1. Concept of a ‘CKD Clinic’
DR SANJAY MAITRA
MD,DM(PGI,CHD),CLIN.FELLOWSHIP TORONTO UNIV.(CANADA)
SR.CONSULTANT NEPHROLOGIST,APOLLO HEALTH CITY, HYDERABAD

2. CKD Clinic-Outline of Talk
The Backdrop
The Rationale
The Logistics
The Outcomes

3. The Back drop

5. These are all Lifestyle
Related Diseases
Life style Related Diseases
are just a subset of NCD’s

6. 10 Leading Causes of Death by Gender, World, 2011
Males Females
Per cent of total deaths in sex group

7. WORLD ECONOMIC FORUM Estimates a total loss of $30 trillion by NCD between
2010 and 2030
By 4 Major diseases

9. Diabetes: A global emergency
Diabetes is likely the 5th leading cause of death worldwide

10. Nearly 35-40% 0f Diabetics will develop diabetic kidney disease

11. 2014 2035
WORLD
387
million
WORLD
592
million
people living
with diabetes
Middle East and North Africa 85%
South East Asia 64%
South and Central America 55%
Western Pacific 46%
North America and Caribbean 30%
Europe 33%
Africa 93%
53%

12.  Pooled analysis of 1479 studies and had measured BP in 19.1 million adults
 Estimated worldwide trends in mean systolic and diastolic BP & no. of adults with BP >140/90 mm of Hg
 In 2015 -Global age standardised prevalence of raised BP was 24.1 % in men and 20.1 % in females
 Mean BP has decreased in high income countries , it has increased in east and south east- Asia and sub-Saharan regions

13.  About 33% urban and 25% rural Indians are hypertensive
 Only 25% of rural and 42% of urban Indians are aware of their hypertension
 Only 25% of rural and 38% of urban Indians are being treated for hypertension
 Only 10% of rural and 20% of urban Indians have their blood pressure under control

14. Almost 30-65% of adult urban Indians are either Overweight or obese or have abdominal obesity

15. The Rationale

16. What is CKD- Current understanding
Heterogeneous group of disorders characterized by alterations in kidney
structure and function, which manifest in various ways depending upon
the underlying cause or causes and the severity of disease

17. CKD- a continuum
Stages of CKD –KDIGO 2012

18.  Prevalence estimated to be 8-16 % worldwide
 Worldwide Diabetes Mellitus is the most common cause of CKD
 In many regions herbal medicines and environmental toxins are important contributors
 Poorest population are at highest risk
 Screening and early intervention can prevent kidney disease
 Awareness is presently low in many communities and amongst physicians
 Strategies to reduce CKD burden and costs need to be included in national programmes
 General practitioners must be involved in the care of these patients

19. Incidence (pmp) of CKD worldwide
Prevalence (pmp) of CKD worldwide

20.  Estimated incidence of CKD in India – 800 per mill. Population
 Estimated incidence of ESRD in India – 150-200 per mill. Population
 Diabetic Kidney Disease – Commonest cause of ESRD
 Approx. 2,20,000 -2,50,000 new patients on dialysis per year
 In India approx. 55,ooo-60,000 patients are on dialysis
 Annual growth of 10-20% in this group

21. INDIAN CKD REGISTRY DATA-2012

22. Data Source: Reference Table A.1. Abbreviation: ESRD, end-stage renal disease.
Figure 1.7(a) Trends in annual number of ESRD incident cases (in thousands),
by primary cause of ESRD, in the U.S. population, 1996-2013
23
Diabetics

23. Significance of CKD & ESRD
Increases the chance of mortality in any patient
Directly and by increasing CVD deaths
Increases morbidity and a poorer quality of life
Increases cost of treatment

24. Monthly Cost Of haemodialysis at 3 HD/wk Rs 15,000- Rs 30,000
Monthly cost Of Erythropoeitin per month Rs 7,000-Rs 12,000
Monthly cost of CAPD 3 exchanges per day Rs. 20,000-Rs 25,000
Cost of transplant procedure Rs 4,00,000- Rs, 8,00,000
Cost of immunosuppressive medicines
(Using Tacrolimus,MMF and steroids)
Rs 12,000-Rs 15,000 per
month
Approximate cost of Renal replacement therapy in India

