
or devices are discussed in this activity. If, on the
basis of information disclosed a conflict exists,
resolution will be achieved based on established
policy by the NKF.
Faculty Disclosure
• Refer to handout in participant folder.
Kidney Early
Evaluation ProgramTM
10 Year Anniversary
KEEP Objectives
Identify those at  risk for CKD using inclusion criteria:
Hypertension and/or Diabetes or family history of
HTN, DM or CKD in first order relatives.
Encourage participants at  risk to seek
further medical evaluation.
Develop a referral network, such as free health clinics, for the
uninsured identified as being at  risk for CKD.
Develop a referral network of specialists for patients identified as
being at  risk for kidney disease.
KEEP Objectives
• To empower individuals to prevent or
delay the onset of CKD or renal failure
through education and appropriate
disease management!
Chronic Kidney Disease is a
Public Health Problem!
Rate of Kidney Disease Jumps by 30%
Chronic Kidney Disease is a
Public Health Problem!
The devastating consequences of CKD
are End Stage Renal Disease (ESRD),
which requires dialysis or
transplantation, or leads to
cardiovascular disease & death.
CKD is a Public Health Problem
Worldwide!
• Early screening, diagnosis, and treatment
should delay or prevent ESRD.
• 26 Million Americans have CKD. Most don’t
know it.
• 73 Million Americans have HTN and/orDM.
• CKD is a worldwide public health problem.
KDOQI CKD Evaluation, Classification
and Stratification (2002)
• Defined 2 independent criteria for CKD:
• Glomerular filtration rate (GFR) <60 ml/min per 1.73m2 for ≥3
months
• Presence of kidney damage [structural/functional/pathological
abnormality; markers (i.e., albuminuria)] for ≥3 months
• Classified CKD by severity according to GFR
• Provided a common language for kidney disease that would:
• Facilitate new research
• Provide clinicians with a stage-specific clinical action plan
• Provide a framework for developing a public health approach
toward resolution
KDOQI CKD Evaluation, Classification
and Stratification (2002)
Concerns with KDOQI Definition and
Classification (2002)
• New information on albuminuria and GFR and their
association with mortality has become available
since publication of the KDOQI CKD definition and
staging.
• Increased recognition of limitations of the CKD
definition and classification initiated debate that:
• Reflects changing knowledge
• Provides opportunities for improvement
Definition of CKD
Identical to 2002
Classification of CKD
It is recommended that CKD be classified by:
• Cause
• GFR category
• Albuminuria category
• Referred to as “CGA Staging”
Represents a revision of the previous CKD
guidelines, which included staging only by level
of GFR
New Albuminuria Emphasis
• Most Family Physicians
perform some type of
office urine test.
• 90% perform a manual
urine dipstick test.
• 53% perform an
automated dipstick test.
• 58% perform an officebased urine microscopic
exam.
American Academy of Family Physicians. Practice Profile II Survey. November 2009
Criteria for CKD
• Glomerular filtration rate (GFR) <60 ml/min/1.73 m2
• GFR is the best overall index of kidney function in health and
disease.
• The normal GFR in young adults is approximately 125
ml/min/1.73 m2.
• GFR <15 ml/min/1.73 m2 is defined as kidney failure
• Can be detected by current estimating equations for GFR
based on serum creatinine or cystatin C (estimated GFR) but
not by serum creatinine or cystatin C alone
• Decreased eGFR can be confirmed by measured GFR, if
required
3 Levels of Prevention in CKD
Primary – Prevent the development of CKD in the
population at risk with Diabetes and/or Hypertension.
Secondary – Prevent the progression of CKD (loss of
kidney function over time) and prevent or delay CKD
complications.
Tertiary – Prevent adverse outcomes in those with
chronic kidney failure treated with dialysis or kidney
transplantation by optimizing care.
Am J Kidney Dis 2009:53:522-535
Conceptual Model of CKD: Continuum of Development,
Progression and Complications of CKD
Each Arrow is a Target for Strategies to Improve Outcomes!
Referral to Nephrology by
CKD Stage
Primary Goals of CKD Care
• To prevent the progression of CKD to ESRD
• To prevent Cardiovascular Events & Death
Heart Attacks
Congestive Heart Failure
Sudden Cardiac Death
Awareness Campaign
WHAT DO THE NUMBERS MEAN?
WHAT CAN I DO ABOUT CHRONIC KIDNEY
DISEASE?
