The National Kidney Foundation’s The National Kidney Foundation’s Kidney Early Evaluation ProgramKidney Early Evaluation ProgramTMTM

““The Greater New YorkThe Greater New York Experience”Experience”

Ellen H. Yoshiuchi, MPSDivision Program Director

National Kidney Foundation Serving Greater New York

Program Objectives•D

escribe 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 EarlyKidney EarlyEvaluation ProgramEvaluation ProgramTMTM

10 Year Anniversary

KEEP ObjectivesKEEP 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 ObjectivesKEEP 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 Chronic Kidney Disease is a Public Health Problem!Public Health Problem!

Rate of Kidney Disease Jumps by 30%

Chronic Kidney Disease is a Chronic Kidney Disease is a Public Health Problem!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 ProblemCKD is a Public Health ProblemWorldwide!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 EmphasisNew 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 office-based urine microscopic exam.

American Academy of Family Physicians. Practice Profile II Survey. November 2009American Academy of Family Physicians. Practice Profile II Survey. November 2009

Criteria for CKD•G

lomerular filtration rate (GFR) <60 ml/min/1.73 m2•G

FR is the best overall index of kidney function in health and disease.•T

he normal GFR in young adults is approximately 125 ml/min/1.73 m2. •G

FR <15 ml/min/1.73 m2 is defined as kidney failure•C

an 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 CKD3 Levels of Prevention in CKDPrimary – 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 CarePrimary 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 DO THE NUMBERS MEAN?WHAT CAN I DO ABOUTWHAT CAN I DO ABOUT CHRONICCHRONIC KIDNEYKIDNEY

DISEASE?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 EvaluationKEEP 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 EvaluationKEEP 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 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 ClassificationBlood Pressure ClassificationKEEP 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 GuidelinesBlood Glucose GuidelinesAmerican

Diabetes Association (ADA) 2008Criteria 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 e-mail 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%•8

61 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 kidney disease: 5.86%•2,967 high cholesterol: 39.40%•2,276 diabetes: 30.41%•3,961 hypertension: 53.23%

Breakdown by Race & Ethnicity

•African American: 2355 31.94%

•Caucasian: 2062 27.97%

•Asian: 2037 27.63%

•Native American: 76 1.03%

•Pacific Islander: 11 0.15%

•Other: 777 10.54%

•Ethnicity—Hispanic: 1100 14.92%

Breakdown by Age Group

• 18 to 25: 219 (2.97%)• 26 to 35: 463 (6.28%)• 36 to 45: 1,035 (14.04%)• 46 to 55: 1,734 (23.52%) • 56 to 65: 1,927 (26.14%)• Over 65: 1,979 (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 CenterOctober 18, 2011

Brentwood, Long Island, 2007

Long Island KEEP ‘04 through ‘11

Total screened: 1394Total who met inclusion criteria: 1212

Repeat participants: 304 (21.81%)Ineligible for KEEP: 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%) Male•

748 (61.72%) Female•

317 (26.16%) African-American•

398 (32.84%) Caucasian•

327 (26.98%) Asian •

151 (12.46%) Other Race•

213 (17.57%) 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.

TREATMENT

Promote optimaltreatment by

offering education to patients, caregivers

and healthcarepractitioners

PREVENTION

Prevent CKD inat-risk population;

prevent progression of early stage CKD

in early stage patients

AWARENESS

Awareness of the

kidney and kidney disease

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.

Key Programs and Initiatives

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

•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

Kidney Community Educators

World Kidney Day!•P

rotect & 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 SupportFor 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 CityApril 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•C

addy•L

etter to Clinician•L

eader’s Guide for Healthcare Professionals

•Educational DVD

•Patient Booklets

•Record of Participation