Goal - Objective

Educate nephrology
community about
new Pre-ESRD classes
and current pilot
programs in the
greater Houston area

At the end of this presentation

the reader will be able to
answer
Why Kidney Education is important in Chronic

Kidney Disease or CKD

What is a community-based education program
What information is included in CKD education
program
How does early CKD education program benefit
patient outcomes and the physicians practice
What patients say about early CKD education
How one can participate or set up a program

Chronic Kidney Disease in

the US
Over 20 Million Americans have some degree
of renal insufficiency.1 in 8 people.
20 million others are at risk
Hypertension & Diabetes are the leading
causes of kidney failure
23% of all Americans have hypertension
16 million Americans have diabetes

Both are independent risk factors for

cardiovascular disease

CKD EDUCATION
Knowledge is Powerfor us and our
patients. To educate patients is the
highest form of care we can give. It
empowers our patients to make changes
big and small to improve their health and
quality of life. It empowers them with
control and information to feel more
relaxed in an anxiety producing situation
of CKD transition to ESRD.

Projection for ESRD

Population

USRDS ADR 2008

Incidence by Race

2008

African Americans Develop

ESRD at a Younger Age

New Conditions of Coverage

ESRD Medicare Reform

Medicare Improvements for Patients and Providers Act of 2008
(HR 6331 MIPPA)
CKD education is recognized by CMS
Reimbursement to nephrologists who provide chronic kidney
disease education
Physicians Must Educate CKD Patients on:
Kidney disease
Access choices and issues
ESRD Treatment options
Physician performance is based on

Influenze vaccine
Blood Pressure control
Referral for an AV fistula
Laboratory values Ca, PO4, PTH, Lipid profile

*Best physicians educate on much more.

Why Educate?
WhyEducate? And When? The earlier the better.Start
education by stage 2 or 3 to have the biggest impact.
One reason is we must. The new cfc regulations are
requiring pt education on kidney disease, treatment
options, accesses. I dont think this man had his Save my
vessels class information or he would not allow anyone to
stick him up and down both arms.
Another reason: It is smart use of patients time and energy.
Pts who use this information stay healthier longer and start
dialysis in a better place both physically and mentally. If
they come to us healthier they start healthier in ESRD
with better Outcomes, more choices and better quality of
life.
They make better choices: more open to dialysis options
when starting dialysis not an emergency. When pt education
is done ahead of starting dialysis Home dialysis is chosen
more often.

What is community-based
education?
Patient education program that
includes:
Multidisciplinary coaching program
Stage-specific education
Easy education referral process
Follow-up with patients and physicians
Sessions are free for patients and guests

Find a comfortable location and time.

Location

The course does not need to be

held in Maui, although it would be
nice. A church down the street
with a large conference room
works fine.
Experience with renal treatment
options training reveaed we
would gain more patients in a
non-medical location.
And our participants have
reinforced that concept.
The Houston Community-based
CKD program sponsored by
DaVita, known as EMPOWER, has
had nearly 200
pts/family/friends
The patient feedback is very
positive

What is Community-Based Education?

Multidisciplinary Coaching
Multidisciplinary
coaching program
Inform patients about their
kidney health
Improve quality of life
Preserve renal function
Help patients identify the
best treatment choice for
their lifestyle
Tools to organize and track
their health care
Health Diary

Multidisciplinary education

Multidisciplinary coaching program can make a difference.

A nurse, a dietitian and a social worker attend each class to

present the information and answer questions.

The goal is help patients learn as much as they can about

kidney health.

Informed patients are less anxious and more equipped to

effectively follow their treatment plan, preserve renal
function and improve their quality of life.

CKD education helps patients to identify the best treatment

choice for their lifestyle and reinforce early fistula
placement.

Benefits of early intervention

and education
Delay or prevent the worsening of
cardiovascular disease, hypertension and
diabetes
Delay or prevent the progression to chronic
kidney disease
Improve outcomes if kidney replacement
therapy ever becomes necessary
Psychologically prepare one for kidney disease
Reduce health care costs
Keep people employed and out of the hospital

Tools Provided
An initial postcard and quarterly e-newsletters
Valuable tools from a well-regarded website,
http://davita.com

GFR calculator and tracker

500 CKD recipes
DaVita Diet Helper
CKD videos
More.

The health diary is a tool given to each CKD

patient and is designed to help organize and
track their health care. We recommend that
patients utilize their Health Diary for all provider
visits to maintain continuity of care.