25.  Globally estimated costs of treating ESRD is > US$ 1 trillion
 Slowing the rate of progression of CKD to ESRD makes clinical and economic sense
 The rate of decline of e-GFR with age is non linear; useful to follow trends
 To differentiate those at risk of progression to ESRD is useful.
 Certain health service providers have shown remarkable improvement in CVS and renal health
using integrated system wide approach
Preventive strategies fruitful and cost-effective

26. Breakdown of chronic kidney disease (CKD) by stage (1–5) in selected countries
Stage 1 & 2 CKD reflect
CVS risk rather than renal risk,
as in elderly individuals

27. Logistics

28. Wagner Chronic Care Model
Early referral to nephrologist
yields better results and may be
cost effective

29. Service delivery of CKD
Primary care
■ Patient assessment by e-GFR trend and/or trajectory reporting
■ Classification of CKD based on risk of progression
■ Identification of CKD as an indicator of elevated cardiovascular risk, with early modification of
traditional risk factors
■ Patient advocacy and self-management during early- stage (1–3) CKD
■ Referral to secondary care for specialist treatment of CKD complications
Secondary care
■ Multidisciplinary management of disease complications
■ Ongoing support for patient self-management programmes
■ Integration with other secondary care services to manage the burden of comorbidities
■ Personalized treatment goals with consideration of quality of life
■ Integration into primary care to support periodic monitoring of stable patients by PCPs
■ Structured follow-up for patients having experienced AKI, with data collection to describe the long-term
effects on GFR trajectory

30. Risk factors for progression of CKD
Non-modifiable Modifiable
Genetic Factors Poor glycaemic control
Male Gender Poorly controlled hypertension
Increasing age Hyperlipidaemia
Long duration of diabetes Smoking
Family history of Diabetic kidney disease, Type 2
diabetes, hypertension & Insulin resistance
Insulin resistance
Metabolic syndrome
Adv. Glycation end products
High salt intake
Low physical activity
Use of indigenous and other nephrotoxic medicines

31. How to screen for CKD
Do a Complete Urine examination
Look for protein, urinary sediments, casts
Categorise degree of proteinuria
Do a Serum creatinine estimation
Calculate the e-GFR
Check the Blood pressure

32. Role of CKD Clinic in management
CKD is largely due to diabetes and hypertension ,both of which are relatively easy to
identify or treat
In CKD the strongest predictors of progression are hypertension and proteinuria
Current day focus has changed from vascular access placement and controlling uremic
symptoms to prevention of progression
Challenge is to identify patients likely to progress fast and to prevent CVS and CKD
related complications
A team based approach ,with well defined roles ,responsibilities and objectives
appears logical and practical
Outcomes can be improved with protocoled blood work ,clinic visits and education

33. Conventional CKD management pathway
Multidisciplinary team in a CKD clinic

35. Diagnosis
Education
Delay in
progression
Management of co-
morbidities, CVS
disease prevention
Anemia, MBD
and nutrition
Vaccination
Preparation
for RRT; access
selection
Key goals of CKD clinic

37. CKD Clinic
 Inter-disciplinary care clinics are better at managing the complex and multi-faceted problems of CKD
 Having different providers work seamlessly and in synergism , there is less chance of fragmentation of care
 Patient centred model of care, patients are part of the decision making process
 Patients are engaged to achieve therapeutic targets and make lifestyle changes
 Timely referral and constant patient education form the back bones of these clinics
 Information technology helps tracking the progress of individual patients and the group as a whole

38.  The IDC team all work together to provide effective care to patients with CKD
 Improved patient education and preparedness prior to ESRD improves health outcomes
 Patients are empowered to be part of the decision making process , including setting short and long term goals
 IDC may also delay the progression to ESRD and reduce mortality

