Christopher Keller, MD
Director of Clinical Operations
Boise Kidney and Hypertension Institute
RPA 2011 Annual Meeting
Friday, March 18, 2011
Disclosure of Conflict of Interest
Name of Faculty or
Presenter
Reported Financial
Relationship
Consulting Fees
Genzyme Corporation
Affymax, AMAG
Christopher Keller, MD
Study Investigator for Research
Cytochroma, Fibrogen, Pfizer,
Takeda, Boehringer Ingelheim,
Johnson & Johnson, Abbott,
Amgen, Advanced Renal
Technologies
Christopher Keller, MD
Director of Clinical Operations
Boise Kidney and Hypertension Institute
RPA 2011 Annual Meeting
Friday, March 18, 2011
What are the issues?
 Primary care providers (PCPs) often defer referrals until
very advanced stages of CKD
 25-50% of all ESRD patients never saw a nephrologist until 3
months or less before onset of dialysis
 Reasons for not referring: advanced age, comorbidities, and
perceived patient nonadherence to therapy
Fischer MJ et al., Am J Nephrol 2011;33:60-69
Navaneethan et al., Clin Nephrol 2010;73:260-267
What are the issues?
 Nephrologists are spending more time focused on CKD
progression and less time on non-nephrology concerns
 The use of a multidisciplinary team (MDT) to manage stage
3-4 CKD patients may slow progression of CKD and may
improve outcomes at the start of dialysis
Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343
Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub
Slowing CKD progression with an MDT
Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub
Mortality benefit with an MDT
Kaplan-Meyer survival after starting dialysis therapy
Curtis et al.
Nephrol Dial
Transplant
2005;20:147
Open the black box…
 PCPs must play a critical role in the multidisciplinary team
 RPA ToolKit website:
http://www.renalmd.org/toolkit-form/
Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343
How do we involve primary providers?
 Step 1: Identify your goals for co-management
 Preferences for timing of referrals
 Step 2: Open communication lines with primary providers
 Ask them directly about their co-management interests
 Let them know that you are willing to answer questions
Tonelli M et al., Ann Intern Med 2011;154:12-21
How do we involve primary providers?
 Step 3: Communicate regularly with primary providers
 Ensure timely, effective communication with the PCPs every
visit
 Track referrals and identify providers that do not refer early;
devote resources for education
 Electronic record systems and note templates make it
easier
Boise Kidney model: Documentation
1) CKD--The current eGFR is [] ml/min. Chronic kidney disease is due to
2) Anemia--goal Hgb is 10-12. Goal ferritin is > 100 and tsat is > 20.
3) HTN--goal BP is < 140/90.
4) Acidosis--goal serum bicarbonate is 22.
5) Vitamin D--goal 25-OH vitamin D is > 30.
6) Ca/Phos--goal Ca is 8.5 to 9.5 and goal phos is < 5; goal PTH is < 100.
7) Nutrition--goal albumin is 4.0.
8) Dyslipidemia--goal LDL is < 100 and triglycerides < 500.
9) Dialysis education--Dialysis and transplant options have been discussed.
10) Vascular access--the patient has been advised to protect the non-dominant arm for
dialysis.
Thanks for allowing the patient to participate in the Conductor Clinic, our clinic program
dedicated to the protection of renal function in patients with late stage CKD.
Conductor labs 1 week before next visit: 1 month / 3 month / 6 month
Conclusions
 The complexity and breath of nephrology management
has been a barrier to PCP communication
 Multidisciplinary care of advanced CKD patients may slow
CKD progression and reduce mortality in CKD patients
 Communication with PCPs is required to:
 Optimize early referrals
 Permit nephrologists more time and energy to focus on
prevention of ESRD