Chronic Kidney Disease and the Electronic Health Record Duaine Murphree, MD Sarah M. Thelen, MD
Definition of Chronic Kidney Disease (CKD) Defined by the National Kidney Foundation Either a decline in glomerular filtration rate (GFR) to 60 ml/min/1.73m 2 or the presence of kidney damage for at least 3 months
Kidney disease screening recommendations National Kidney Foundation Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines American Diabetic Association
Some causes and risk factors for CKD Diabetes mellitus Hypertension Medications such as NSAIDs SLE HIV nephropathy CHF Hepatorenal syndrome Nephrolithiasis BPH Glomerulonephritis Age greater than 60 Family history of kidney disease
Screening Intervals for Complications of CKD by Stage Stage Complete Blood Count Intact PTH Phosphorus/ Calcium Total CO2 3 (GFR 30-59) 12 12 12 12 4 (GFR 15-29) 12 3 3 3 5 (GFR < 15) 12 3 1 3 Dialysis 12 3 1 1 Values are presented as monthly intervals. PTH, parathyroid hormone; GFR, glomerular filtration rate
National Kidney Foundation Guidelines 1. Determine etiology: DIABETES: follows classical presentation of onset associated with diabetic retinopathy; begins with microalbuminuria with subsequent increasing proteinuria, then development of hypertension, finally followed by decline in GFR HYPERTENSION: associated with other evidence of end-organ damage from HTN (LVH, etc) CONSIDER in all patients: as etiology may be multi-factorial Hepatitis B &C HIV SLE CHF (decreased renal blood flow) Obstruction: stones, BPH Infectious: UTI/pyelonephritis, postinfectious glomerulonephritis Multiple myeloma Cancer Nephrotoxic medications (including NSAIDs) Renal artery stenosis
National Kidney Foundation Guidelines 2. Quantify proteinuria No need for 24 hr urine collections for proteinuria Assess with spot (untimed) urine for protein and creatinine Ratio of protein/creatinine in urine = grams of proteinuria in 24 hr period 3. GFR: Follow GFR closely: if stable then measurement needed less frequently Average decline is 4mL/min/1.73m2 per year NOT using creatinine as ½ renal function lost before creatinine is elevated
National Kidney Foundation Guidelines 4. Imaging: Assess kidneys with renal ultrasound: rule out hydronephrosis suggesting obstruction; if significant renal asymmetry present, consider renal artery stenosis Further imaging per findings on ultrasound and patient history 5. Health Maintenance: Pneumovax Annual Influenza 6. Patient Counseling: Avoidance of nephrotoxic meds, including NSAIDs
National Kidney Foundation Guidelines 7. Factors to control to slow progression of CKD: Strict BP control to at least less than 130/80, consider goal of 125/75 if significant proteinuria Tight glycemic control Smoking cessation Decrease in degree of proteinuria ACE: first-line choice for all CKD regardless of etiology ARB: alternative first-line choice for diabetic CKD; can also be combined with ACE. ARB is alternative to ACE in patients with ACE allergy or ACE cough Diuretics: thiazide or loop diuretics; combo with ACE and/or ARB Non-DHP Calcium Channel Blockers: (diltiazem and verapamil); combo with above 8. Address increased cardiovascular disease: >20% mortality due to CVD in 10 yrs LIPID goals: LDL: at least <100, Non-HDL: at least < 130, Triglycerides: <150
National Kidney Foundation Guidelines Stage 1 CKD: GFR >90 but evidence of kidney damage (microalbuminuria, proteinuria, etc) 1. See previous recommendations for all CKD patients Stage 2 CKD: GFR 60-89 but evidence of kidney damage (microalbuminuria, proteinuria, etc) 1. See previous recommendations for all CKD patients 2. Monitor GFR decline closely as recommendations change as patient enters Stage 3 CKD with GFR<60
National Kidney Foundation Guidelines Stage 3 CKD: GFR 30-59 1. See previous recommendations for all CKD patients 2. Screening intervals for complications of CKD: Anemia: CBC at least every 12 months Bone Metabolism Abnormalities: Calcium, Phosphorus & Intact PTH every 12 months If PTH elevated then check serum 25-OH Vitamin D level, if normal then repeat annually Metabolic Acidosis: CO2 from chemistry every 12 months 3. Treatment for complications of CKD: If not comfortable with treatment, then referral to nephrology