TOOLS FOR BETTER CARE

Health Diary
Resource for the patients
Patient information
Healthcare phone numbers
History and Physical
Medication list
Lab work
Diabetes and Hypertension
Glossary

The health diary

Both the patients and the doctors really like this diary.
Not only is it a great resource but it gives the patients
a central location to keep their valuable health
information.
They just ask for copies and file it away.
When they go to any health professional, they have it.
Even with Hurricane Ike pick it up and go.
The doctors like it when they can see all the
information.
Best from patients is the questions to ask the doctor.
Reminds them of the importance of the medication, BP
or lab results.

What stage am I?
This is the question most patients ask. We review kidney function and the
stages of kidney disease. We review how this calculation works and that is
based on both kidneys. We discuss that the stages are generally progressive
but that patients can impact or slow the progression of kidney disease with
diet, medications and healthy behaviors. Patients need to be informed and
ask lots of questions of their health care team and physicians.

Stage 1 GFR 90 cc/min/1.73m2

Kidney Damage with normal or high GFR

Stage 2 GFR 60 to 89 cc/min/1.73m2

Kidney Damage with mildly decreased GFR

Stage 3 GFR 30 to 59 cc/min/1.73m2

Moderate decreased GFR

Stage 4 GFR 15 to 29 cc/min/1.73m2

Severely decreased GFR

Stage 5 GFR - < 15 cc/min/1.73m2

Kidney failure
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

Glomerular filtration rate

The serum creatinine by itself is a very POOR way
to assess kidney disease.
It does not take into account variation in muscle
mass, nutritional status or body habitus
GFR measures how well your kidneys filter waste
products, which tells your doctor how well your
kidneys are working.
In 2002, the National Kidney Foundation began
recommending the use of GFR instead of just
serum creatinine for a more accurate
measurement of kidney function.
GFR is calculated from your blood creatinine, age,
race and gender.
From AAKP Healthline, 2009 Stephen Z. Fadem

Assessment of kidney disease

Learning how well the kidney is functioning is important not only in screening and diagnosing chronic kidney disease (CKD), but in following
its progress.
Although there are various ways to do this, the simplest is the MDRD GFR (glomerular filtration rate) which can be calculated using a
patients age, race, gender and a laboratory test, known as the serum creatinine. The muscles are in a constant state of being broken down
and being repaired.
The creatinine is a byproduct of this breakdown and is generally stable in the blood from day to day.
While the serum creatinine is an indication of kidney function, its variation with muscle mass makes using the other factors mentioned
above necessary.
This equation was derived from a large study published in 1994 that looked at how the modification of dietary protein would affect renal
disease hence Modification of Diet in Renal Disease (MDRD).
This study required a very accurate measurement of kidney function. The investigators noticed the mathematical relationships between the
accurately measured GFR, age, race, creatinine and gender, and derived the MDRD study equations still in use today.
It is also referred to as the eGFR. This GFR is used to determine what stage of kidney disease one has, stages 1 and 2 being very mild,
with GFRs above 60 ml/min.
When the GFR is greater than 60, other markers of kidney function such as an abnormal urine or abnormal ultrasound are necessary for
making the diagnosis. When the GFR is less than 60 for greater than three months, it indicates the presence of CKD.
Once the GFR is calculated, and repeated in 3 months we also need to look at other markers of Kidney disease. While this is
necessary if the GFR is > 60, we also recommend testing for markers strongly in everyone since it helps us reverse the reversible
and get a better diagnosis. Markers include the renal ultrasound and the urinalysis.
Although the calculation involves some complicated math tricks, it was programmed for the Internet shortly after it was discovered, and is
on the Web at www.mdrd.com.
The National Kidney Foundation uses the same application. It has also been programmed for handheld calculators.
Many laboratories routinely report the MDRD GFR along with the serum creatinine value. As more and more laboratories standardize their
serum creatinine measurements to the National Institute of Standards, the equation will change slightly, but that change is also programmed
and available at www.mdrd.com.
When using the program, simply key in your serum creatinine, age, race and gender and your GFR value will appear. The site will also
calculate your kidney disease stage. It is important that you personally keep track of your serum creatinine and GFR values.