39. Specific roles of persons in the Inter-
disciplinary care clinics
Personnel Exact role
Nephrologist Evaluates etiology of CKD and determines the care plan
Advanced practitioner Educates about CKD and kidney failure treatment options Coordinates care with
family and members of the IDC team
Dietitian Dietary counseling and fluid management
Pharmacist Reviews medications, dosing, and adherence
Geriatrician/palliative care Addresses geriatric and palliative care needs
Discusses prognosis and ensures treatment plans align with goal of care
Case management/social worker Assists patients to obtain needed resources (e.g., transportation and issues with
housing)
Transplant team Educates patients about transplant options Evaluates potential transplant
candidates with progressive CKD
Vascular surgery/general surgery Places and monitors access for dialysis (hemodialysis and peritoneal dialysis)
Interventional Radiology Intervenes on immature or nonfunctioning AVG/AVF to improve access flow in
order to initiate dialysis

40. OUTCOMES
ARE CKD CLINICS EFFECTIVE?

41.  Case control study across 2 countries (Canada & Italy) and 2 continents
 Showed IDC care to be better than traditional nephrology care in terms of
 Better Lab parameters at dialysis initiation
 Significant survival advantage after dialysis initiation
 Av. exposure to IDC clinic was 8hrs/patient yr. compared to 4hrs/patient yr.
in the traditional method

42.  Looked into the impact of MDC clinics in elderly(>66yrs) CKD patients
 6978 patients with CKD followed for 3 years
 Found 50% reduction in all cause mortality as compared to controls
 Trend towards reduced risk of all cause and cardiovascular specific hospitalisations

43.  3 years prospective cohort study
 528 matched pairs of CKD patients on traditional vs IDC
 IDC care patients had lower rate of GFR decline( -5.1vs 7.3ml/min)
 51% reduction in mortality
 Patients in IDC group were more likely to choose PD and have
AV fistulas in place before dialysis initiation

46. The key role of the advance practitioners
Advanced practitioners are well positioned to drive the IDC clinic and implement
the guidelines
MASTERPLAN study showed that the intervention of a nurse practitioner led to
slower GFR decline and composite renal endpoint of death,ESRD and 50%
increase of S.creatinine
In Canadian Prevention of Renal and Cardiovascular Endpoints Trial
 The IDC group comprising of the Nephrologist and Nurse practitioner implemented goal
directed therapy better and made timely referrals
 At 2 years ,intervention group had better quality of life and had less hospitalisations resulting
in cost savings

51.  The use of IT solutions is not much in nephrology
 IT can bridge the gap amongst patients, primary providers, nephrologists and inter-disciplinary clinics
 Computer decision support tools generated through electronic medical records helps one implement
evidence into practice
 Current ongoing trial exploring whether a 9 point action plan (TRANSLATE) to computer decision support
will improve CKD care in the primary care setting

54. Date of download: 2/9/2017
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: journals.permissions@oxfordjournals.orgOxford University Press
From: Creating a model for improved chronic kidney disease care: designing parameters in quality,
efficiency and accountability
Task cards given to all care providers during the time study.
Figure Legend:
Nephrol Dial Transplant. 2010;25(11):3623-3630. doi:10.1093/ndt/gfq244

55. Date of download: 2/9/2017
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: journals.permissions@oxfordjournals.orgOxford University Press
From: Creating a model for improved chronic kidney disease care: designing parameters in quality,
efficiency and accountability
Time study and chart review timeline.
Figure Legend:
Nephrol Dial Transplant. 2010;25(11):3623-3630. doi:10.1093/ndt/gfq244

57. Summary and conclusions
The Incidence and prevalence of CKD and ESRD is on the rise particularly in the
poorer countries
As Diabetes ,hypertension and obesity in the Indian population is increasing rapidly,
the prevalence of CKD will rise rapidly in the future.
Identifying CKD early and taking appropriate measures will definitely slow disease
progression and reduce the incidence of ESRD
 This will reduce mortality, morbidity and cost of treatment
CKD Clinics can be a novel method of providing effective care to these patients
With the current popularity of Diabetic clinics in India, CKD clinics could also be
organised in the same premises with minimal additional cost.
The CKD clinic structure could be modified to suit the Indian patient requirement

58. Thank You