1. Christopher Keller, MD Director of Clinical Operations Boise Kidney and Hypertension Institute RPA 2011 Annual Meeting Friday, March 18, 2011

2. Disclosure of Conflict of Interest Name of Faculty or Presenter Reported Financial Relationship Christopher Keller, MD Consulting Fees Genzyme Corporation Affymax, AMAG Study Investigator for Research Cytochroma, Fibrogen, Pfizer, Takeda, Boehringer Ingelheim, Johnson & Johnson, Abbott, Amgen, Advanced Renal Technologies

3. Christopher Keller, MD Director of Clinical Operations Boise Kidney and Hypertension Institute RPA 2011 Annual Meeting Friday, March 18, 2011

5. What are the issues? Primary care providers (PCPs) often defer referrals until very advanced stages of CKD 25-50% of all ESRD patients never saw a nephrologist until 3 months or less before onset of dialysis Reasons for not referring: advanced age, comorbidities, and perceived patient nonadherence to therapy Fischer MJ et al., Am J Nephrol 2011;33:60-69 Navaneethan et al., Clin Nephrol 2010;73:260-267

6. What are the issues? Nephrologists are spending more time focused on CKD progression and less time on non-nephrology concerns The use of a multidisciplinary team (MDT) to manage stage 3-4 CKD patients may slow progression of CKD and may improve outcomes at the start of dialysis Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343 Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub

7. Slowing CKD progression with an MDT Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub

8. Curtis et al. Nephrol Dial Transplant 2005;20:147 Kaplan-Meyer survival after starting dialysis therapy Mortality benefit with an MDT

9. Open the black box… PCPs must play a critical role in the multidisciplinary team RPA ToolKit website: http://www.renalmd.org/toolkit-form/ http://www.renalmd.org/toolkit-form/ Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343

10. How do we involve primary providers? Step 1: Identify your goals for co-management Preferences for timing of referrals Step 2: Open communication lines with primary providers Ask them directly about their co-management interests Let them know that you are willing to answer questions Tonelli M et al., Ann Intern Med 2011;154:12-21

11. How do we involve primary providers? Step 3: Communicate regularly with primary providers Ensure timely, effective communication with the PCPs every visit Track referrals and identify providers that do not refer early; devote resources for education Electronic record systems and note templates make it easier

12. Boise Kidney model: Documentation

13. Conclusions The complexity and breath of nephrology management has been a barrier to PCP communication Multidisciplinary care of advanced CKD patients may slow CKD progression and reduce mortality in CKD patients Communication with PCPs is required to: Optimize early referrals Permit nephrologists more time and energy to focus on prevention of ESRD