From AAKP Healthline, 2009 Stephen Z. Fadem

You have heard about

Cystatin C

Serum creatinine has a drawback in the measurement of glomerular

filtration rate (GFR) in that it may vary according to muscle mass.
Cystatin C is a 13 kilodalton protein that is filtered by the glomerulus and
reabsorbed and metabolized by tubular cells. The amount that is excreted
into the urine is negligible. Its production is very steady, and not dependent
on muscle mass.
It has been proposed as an alternate marker for estimating GFR by Dr. Joe
Coresh.
An elevated serum cystatin C level may indicate a worse cardiovascular risk
in patients with the metabolic syndrome. (18456039) .
The literature is emerging, and showing that it has benefit as a marker. Here
are two formulae that might be useful in demonstrating the relationships
between serum creatinine and serum cystatin C
The serum cystatin C calculation is found at http://touchcalc.com
Joe Coresh recommends averaging the Cystatin C and the MDRD GFR

Clinical evaluation of patients

at increased risk for CKD

All Patients
Measurement of blood pressure
Serum creatinine to estimate GFR
Protein to creatinine or albumin to
creatinine ratio in first AM or random
untimed spot urine specimen
Examination of the urine sediment or
dipstick for red blood cells and white
blood cells

Stage-Specific Education
Taking Control of Kidney Disease
Living with Stage 3 and Early Stage 4 CKD
Focus on preserving renal function

Normal Kidney functions / Kidney Disease

Control of co-morbidities / Diabetes / HTN
Diet and medication
Heart healthy behaviors
Preserving veins
Insurance questions
Questions to ask physician

Treatment of CKD

Treat the underlying disease

Treat associated problems
Slowing the loss of kidney function
Prevent heart disease
Reduce complications
Preparation for
dialysis/transplantation
Kidney transplant or dialysis
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

Definition of Chronic Kidney

Disease
Chronic kidney disease is defined as
either kidney damage or GFR < 60
cc/min/1.73m2 for 3 months.
Kidney damage is defined as
pathologic abnormalities or markers
of damage, including abnormalities in
blood or urine tests or imaging
NKF/KDOQI Clinical Practice Guidelines for Chronic Kidney Disease

Clinical Practice Guidelines for

Management of Hypertension in CKD
Type of Kidney Disease

Blood Pressure
Target
(mm Hg)

Preferred Agents
for CKD, with or
without
Hypertension

Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target

ACE inhibitor
or ARB

Diuretic preferred,
then BB or CCB

Diabetic Kidney Disease

Nondiabetic Kidney
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
Nondiabetic Kidney
Disease with Spot Urine
Total Protein-to-Creatinine
ratio <200 mg/g
Kidney Disease in Kidney
Transplant Recipient

<130/80
None preferred

Diuretic preferred,
then ACE inhibitor,
ARB, BB or CCB
CCB, diuretic, BB,
ACE inhibitor, ARB

Clinical Practice Guidelines for the

Detection, Evaluation and Management of
CKD

Stages 1 and 2: Preventing Heart

Disease in CKD

Traditional cv
risk factors
Non
traditional
risk factors

How Can You Protect Yourself Against Heart Disease

And High Blood Pressure?

Get regular medical checkups

Control your blood pressure
Monitor your blood pressure weekly
Check your cholesterol regularly watch saturated fats and
fructose
Watch your diet - SALT
Regular doctor visits
Blood pressure - 130/80
It make take several medications
Dont smoke
If you choose to drink, do so in moderation
Exercise regularly
Manage stress

Traditional Risk Factors

Smoking
Cholesterol
Obesity
Family History

Non Traditional Risk

Factors
Inflammation
Mineral-bone
disorder
Anemia

ACEs and ARBs

These drugs are critical to care starting in
Stage 1 and 2
ACES and ARBs have a compound effect on
blocking the renin-angiotensin system.
The goal is to lower the blood pressure to
120 mm Hg and to titrate proteinuria.
Contraindications include allergy and
bilateral renal artery stenosis
Potassium levels should be monitored
closely when patients are on ACES or ARBS
(Beta blockers, NSAIDS, ACES and ARBS can
raise serum potassium)

Blood Pressure Is Poorly Controlled in

Patients With CKD

Inflammation

Associated with CKD

Atherosclerosis
Vascular calcification
Statins not helpful in CKD5
CRP not diagnostic
MIA

Exercise And Kidney Care

Talk to your doctor about starting an

exercise program thats right for you.
Exercise can help you improve physical
functioning and emotional well-being,
increase physical stamina, improve blood
pressure and reduce the risk of heart
disease, lower cholesterol, help you sleep
better and control body weight.
Incorporating consistent aerobic exercise,
even taking a 20-minute walk, can help
especially if your CKD is a result of
hypertension or diabetes.

