AFMC : A CLOSER LOOK AT QUALITY
EDITORIAL PANEL Chad T . Rodgers , MD , FAAP ; Elena M . Davis , MD , MPH ; William L . Mason , MD ; Michael Moody , MD ; Pramod K . Nelluri , MD ; J . Gary Wheeler , MD , MPS
Meeting Treatment Challenges of Chronic Kidney Disease
BY GERREN HOBBY , MD ; ANDREA EASOM , MNSc , APRN ; and MANISHA SINGH , MD
Chronic kidney disease ( CKD ) is a common disease that creates a subset of patients with complex , intertwining medical conditions , high morbidity and mortality , high health care expenditures and a low quality of life . Despite our various specialties , we all take care of these patients , presenting unique challenges to every clinical scenario .
Fifteen percent of adults have CKD , 1 meaning more than 45 million Americans have kidney failure . More than 400,000 Arkansans have some degree of CKD . On average , CKD patients have more than six symptoms across different organ systems and take more than eight medications . Low awareness of CKD symptoms , disease course and outcomes can cause lower support for these patients .
CKD and end-stage renal disease ( ESRD ) treatment costs comprise some of Medicare ’ s highest costs . Medicare spending for beneficiaries younger than age 65 with CKD exceeded $ 8 billion in 2014 , representing 44 percent of all health care spending for this age group . The same metric for those above age 65 was $ 50 billion and 20.8 percent of all health care spending for this cohort . 1
The most common causes of CKD are diabetes and hypertension . Other risk factors include : African-American decent , older age , low birth weight , family history of CKD , smoking , obesity , analgesic medications , exposure to heavy metals , excessive alcohol consumption , acute kidney injury , cardiovascular disease , hyperlipidemia , metabolic syndrome , hepatitis C virus , HIV infection and malignancies . 2
STAGING CKD
CKD is defined by the presence of kidney damage or decreased kidney function for at least three months based on documentation or inference . 3 Kidney damage is defined by albuminuria > 30mg / 24 hours , urine sediment abnormalities , electrolyte abnormalities due to tubular disorders , abnormalities shown on renal histology and structural abnormalities shown on imaging . Kidney transplant also qualifies as CKD .
The classification of stages is done from estimated glomerular filtration rate ( eGFR ):
• CKD Stage 1 : eGFR > 90 mL / min / 1.73m2 ( must meet non-eGFR criterion for CKD )
• Stage 2 : eGFR 60-89 mL / min / 1.73m2 ( must meet non-eGFR criterion )
• Stage 3 : eGFR 30-59 mL / min / 1.73m2
• Stage 4 : eGFR 15-29 mL / min / 1.73m2
• Stage 5 : eGFR < 15 mL / min / 1.73m2
• ESRD : permanent renal failure requiring chronic dialysis to maintain life ( sometimes represented as CKD Stage 5D for dialysis dependence )
MORTALITY AND MORBIDITY
Rates of re-hospitalization for CKD patients are higher ( 22.3 %) than for patients without diagnosed CKD ( 15.8 %). In 2013 , adjusted mortality rates remained higher for Medicare patients with CKD ( 117.9 / 1000 ) than for those without CKD ( 47.5 / 1000 ). 1 Rates increase with CKD severity . Coronary artery disease is common in CKD patients . The risk of coronary death or nonfatal MI in adults , with CKD stage 1 to 4 and over the age of 50 , is greater than 10 percent in a 10-year period . 1 The dialysis population has an adjusted one-year survival rate of 76 percent ; dropping to 36 percent at five years .
A study published in Kidney International examined the quality of life of patients with stage 4 or 5 CKD . Patients reported a poor quality of life 4 and 61 percent of patients regretted their decision to start dialysis . 5
THE ARKANSAS FOUNDATION FOR MEDICAL CARE , INC . ( AFMC ) WORKS COLLABORATIVELY WITH PROVIDERS , COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH EDUCATION AND EVALUATION . FOR MORE INFORMATION ABOUT AFMC QUALITY IMPROVEMENT PROJECTS , CALL 1-877-375-5700 . • SEPTEMBER 2018
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