Register for KEEP today!
Call 1-800-622-9010.
Learn more about CKD on your own…
*Read your KEEP Health Screening
Report & educational materials.
*Visit www.kidney.org.
See your Doctor…
*Discuss your test results.
*Ask questions about what the
numbers mean and what can be done.
Find a Doctor or Health Care Facility
if you do not have one!
KEEP OVERVIEW
• KEEP is a free public health screening program.
• It was initiated in New York City by the National Kidney
Foundation in August of 2000.
• Screenings are held in all areas of the US by local
National Kidney Foundation divisions or affiliates.
• Over 180,000 people have been screened to date.
• Visit www.KEEPonline.org for more information.
Criteria to Participate In KEEP
Anyone age 18 or older with one or more of
the following risk factors:
• History of diabetes
• History of high blood pressure
• Family history in first order relatives of
diabetes, high blood pressure and/or
kidney disease
Six Screening Stations
• Station One – Registration: Participant
receives paperwork packet
• Station Two – Screening Questionnaire &
Informed Consent: Filled out by a
professional volunteer
• Station Three – Physical Measurements:
Height, weight, waist circumference &
blood pressure
Six Screening Stations
• Station Four – Urine & Blood Testing
• Station Five – Clinician Consultation:
Interview with a physician, nurse
practitioner or physician assistant
• Station Six – Screening Review:
Participants receive copy of informed
consent & test results
KEEP Screening Evaluation
•
•
•
•
•
•
•
•
Medical history: DM, HTN, CVD, CKD
Blood pressure
Height and weight
Waist circumference
Body mass index (BMI)
Blood glucose measurement
Serum creatinine
Hemoglobin
KEEP Screening Evaluation
• Albumin to Creatinine Ratio
• eGFR
• A1C for elevated glucose or self-reported
diabetes
• Total Cholesterol:
HDL, LDL, Triglycerides
• For eGFR<60 ml/min
Calcium, Phosphorus & PTH
HEMOGLOBIN A1c
 Not affected by short-term fluctuations in blood
glucose levels
 Reliable measurement of blood glucose
concentrations over the prior 6 to 8 weeks
• <7% of total hemoglobin
Normal
• > 7% is an indication of
increased blood sugar levels
High
Waist Circumference
High Risk Groups
• Women
with a waist
circumference of more
than 35 inches
• Men with a waist
circumference of more
than 40 inches
Blood Pressure Classification
KEEP uses the Blood Pressure Classifications according to The 7 th National Report Guidelines on
Prevention, Detection, Evaluation & Treatment of High Blood Pressure from the National Heart, Lung
& Blood Institute of the National Institutes of Health, referred to as JNC 7.
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Pre-hypertension
120–
139
or
80–89
Stage 1
Hypertension
140–159
or
90–99
Stage 2
Hypertension
>160
or
>100
Blood Glucose Guidelines
American Diabetes Association (ADA) 2008
Criteria for the Diagnosis of Diabetes Mellitus
Normal Fasting Glucose
FPG <100 mg/dl
Impaired Fasting Glucose
FPG 100–125 mg/dl
Provisional Diagnosis of Diabetes
FPG >126 mg/dl
(The diagnosis must be confirmed. The KEEP consultant would recommend follow-up
testing & review by the participant’s primary care provider.)
Follow Up after the Screening
• 2 to 3 days: Participants with critical lab results are
called by dedicated bilingual (Spanish/English) staff.
• 3 to 4 weeks: All screening results are mailed to
participants and their physicians if participants wish to
have their doctor receive a report.
• 2 to 3 months: A follow up survey is mailed out &
participants will be called if the survey is not received.
• 12 months: Invitations are sent by mail, phone or email to attend an annual screening.
KEEP in Greater New York
9 Years/96 Screenings
2/1/2004 to 4/1/2013
• 8175 attended the screenings.
• 7373 met inclusion criteria & completed the
screening.
• 2148 were repeat participants.
• Breakdown by gender:
Male:
34.98% (2579)
Female: 64.91% (4786)
Of the 5967 who learned
of a new problem…
• 3075 learned they may have kidney disease:
41.71%
• 763 learned they may have diabetes:
10.35%
• 861 learned they may have hypertension:
11.68%
• 1268 learned they may have high cholesterol:
17.20%
5461 (74.07%) individuals were aware
of a pre-existing condition.
