The National Kidney Foundations Kidney Early Evaluation Program TM The National Kidney Foundations Kidney Early Evaluation Program TM Essex-Passaic Wellness Coalition March 24, 2014 Ellen H. Yoshiuchi, MPS Division Program Director National Kidney Foundation Serving Greater New York

Kidney Early Evaluation Program TM

10 Year Anniversary

KEEP Objectives KEEP 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 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 Public Health Problem! Rate of Kidney Disease Jumps by 30%

Chronic Kidney Disease is a 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 Problem Worldwide! Early screening, diagnosis, and treatment should delay or prevent ESRD. 26 Million Americans have CKD. Most dont know it. 73 Million Americans have HTN and/or DM. 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 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 2009

Criteria for CKD Glomerular filtration rate (GFR) <60 ml/min/1.73 m2 GFR is the best overall index of kidney function in health and disease. The normal GFR in young adults is approximately 125 ml/min/1.73 m2. GFR <15 ml/min/1.73 m2 is defined as kidney failure Can 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 CKD Primary – 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:

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 Care To prevent the progression of CKD to ESRD To prevent Cardiovascular Events & Death Heart Attacks Congestive Heart Failure Sudden Cardiac Death

YOUR KIDNEYS and YOU

Did You Know? 1 in 3 American adults is at high risk for developing kidney disease 1 in 9 American adults has kidney disease and most dont know it Early detection and treatment can slow or prevent the progression of kidney disease Kidney disease kills over 90,000 Americans every year

What You Will Learn Today What kidneys do Why kidneys are important to your health What kidney disease is Who is at risk Actions you can take to protect your kidneys

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 Screenings were held in all areas of the US by local National Kidney Foundation divisions or affiliates. Over 180,000 people were screened as of 6/30/13. Visit 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 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 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 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 Classification KEEP 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 ClassificationSBP mmHgDBP mmHg Normal<120and<80 Pre-hypertension120– 139 or 80–89 Stage 1 Hypertension 140–159or90–99 Stage 2 Hypertension >160or>100

Blood Glucose Guidelines American Diabetes Association (ADA) 2008 Criteria 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 participants 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/ attended the screenings met inclusion criteria & completed the screening 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% 861 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: % Caucasian: % Asian: % Native American: % Pacific Islander: % Other: % EthnicityHispanic: %

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 (71.64%) have health insurance (36.88%) request that a report be sent to their doctor. Of 7274 with reported BMI: Overweight: % Obese: %

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!

CentraState Medical Center September 16, 2011

Trinitas Regional Medical Center October 18, 2011

New Jersey KEEP Total screened: Nutley 1 Montclair 1 Sparta 1 East Orange 1 Toms River 1 Clifton 1 Paterson

New Jersey KEEP 6 Elizabeth 5 Freehold 5 Newark 3 Lakewood

New Jersey KEEP 04 through (34.52%) Male 1,191 (65.48%) Female 461 (25.34%) African-American 991 (54.48%) Caucasian 155 (8.52%) Asian 193 (10.61%) Other Race 370 (20.34% ) Hispanic

New Jersey KEEP 04 through 12 Breakdown of individuals that learned of a new problem: 152 (8.36%) learned they may have diabetes. 199 (10.94%) learned they may have hypertension. 278 (15.28%) learned they may have high cholesterol. 694 (38.15%) learned they may have kidney disease.

New Jersey KEEP 04 through 12 1,668 (91.70%) indicated that they have a doctor. 1,372 (75.43%) indicated that they have insurance. 906 (49.81%) requested that their report be sent to their doctors. 795 (43.71%) responded to the survey. 595 (74.84%) who responded to the follow- up survey reported seeing a doctor.

TREATMENT Promote optimal treatment by offering education to patients, caregivers and healthcare practitioners PREVENTION Prevent CKD in at-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 Providers (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 Foundations 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 PCPs and other educational tools

KEEP Healthy For the general public Risk survey Height & weight measurement Body mass index (BMI) Blood pressure check Consultation with a clinician Over the age of 18

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:

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 Having a health discussion together with several family members Evaluation forms for patients and the social worker Pilot in dialysis centers

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

World Kidney Day! Protect & Prevent on World Kidney Day: Information on the NKF Web site Local events at many locations 2014 Grand Central Terminal Awareness & Education Event 2014 Social Media Campaign on Facebook, Instagram & Twitter

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 Support For 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 City April 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 Caddy Letter to Clinician Leaders Guide for Healthcare Professionals Educational DVD Patient Booklets Record of Participation