Disclosures CKD/ESRD care among vulnerable populations I have nothing to disclose Delphine Tuot, MDCM, MAS Assistant Professor of Medicine Objectives Recognize disparities related to kidney health Learn about early CKD management strategies that may be of particular importance in this patient population Appreciate that poor CKD awareness may contribute to suboptimal risk factor modification among vulnerable patients Learn strategies to alleviate the impact of homelessness on CKD/ESRD care 50yo AA woman PmHx: hypertension Case: Ms. S Meds: chlorthalidone 25mg daily PE: 125/75 mmhg, 80 bpm Older brother just initiated dialysis at age 58. She asks about her risk for dialysis. Is she at risk for CKD? Does she have CKD? 1
What is CKD? Why should you care? For every level of egfr, higher albuminuria confers higher mortality risk. Population: 14,586 NHANES participants (1988-2000) 11.5% adult population 23 million adults Low egfr is associated with high mortality and CV morbidity All cause mortality Setting: KP of Northern California Go et al. NEJM. 2004 Astor. Am J Epi. 2008 Prognosis of CKD progression to ESRD by egfr and albuminuria categories. albuminuria categories (mg/g) CKD prevalence: racial/ethnic disparities Study population: NHANES adult participants, 1988-2012 egfr categories (ml/min/1.73m 2 ) Levy, KI, 2013. USRDS Data Report, 2015 2
CKD prevalence: racial/ethnic disparities Study population: NHANES adult participants, 1998-2012 CKD prevalence: SES disparities Setting: community adults from 12 representative census tracts in Baltimore; equal numbers by sex, race, SES (high/low) Low SES: < 125% federal poverty level USRDS Data Report, 2015 Crews. AJKD, 2010. ESRD Incidence: race/ethnic disparities ESRD is nearly 3x greater among African Americans ESRD mortality: SES disparities Setting: 11,027 young adults initiating dialysis in US, 2006-2009 Predictor: Neighborhood SES (>20% residents below FPL) Outcome: probability of survival Blacks have poor survival Low SES: Blacks vs Whites: ahr for mortality =1.52 (1.28 1.85) High SES: Blacks vs. Whites: ahr for mortality =1.26 (1.07 1.48) **slide courtesy of Neil Powe, MD USRDS Data Report, 2015 Johns, JASN, 2014 3
CKD disparities: plausible mechanisms CKD disparities: plausible mechanisms System Patient Provider Traditional biological risk factors DM/HTN, obesity Genetics Non-traditional biologic risk factors Co-morbid diseases (HIV, HCV) Depression, substance abuse Periodontal disease Social determinants of health Poor patient CKD awareness/health related behaviors Mistrust of medical system Homelessness Health system barriers Poor access to care (insurance issues, fragmented care) Communication barriers Low PCP self-efficacy for managing CKD System Patient Provider Traditional biological risk factors DM/HTN, obesity Genetics Non-traditional biologic risk factors Co-morbid diseases (HIV, HCV) Depression, substance abuse Periodontal disease Social determinants of health Poor patient CKD awareness/health related behaviors Mistrust of medical system Homelessness Health system barriers Poor access to care (insurance issues, fragmented care) Communication barriers Low PCP self-efficacy for managing CKD Paradigm shift: early detection of CKD Screening for CKD 2013 ACP recommendation #1: No screening for CKD in asymptomatic adults without risk factors of CKD. Grade: weak recommendation, low quality evidence Strong risk factors for CKD morbidity/mortality Diabetes (presence and glycemic control) HTN (presence and control) Family history of ESRD Low socioeconomic status Racial/ethnic minorities Levy, AJKD, 2009. Qaseem,, Annals of IM 2013. 4
50yo AA woman PmHx: hypertension Case: Ms. S Meds: chlorthalidone 25mg daily PE: 125/75 mmhg, 80 bpm Labs: Cr=0.7 mg/dl; egfraa: >60 ml/min/1.73 m 2 UACR: 800mg/g You start AceInh (i.e., Benazepril 10mg daily) Now what? Titration of ACEi/ARB? 2013 ACP recommendation #2: No testing for proteinuria in adults with or without diabetes who are currently on an ACEi/ARB. Grade: weak recommendation, low quality evidence Setting: 298,875 Veterans, 2004 2009 Predictor: UACR Outcome: mortality **Higher UACR is associated with greater mortality, independent of demographics, co morbidities, egfr, ACEi/ARB use. Qaseem, Annals of Int Med 2013; Csaba, JACC, 2014. Titration of ACEi/ARB? Setting: China, ROAD trial Study population: 360 non-diabetic patients with avg scr of 2.7 mg/dl Intervention: titration of ACEi/ARB vs. standard dose Summary thus far CKD is common Titration of ACEi/ARB in pts with moderate CKD was associated with decreased composite endpoint of ESRD, doubling scr, mortality, independent of BP control. Socioeconomic and racial/ethnic disparities exist egfr and albuminuria are both important Early detection in primary care is key Strongly consider screening for CKD in vulnerable populations Potential role for titration of ACEi/ARB to achieve maximum albuminuria suppression Hou. JASN, 2007. 5