Watch meds and therapies

Here are some examples:

Avoid Metformin in Stage 3 and beyond

Contrast media
Nephrogenic sclerosing fibrosis may occur
with an MRI due to galadinium contrast so
procedure should be done without this
contrast agent
Iodine can be nephrotoxic and patients
should be well hydrated pre procedure

NSAIDS should not be given to kidney

patients

Diet

Sodium - 100 mmoles

Lipids - pre dialysis
Carbohydrates - Diabetes
Proteins - MDRD Trial
Potassium - watch because of ARBs
and ACE inhibitors

Nutritional Tips For Healthy Kidneys

In order to help maintain healthy kidneys it is important to eat properly

Keep track of daily calories
Limit total fat
Watch high fructose corn syrup
Watch excess proteins and phosphorus - Monitor the amount of protein
eaten
You may need to watch potassium - Learn about potassium
Your dietitian can help you with recipes that fit your needs
Control salt intake
Take care of your bones exercise and take vitamin D
Be sure to get enough iron
Watch fluid intake
Understand your nutritional plan

Stage 3 Medical Focus

CKD MBD Metabolic bone
disease
Acidosis - Bicarbonate
Anemia Erythropoietin

Class reinforces
bone and
heart healthy diet.

Stage 3

a. Cardiovascular risks and therapy stay

the course
b. Preparation:
1. Anemia
2. Acidosis
3. Blood pressure/ACEs and ARBS
4. Inflammation
5. Diet
6. Modality choice
7. Access preparation
c. Modalities of therapy

Preparation

Anemia
Acidosis
Blood pressure - ACES & ARBS
Inflammation
Diet
Modality Choice
Access Preparation

Anemia in CKD
Anemia management with EPO since 1990s Keep Hct < 42
N Eng J Med 339:584-90, 1998

Keep hgb 10 - 12
CHOIR

N Eng J Med 355:2071-2084, 2006.

34% worse when hgb target is 13.5 than 11.2

CREATE

N Eng J Med 355:2084-2098, 2006

22% worse when hgb is 13-15 than 10.5-11.5

Check Iron levels and correct first

EPO can be given in the office - monitor blood
work

EPO

RBC

RBC PRECURSOR

Acidosis
Increased protein catabolism of amino
acids
Inhibition of protein synthesis can cause a
low albumin
Accelerates renal osteodystrophy
Modulates vitamin D and parathyroid
hormone levels
Evokes insulin resistance

Albumin Synthesis
Chronic acidosis impairs albumin
synthesis and causes negative
nitrogen balance
JCI 95:35-45, 1995
Albumin - major marker for
nutrition
Low serum albumin - risk factor
for poor dialysis outcome
It is advisable not to restrict
dietary protein once the serum
albumin level starts to fall

Metabolic Acidosis

REGENERATES
BUFFER

The kidney has a major responsibility

to eliminate and buffer acids. In renal
failure these acids accumulate.
When the clearance falls below 25 cc
per minute, the accumulated acids
cause loss of appetite. Protein stores
and albumin fall, and muscle is
broken down and used as a nutrient.
It is not clear whether correction of
acidosis with bicarbonate solution is
helpful, but there is consensus that
as renal function deteriorates and
albumin falls, the diet needs to be
adjusted, and if that does not work,
dialysis is needed to correct the
acidosis.

SECRETES
ACIDS

Benefits of anemia
correction

Improved work and aerobic capacity

Reduced cardiovascular
complications
Reduced hospitalizations
Decreased mortality
Improved quality of life
Improved cognition
Improved sexual function
Besarab. Am J Kidney Dis. 2000;36 (suppl 3):S13.
Fink. Am J Kidney Dis. 2001;37:348.
Kausz. Am J Kidney Dis. 2000;36(suppl 3):S39.

Vascular Calcification
Kidney damage causes decreased
phosphorus excretion. This stimulates
phosphotonins to increase phosphorus
excretion.
Phosphotonins and kidney damage decrease
the activation of vitamin D
This weakens muscles, decreasing bone
strength.
This decreases the calcium depositing in
bone, and along with phosphorus leads to
changes in blood vessel cells
Calcium deposits in blood vessels
Inflammation and Hyperlipidemia (metabolic
syndrome) make this worse
High fructose corn syrup makes metabolic
syndrome works

DIET IS IMPORTANT!!!

