Program Objectives

1. The National Kidney Foundation’s Kidney Early Evaluation ProgramTM“The Greater New YorkExperience” Ellen H. Yoshiuchi, MPSDivision Program DirectorNational Kidney Foundation Serving Greater New York

2. Program Objectives • Describe the goal of the Kidney Early Evaluation Program (KEEP) and it’s relation to CKD as a public health problem. • List KEEP criteria and rationale for each function to assist in identifying individuals at risk for CKD and in providing appropriate early treatment options to minimize co-morbidities. • Explain KEEP’s impact and its role in the CKD awareness initiative to help improve patient outcomes.

3. Declaration of Disclosure • It is the policy of the National Kidney Foundation to ensure balance, independence, objectivity, and scientific rigor in all CME/CE activities. Any individuals who have control over CME content are required to disclose to learners any relevant financial relationship(s) they may have with commercial interests supporting this activity or whose products or devices are discussed in this activity. If, on the basis of information disclosed a conflict exists, resolution will be achieved based on established policy by the NKF.

4. Faculty Disclosure • Refer to handout in participant folder.

5. Kidney EarlyEvaluation ProgramTM

6. 10 Year Anniversary

7. 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.

8. KEEP Objectives • To empower individuals to prevent or delay the onset of CKD or renal failure through education and appropriate disease management!

9. Chronic Kidney Disease is a Public Health Problem! Rate of Kidney Disease Jumps by 30%

10. 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.

12. CKD is a Public Health ProblemWorldwide! • Early screening, diagnosis, and treatment should delay or prevent ESRD. • 26 Million Americans have CKD. Most don’t know it. • 73 Million Americans have HTN and/orDM. • CKD is a worldwide public health problem.

13. 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

14. KDOQI CKD Evaluation, Classification and Stratification (2002)

15. 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

16. Definition of CKD Identical to 2002

17. 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

18. 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

19. 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

22. 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 2009:53:522-535

23. Conceptual Model of CKD: Continuum of Development, Progression and Complications of CKDEach Arrow is a Target for Strategies to Improve Outcomes!

24. Referral to Nephrology by CKD Stage

25. 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

28. Awareness Campaign

29. WHAT DO THE NUMBERS MEAN?WHAT CAN I DO ABOUTCHRONICKIDNEYDISEASE? Register for KEEP today! Call 1-800-622-9010. Learn more about CKD on your own… *Read your KEEP Health Screening Report & educational materials. *Visit www.kidney.org. See your Doctor… *Discuss your test results. *Ask questions about what the numbers mean and what can be done. Find a Doctor or Health Care Facility if you do not have one!

33. KEEP OVERVIEW • KEEP is afree public health screening program. • It was initiated in New York City by the National Kidney Foundation in August of 2000. • Screenings are held in all areas of the US by local National Kidney Foundation divisions or affiliates. • Over 180,000 people have been screened to date. • Visit www.KEEPonline.orgfor more information.

34. 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 relativesof diabetes, high blood pressure and/or kidney disease

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. Blood Pressure Classification KEEP uses the Blood Pressure Classifications according to The 7th 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.

42. 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 participant’s primary care provider.)

43. 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.

44. KEEP in Greater New York 9 Years/96 Screenings 2/1/2004 to 4/1/2013 • 8175 attended the screenings. • 7373 met inclusion criteria & completed the screening. • 2148 were repeat participants. • Breakdown by gender: Male: 34.98% (2579) Female: 64.91% (4786)

45. 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%

46. 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%

47. Breakdown by Race & Ethnicity • African American: 2355 31.94% • Caucasian: 2062 27.97% • Asian: 2037 27.63% • Native American: 76 1.03% • Pacific Islander: 11 0.15% • Other: 777 10.54% • Ethnicity—Hispanic: 1100 14.92%

48. 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%)

49. Who is coming to KEEP? • 6511 (88.31%) have a physician. • 5282 (71.64%) have health insurance. • 2719 (36.88%) request that a report be sent to their doctor. • Of 7274 with reported BMI: Overweight: 2458 33.79% Obese: 2490 34.23%

50. 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.