Other CKD management strategies Aggressive BP control (target still not clear) < 130/80 mmhg if proteinuria < 140/90 mmhg without proteinuria Glycemic control Statin for CV risk reduction Lifestyle modifications Consult Nephrology egfr < 30 ml/min etiology of CKD is not clear Rapid CKD progression (loss of 5 ml/min/year) System CKD disparities: plausible mechanisms Patient Provider Traditional biological risk factors DM/HTN, obesity Genetics Non-traditional biologic risk factors Co-morbid diseases (HIV, HCV) Depression, substance abuse Periodontal disease Social determinants of health Poor patient CKD awareness/health related behaviors Mistrust of medical system Homelessness Health system barriers Poor access to care (insurance issues, fragmented care) Communication barriers Low provider self-efficacy for managing CKD and competing priorities Patient Awareness of CKD is low even among individuals with clinical markers of CKD National estimate of CKD awareness =6.0% Study population: 2292 NHANES participants with CKD; 1999-2004. Percentage of CKD awareness and unawareness 100 80 60 40 20 0 P for linear trend=0.08 94 90 89 88 6 10 11 12 0-1 2-3 4-5 6-7 Number of Clinical Manifestations of CKD Clinical markers Anemia Hyperkalemia Hyperphosphatemia Albuminuria Acidosis Elevated BUN Uncontrolled HTN Unawareness of CKD Awareness of CKD Plantinga, Archives Med. 2008; Tuot. CJASN, 2011. 6
Competing priorities and discomfort talking about CKD may contribute to poor awareness Setting: 15 low-income primary care clinics in/near Baltimore Study population: 236 patients with or at risk for CKD, largely AA Topics of conversation (% of visits) How should we describe CKD? Study population: 220 English and Spanish speaking patients with chronic diseases in safety-net primary care; 50% limited health literacy 100 90.1 91.8 Percentages Aware 80 60 40 20 33.2 27.7 40.1 26.4 39.80 70.8 0 Awareness questions Greer, AJKD, 2010. Tuot, Under review 25% pts with CKD/ESRD have limited health literacy Greater mortality among ESRD pts with low health literacy Low literacy Adequate health literacy Practical strategies to enhance CKD awareness Kidney Problem resonates well Protein in the urine Introduce within context of HTN/DM to encourage r9sk modification Pre-empt negative reactions Censoring: Total deaths = 103 (21%) Xplant = 29 (6%) Most people live normal lives with little kidney function. You are not near that point, but we need to work together to keep your kidneys as healthy as possible and prevent them from losing too much protein in the urine. Cavanaugh, JASN, 2010 7
System CKD disparities: plausible mechanisms Patient Provider Traditional biological risk factors DM/HTN, obesity Genetics Non-traditional biologic risk factors Co-morbid diseases (HIV, HCV) Depression, substance abuse Periodontal disease Social determinants of health Poor patient CKD awareness/health related behaviors Mistrust of medical system Homelessness Health system barriers Poor access to care (insurance issues, fragmented care) Communication barriers Low provider self-efficacy for managing CKD and competing priorities Homelessness is a risk factor for ESRD/death among those with CKD Crude HR: 1.8 (1.49 2.22) Adjusted HR: 1.28 (1.04 1.58) Population: 15,353 adults with CKD in SF safety net; 6% were homeless Hall, CJASN, 2012 Among homeless populations, ESRD is associated with increased mortality Strategies to improve kidney care among homeless patients Refer patients to nephrology early Advocate for permanent (AVF/AVG) access placement Medication adherence Daily dosing; long-acting medications Pharmacy that delivers medi-sets to dialysis unit Partnering with Methadone dosing programs Dialysis adherence Late shift if needed for odd jobs Early shift if needed for shelter beds Transportation Case management programs Population: 558 homeless adults in Boston, 1988 2003 Hwang, Archives, 1998 8
Homelessness is a risk factor for late nephrology referrals Population: 460 patients who initiated dialysis at Grady hospital, 1999 2002 Early referral: >3 mo Late referral: 1 3 mo Ultra late referral: <1 mo Strategies to improve kidney care among homeless patients Refer patients to nephrology early Advocate for permanent (AVF/AVG) access placement Medication adherence Daily dosing; long-acting medications Pharmacy that delivers medi-sets to dialysis unit Partnering with Methadone dosing programs Dialysis adherence Late shift if needed for odd jobs Early shift if needed for shelter beds Transportation Case management programs Obialo, AJKD, 2005 Take home points CKD is common, defined by egfr and albuminuria Socioeconomic disparities exist with respect to CKD/ESRD outcomes Patient, provider, system-level factors contribute to these suboptimal outcomes Small changes in practice can make a difference Screen among high-risk populations (low SES) Discuss CKD during visits Coordinate with care management programs to refer homeless patients to nephrology early and optimize care delivery for ESRD patients Thank You Delphine.Tuot@ucsf.edu 9