Chronic Kidney Disease

And Mineral Bone Disorder
Too much phosphorus and
Damaged kidneys do not produce enough
vitamin D
Vitamin D helps maintain calcium levels which
keep bones strong
Calcium may build up in blood vessels with
CKD
Without enough vitamin D, you are more likely
to have weak bones that may break easily

How to Protect Against

CKD MBD?

Vitamin D level
Parathyroid hormone level
Ergocalciferol over the counter
Vitamin D is probably for everyone
regargless of stage
At later stages you might need an
active form of vitamin D
Exercise and diet management
The doctor may want to check for
vascular calcification

What Effect Can Chronic Kidney Disease

Have On The Body?
Heart disease
High blood pressure
Vitamin D deficiency - bone and
mineral disorder
Anemia
Malnutrition and low serum albumin
Acid buildup

Recommendations
Inflammation - Dental hygiene, fiber in early
stages, exercise, keep trim. If we develop a
stomach illness like helicobacter, get it
treated. Keep toenails trim.
Atherosclerosis - Check the serum
cholesterol, LDL, VLDL, HDL - use diet,
exercise, medications (statins, usually) to
keep these numbers in the proper range

PHOSPHORUS AND VITMIN

D

CKD-MBD - Avoid excess

phosphorus in the diet
and have vitamin D
levels checked. If low,
start on ergocalciferol or
cholecalciferol. Later, an
active vitamin D like
calcitriol, doxercalciferol
or paricalcitol will be
needed
Vascular calcification - As
the disease progresses,
restrict phosphorus and
use a phosphate binder.

Stage-Specific Education
Making
Healthy
Choicesfor Stages 4 and 5 CKD
Preparing
for dialysis

Symptoms of Uremia
Controlled dialysis start
CKD and dialysis diet
Control of co-morbidities DM/HTN
Medications Call your Nephrologist
Access No to catheters, Yes to fistulas Vein Map
All treatment choices
Insurance issues

Stage 4 and 5 CKD Class

Making Healthy Choices

Preparing for dialysis in later Stage 4 to early Stage 5 Chronic Kidney Disease
This is the longer class due to the number of questions we have from the patients and family members.
We focus on maintaining the patients kidney health as long as possible but also educate the patients on the symptoms of uremia
and the transition process to ESRD.
Class detail:

What kidneys do
What causes kidney disease Symptoms of Uremia Nausea and vomiting, Taste changes, Swelling, SOB, Itching, Lack of concentration
and memory issues.
Preparing for dialysis Preventing the Crash and Burn admission to dialysis. No one knows the exact moment but working with your
doctor will help to get the time right for you. We can delay but not forever without it damaging your health due to malnutrition or heart or
stroke.
Managing your health through diet. Review diet changes at the end of stage4, especially related to low protein, potassium, phosphorus,
salt and fluid. What the stage 5 diet is for the different treatment modalities. Most of the pts enjoy knowing their diet will get more protein
on ESRD than in stage 4.
Control of DM and HTN Protect your heart and vasculature as well as your kidney function never stops. Dialysis patients do not die from
dialysis. They die from infection and Cardiac/Vascular disease due to DM and HTN. BP and BS Heart healthy behaviors. Diet, Exercise,
Stop smoking. We all know it .
Common medicines for people with kidney disease Phosphorus binders, Vitamin D, Renal Vitamins, Bicarbonate, EPO. Stay off magnesium,
aluminum products. Call doctor for any new meds prescribed or OTC or from other doctors. Stay away from IV dye contrast.
Access information and planning early with stage4 No to catheters yes to fistulas. Lots of info about best choice and get it now.
Fistulas may take months to mature. Be sure to get vein mapping done prior to surgery for improved success with fistulas. You dont take
a trip without a map you dont want surgery without a map either. CVC catheters have more infections, clotting, hospitalizations and
deaths. Be sure to remove CVC catheters as soon as possible. Getting a CVC catheter may be necessary for a short while for initial dialysis
but getting your fistula now will shorten that time and may save your life.
An in-depth look at all of treatment choices:

Peritoneal Dialysis (PD)

Home Hemodialysis (HHD)
Hemodialysis (HD)
Nocturnal hemodialysis
Self-Care hemodialysis

Transplant
Conservative treatment

Choosing the right treatment for your lifestyle, especially if you want to continue working or have active life.