•
•
•
•
433
2,967
2,276
3,961
kidney disease:
high cholesterol:
diabetes:
hypertension:
5.86%
39.40%
30.41%
53.23%
Breakdown by Race & Ethnicity
•
•
•
•
•
•
•
African American: 2355
Caucasian:
2062
Asian:
2037
Native American:
76
Pacific Islander:
11
Other:
777
Ethnicity—Hispanic: 1100
31.94%
27.97%
27.63%
1.03%
0.15%
10.54%
14.92%
Breakdown by Age Group
•
•
•
•
•
•
18 to 25:
219
26 to 35:
463
36 to 45: 1,035
46 to 55: 1,734
56 to 65: 1,927
Over 65: 1,979
(2.97%)
(6.28%)
(14.04%)
(23.52%)
(26.14%)
(26.84%)
Who is coming to KEEP?
• 6511 (88.31%) have a physician.
• 5282 (71.64%) have health insurance.
• 2719 (36.88%) request that a report be sent
to their doctor.
• Of 7274 with reported BMI:
Overweight: 2458 33.79%
Obese:
2490 34.23%
Follow-Up Survey
• 2333 (31.64%) responded!
• Of these, 71.50% reported seeing a physician
post-screening.
• Of these, 10.97% had a doctor confirm that
they had kidney disease.
• Of these, 90.61% indicated they were willing
to participate in another screening.
YOU MAKE IT POSSIBLE.
KEEP UP THE GOOD WORK!
New York, New York
Trinitas Regional Medical Center
October 18, 2011
Brentwood, Long Island, 2007
Long Island KEEP ‘04 through ‘11
Total screened:
1394
Total who met inclusion criteria: 1212
Repeat participants:
Ineligible for KEEP:
304 (21.81%)
182 (13.06%)
Long Island KEEP
•
•
•
•
•
•
•
•
•
1 Southampton
1 Manhasset
1 Westbury
1 Hempstead
1 Bay Shore
1 Huntington Station
1 Brentwood
1 New Hyde Park
1 Glen Cove
Long Island KEEP
• 2 Roosevelt
• 2 Great Neck
• 2 Freeport
• 3 East Williston
Long Island KEEP
•
•
•
•
•
•
•
486 (38.20%)
748 (61.72%)
317 (26.16%)
398 (32.84%)
327 (26.98%)
151 (12.46%)
213 (17.57%)
Male
Female
African-American
Caucasian
Asian
Other Race
Hispanic
Long Island KEEP ‘04 through ‘11
Breakdown of individuals that learned of a new
problem:
• 132 (10.89%) learned they may have diabetes.
• 172 (14.19%) learned they may have hypertension.
• 193 (15.92%) learned they may have high
cholesterol.
• 585 (48.27%) learned they may have kidney disease.
Long Island KEEP ‘04 through ‘11
• 1046 (86.30%) indicated that they have a
doctor.
• 456 (37.62%) requested that a report be
sent to their doctor.
• 916 (75.58%) indicated that they have
insurance. (4.04% Medicaid)
• 456 (37.62%) requested that their report
be sent to their doctors.
Long Island KEEP ‘04 through ‘11
• 953 (78.64%) were 46 to over 65 years of age.
• 337 (27.81%) responded to the survey.
• 249 (73.89%) who responded to the follow- up
survey reported seeing a doctor.
• 296 (87.83%) who responded to the follow- up
survey were willing to attend another
screening.
Key Programs and Initiatives
AWARENESS
PREVENTION
TREATMENT
Awareness
of the
kidney and
kidney disease
Prevent CKD in
at-risk population;
prevent progression
of early stage CKD
in early stage patients
Promote optimal
treatment by
offering education
to patients, caregivers
and healthcare
practitioners
PROGRAM FOCUS: EDUCATING Primary Care Provider’s (PCP)
Research shows that early detection and evidence-based treatment can prevent or delay the onset of
chronic kidney disease and its adverse outcomes, including cardiovascular disease and kidney failure.
A recent Multi-Site Cross Sectional NKF Study enrolled 460 primary care practitioners to determine
the prevalence of CKD overall and by stage in patients with type 2 Diabetes within the primary care
setting, based on the use of eGFR calculations and urinary protein excretion (albuminuria).
Of the 9,307 patients in the study, 5036 (54.1%) had Stage 1-5 CKD based on eGFR and albuminuria;
however, only 607 (12.1%) of those patients were identified as having CKD by their clinicians.