National Kidney Foundation Guidelines Stage 4 CKD: GFR 15-29 1. See previous recommendations for all CKD patients 2. Screening intervals for complications of CKD: Anemia: CBC at least every 12 months Bone Metabolism Abnormalities: Calcium, Phosphorus & Intact PTH every 3 months If PTH elevated then check serum 25-OH Vitamin D level, if normal then repeat annually Metabolic Acidosis: CO2 from chemistry every 3 months 3. Treatment of complications of CKD If not comfortable with treatment, then referral to nephrology 4. Health maintenance: Hepatitis B series (in addition to Pneumovax and Influenza) 5. Patient counseling: No blood draws or IV lines (particularly PICC or Subclavian lines) in non-dominant upper extremity in order to avoid procedure complications that can eliminate this site for future dialysis access Renal diet: catered to patient's renal complications and co-morbid conditions; nutritionist 6. Nephrology referral : Recommended for all patients with GFR <30 Discussion about future hemodialysis vs. peritoneal dialysis vs. transplantation options
National Kidney Foundation Guidelines Stage 5 CKD: GFR<15 1. See previous recommendations for all CKD patients 2. Screening intervals for complications of CKD: Anemia: CBC at least every 12 months Bone Metabolism Abnormalities: Calcium, Phosphorus every month; Intact PTH every 3 months If PTH elevated then check serum 25-OH Vitamin D level, if normal then repeat annually Metabolic Acidosis: CO2 from chemistry every 3 months (every month if on dialysis) 3. Treatment of complications of CKD: If not comfortable with treatment, then referral to nephrology if not already in place 4. Health maintenance: Hepatitis B series (in addition to Pneumovax and Influenza) 5. Patient counseling: No blood draws or IV lines (particularly PICC or Subclavian lines) in non-dominant upper extremity in order to avoid procedure complications that can eliminate this site for future dialysis access (if doesn't already have access site) Renal diet: catered to patient's renal complications and co-morbid conditions; nutritionist 6. Nephrology referral: ASAP if not already in place
National Kidney Foundation Guidelines TARGET LEVELS FOR COMPLICATIONS: Hemoglobin target: 11-12 Tx with recombinant erythropoietin to Hgb>13 increases risk of CVD Phosphorus and Intact PTH Targets Vary by Stage of CKD: Stage 3: Phosphorus: 2.7-4.6 mg/dl Intact PTH: 35-70 pg/ml Stage 4: Phosphorus: 2.7 to 4.6 mg/dl Intact PTH: 70-110 pg/ml Stage 5: Phosphorus: 3.5 to 5.5 mg/dl Intact PTH: 150-300 pg/ml Calcium Target: corrected by albumin level and should be within normal range. Stage 5 CKD patients should be towards lower end of normal. CO2 Target: >22
National Kidney Foundation Guidelines Who can remember all of this? Why not use the EHR to put in note Templates and Guidelines to help?
Guidelines and Templates can be a part of the EHR Guidelines can be informational only Guideline text does not have to be added to the note Templates can have optional information that can remind the provider about needed tests or data but this information does not have to become part of the note
EHR template for CKD stage 1 & 2
EHR s can have groups of orders Examples: Orders grouped by diagnosis Orders linked to a diagnosis Order sets These order groups remind the provider what to order
Example: EHR and CKD stage 3
Example: EHR and CKD stage 4
EHR and setting reminders
EHR and setting reminders
Cost savings Tests for CKD can be ordered according to Guidelines, avoiding unnecessary testing. Nephrology referral and appointment is time consuming and costly for patients. Early CKD does not need a nephrologist but does need follow up. Routine, cost effective follow-up can be done by the patient s PCP.
EHR and cost savings Chart always available Patients seen without charts 1 FTE hunting for charts No duplication of tests Messages answered faster Note legibility Flowsheets
Resources The Centers for Medicare and Medicaid Services EHR Incentive Programs http://www.cms.gov/ehrincentiveprograms FMQAI-Florida s Medicare Quality Improvement Organization (QIO) and the End Stage Renal Disease (ESRD) Network of Florida www.fmqai.com CKDTeam@fmqai.com 1-800-564-7490 (CKD Team)