Understanding Insurance state and federal insurances and when to apply for secondary insurance especially if want transplant due
to medication cost. We have saved patients money by assisting with insurance questions.

Modality Choice
PD - 7% of population
Preference values higher than for HD 74-69
Physicians in practice 11 years along more likely to refer
to PD
More likely recommended to men, people with residual
function, with weight less than 200 lb and the absence of
diabetes

Hong Kong

Half the mortality

5 staff for 300 patients
Less mortality because residual function preservation
Loss of residual function is a cardiovascular risk factor

Stage 4 Medical focus

Modalities Incenter and Home Dialysis,
Transplant or Conservative therapy
Referral for access Vein mapping and
surgery
Serum Albumin Prevent malnutrition
Continue other therapies ACE or ARB
Anemia Erythropoietin therapy

Stage 5 but not yet on

dialysis
One-on-one modality options
Conservative treatment Medical, diet
management, Hospice Assistance
Transplant refer early
Home therapies (Peritoneal, Home Hemodialysis)
In-center therapies (ICHD, Nocturnal, Self-Care)
Physicians focus - Therapy choice/transition

PD References Early
referral helps
1. Bass EB, Wills S, Fink NE, et al: How strong are patients' preferences
in choices between dialysis modalities and doses? Am J Kidney Dis
44:695-705, 2004
2. Winkelmayer WC, Glynn RJ, Levin R, et al: Late referral and modality
choice in end-stage renal disease. Kidney Int 60:1547-1554, 2001
3. Lin C-L, Chuang F-R, Wu C-F, et al: Early referral as an independent
predictor of clinical outcome in end-stage renal disease on hemodialysis
and continuous ambulatory peritoneal dialysis. Ren Fail 26:531-537, 2004
4. Thamer M, Hwang W, Fink NE, et al: US nephrologists'
recommendation of dialysis modality: results of a national survey. Am J
Kidney Dis 36:1155-1165, 2000
5. Wang AY-M, Wang M, Woo J, et al: Inflammation, residual kidney
function, and cardiac hypertrophy are interrelated and combine adversely
to enhance mortality and cardiovascular death risk of peritoneal dialysis
patients. J Am Soc Nephrol 15:2186-2194, 2004

Home Hemodialysis
Short - 2 hour per day X 6 days per
week
Long - Overnight X 6
Prospective patients
Visit during CKD
Logistics, location and type of
equipment

NxStage - 70 pounds
2008K@home (BabyK)
May need plumbing and electrical

Need ample storage

Need for vascular access
Need a partner

Nocturnal Home
Hemodialysis
May be able to stop
binders
May need supplemental
phosphorus
Less hypertensives
Less epo
Less fluid restriction
Nocturnal in-center for
select patients

Access Preparation
Arteriovenous
fistula - 1966
Lasts many years
Veins arterialize
Arteries expand
Capillaries and
larger vessels
absorb shock
Graft transmits
shock and lasts only
around 18 months

Easy Education Referral

Process

Easy education referral process

Identify patient
Inform patient
Order education
Refer & Fax

Empower Team
Call patient
Schedule class

How the program works

The CKD community-based process begins and ends with the office team

First, the office will need to identify patients who are Stage 3, 4 and 5 that need
CKD education.

Next, refer those patients for education by completing and faxing the referral
form (show form). The patients are notified, enrolled in a class and called to
remind them of class approximately 1 week prior. The day of class, patients will
complete an attendance form and evaluate the class. This data will be recorded
at the call center.

The recorded data allows the educators to provide the office with information
affecting patients and practice. We can extract the number of your patients
who have attended a class, which class they have attended, their stage of CKD,
access preparation for dialysis, type of access, modality choice just to name a
few of the components.

Ultimately, the goal is help patients to take control of their CKD and, if dialysis
is needed, that they begin dialysis healthier and prepared.