Clinical practice guidelines on chronic kidney disease exist, findings from two recent studies demonstrate
that a large number of PCPs are not aware of the National Kidney Foundation’s clinical practice
guidelines for the evaluation and staging of CKD.
STRATEGIC PROGRAMS FOR 2013:
- CME Symposia at NKF Spring Clinicals April 2013: Practical CKD Knowledge
for Primary Care Providers
- Enduring Web Based CME program for PCP’s and other educational tools
Programs for Patients
NKF Cares
• Patient information help line to answer
questions & address concerns
• For any CKD, dialysis or transplant patient
• Staffed daily by social workers & information
specialists for the majority of the day
• Toll-free number: 1-855-653-2273
Family Talk
• An informational packet to help patients talk
to their families about kidney disease and its
connection to diabetes and high blood
pressure
• Includes booklets with basic information on
CKD, Kidney Risk Quizzes, bracelets and
stickers to distribute to the family
Family Talk
The “Family Talk” can take place in several ways:
•
Talking one-on-one with family members at risk
for CKD in person, via telephone or email
•
Having a health discussion together with several
family members
•
Evaluation forms for patients and the social
worker
•
Pilot in dialysis centers
Your Kidneys & You
• A public health education Power Point
program on kidney health & kidney disease
• Presented free of charge to community
groups, senior centers, associations, schools &
places of business throughout the year
• 11 slides with very basic information for the
general public
Kidney Community Educators
• Volunteers trained to go into the community to
present “Your Kidneys & You”
• Trained live or via Webinar
• Receive a volunteer training manual, educational
materials on kidneys & kidney disease
• Flash drive with presentation slides & training slides
• Documentation includes an agreement letter, sign-in
sheets, participant evaluation & presenter evaluation
Kidney Community Educators
• Volunteers can be professionals, patients,
family members & friends or anyone with a
connection to the mission
• Handouts for attendees include Kidney Risk
Quizzes & NKF Bookmarks
• Volunteers commit to two programs per year
at a venue of their choice
World Kidney Day!
• Protect & Prevent on World Kidney Day:
Information on the NKF Web site
• NASDAQ Ringing of the Bell
• Times Square Jumbo-Tron
• Local events at many locations
• 2012 Grand Central Terminal Awareness &
Education Event
• 2013 Social Media
Facebook WKD Campaign
March 14, 2013
World Kidney Day Goes Viral!
Reach
• Reach: The number of people who saw
content from our page through various
channels.
• Viral Line: The number of unique people who
saw a story about our page published by a
friend.
• Peak: 229,587 total people reached from
3/9/13- 3/15/13!
Ask the Doctor!
Dr. Leslie Spry, MD, FACP
• Are you concerned about yourself, a friend or
family member? Ask away. Dr. Leslie Spry is
happy to provide answers to any questions.
• Dr. Spry practices consultative nephrology, is
the medical director of the Dialysis Center of
Lincoln in Nebraska, & participates in
research/innovative projects to benefit dialysis
patients.
PEERS Lending Support
For those who want more one-on-one support
than a healthcare professional can provide in a
brief office visit…
• A telephone-based peer support program
• Connects people who want support with
someone who has been there
• Helps people adjust to living with any stage
CKD, kidney failure, or a kidney transplant
WELCOME!
Seventh Annual Symposium on
Chronic Kidney Disease:
The Cardiac-Kidney-Diabetes Connection
The Roosevelt Hotel, New York City
April 4, 2014
Free CME Programs
Achieving Better Outcomes for Kidney Transplant Recipients:
Optimizing Patient Management
• Available through February 25, 2015
• This web-based interactive virtual patient program will help
participants: 1) consider available immunosuppressive
therapies for kidney transplant recipients; 2) make optimal
clinical decisions based on the needs and comorbidities of
their patients; 3) individualize therapy for kidney transplant
patients; and 4) provide the necessary patient teaching so
that patients are more able to adhere to immunosuppressive
regimens.
• Approved for 1.5 continuing education clock hours
What is “Living Well With
Kidney Failure?”
• A six-part educational
video series
• Created by the National
Kidney Foundation to
educate patients and
their families about
kidney failure and its
treatment
• An update of the popular
“People Like Us” Video
series
Materials
• Caddy
• Letter to Clinician
• Leader’s Guide for
Healthcare
Professionals
• Educational DVD
• Patient Booklets
• Record of Participation