Communication is crucial
Nephrologist receives a letter from CKD
educator
Indicates what class patient attended
High lights no shows
Lists concerns and/or modality interests if
expressed

CKD patient receives a phone call from CKD

educator & education materials
Assess for additional teaching
Answer questions and provide resources
Initial postcard mailing & quarterly e-newsletters

Follow-up
We will provide a follow up letter for every patient that is
educated, indicating which class the patient attended;
what material was covered; any concerns they
expressed and for late stage patients, their modality
interest.
We maintain telephonic contact with your patients
referred and educated to develop an understanding of
their education needs and to help support them through
additional classes and guidance to resources. As
previously mentioned, an initial postcard and quarterly
e-newsletter are delivered to introduce the valuable
tools that a well known website, DaVita.com offers GFR
calculator and tracker, over 500 CKD recipies, DaVita
Diet Helper, CKD videos and more.
All medical questions will be referred the physician.

Summary of Stages

Pre-ESRD patient education does better when referred early to an education

program. An educated patient will adhere better to the therapy that slows
progression of disease
In the early stages, 1 and 2 it is important to control for diabetes and blood
pressure. Generally an ACE or an ARB is recommended

By Stage 3 patients are starting to manifest signs of anemia, metabolic acidosis

and early metabolic bone disease.

They need to have laboratory studies Ca, PO4, PTH, lipid profile

By stage 4, the serum phosphorus is elevated. Vitamin D analogs may be

necessary. Phosphorus control can be done with diet, but most likely at this
stage will require a binder.

Vitamin D management should start early in the course of disease

Some recommend restricting the use of process foods early
In addition to diet and blood pressure control with an ACE or ARB, control of glucose is
valuable in diabetics

Patients have other choices beside in center hemodialyssi. In stage 4 it is important to

discuss options such as home hemodialysis and home peritoneal dialysis. Patients who
have been educated are more likely to choose these modalities, and are more satisfied
with them.
The patient should be evaluated early for a permanent vascular access, and
depending upon the modality chosen, a fistula or peritoneal dialysis access placed.

Pre-ESRD classes lead to a smoother transition into a dialysis (stage 5) regimen.

CKD Education Benefits

Feel more engaged and in-control

Patients

Slow the progression of renal disease

Healthier on First Date of Dialysis

Physician

Free education to patients and

community
Physician able to compliment own
education
Saves physician time, resources and
money
Patients learn of laws that protect

Taxpayers

them
Patients stay employed and
insured
Decrease burden on Medicare

Win Win - Win

CKD Education is a Win-Win-Win program. It is
provided to patients and the community at no cost or
obligation.
Patients who attend are empowered to take control of
their kidney health. They are provided with the tools
they need to preserve renal function.
Physicians are able to compliment their own excellent
education, saving them time, resources and money.
Finally, by helping patient to understand the laws that
protect them, we can help keep patients employed
and maintain their insurance, thus decreasing the
burden on Medicare.

How Do You Participate?

Establish CKD Education as part of your
practice
Protocol: Educate all patients Stages 3,4 and 5
Process:
Identify eligible patient during office visit
Patient communication (discussion and flyer)
Clinician orders education need using:
Sticky note
Referral form

Office staff completes and faxes referral form

CKD education team contacts patient and
schedules class

How to work with a

physician office
Every physician practice operates differently. The 3
biggest things to walk away from the meeting with are:
The physicians commitment to refer their CKD pts (get
granular as to are they willing to send Stage 3 pts as well as
4 and 5 or just 4 and 5 which is fine too)
A solid detailed process in writing on how the doctor is going
to notify the administrative team of the order for education
and how the administrative team is going to send the fax
referral. If the Physicians are willing to set a "protocol" or
"standing order" that states the admin staff is to refer all
CKD pts (or all Stage 4/5 pts) that is great because it takes
the step of the physicians remembering to refer for
education out of the mix.

An agreement on how often you and the administrative

staff will touch base to make sure everything is good.

Early CKD Education Benefit Patients?

What Houston CKD patients say about CKD
Education:
I wish I had this information sooner
I will really study my lab values and check my diet
I will talk to my doctor about my NSAIDs and
decongestants
The health diary is excellent. I really like the glossary
As a family member, I think my father (patient) will
feel more comfortable about the possibility of dialysis.

Success Stories

Success Stories
Patients need information and change can
happen
Pt went from stage 4 to stage 3 and thanked us for
the class.

Office staff tell of a pt they were dreading to tell

about time to start dialysis
Pt said Its OK, I know about it. The office nurse
was amazed.

Access placements before starting dialysis

As they should be

Insurances saved or supplemental insurance

obtained before ESRD.

The End