Module 1 Understanding Chronic Kidney Disease CKD Epidemiology

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Module 1: Understanding Chronic Kidney Disease (CKD) Epidemiology, Identification, and Monitoring; Medical Nutrition Therapy

Module 1: Understanding Chronic Kidney Disease (CKD) Epidemiology, Identification, and Monitoring; Medical Nutrition Therapy

This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP),

This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD), especially among communities most impacted by the disease, NKDEP works in collaboration with a range of government, nonprofit, and health care organizations to: • raise awareness among people at risk for CKD about the need for testing; • educate people with CKD about how to manage their disease; • provide information, training, and tools to help health care providers better detect and treat CKD; and • support health system change to facilitate effective CKD detection and management. To learn more about NKDEP, please visit: http: //www. nkdep. nih. gov. For additional materials from NIDDK, please visit: http: //www. niddk. nih. gov. Slide 2 of 80

Meet our Presenters Theresa A. Kuracina, M. S. , R. D. , C. D.

Meet our Presenters Theresa A. Kuracina, M. S. , R. D. , C. D. E. , L. N. Ms. Kuracina is the lead author of the Academy of Nutrition and Dietetics’ CKD Nutrition Management Training Certificate Program and NKDEP’s nutrition resources for managing patients with CKD. Ms. Kuracina has more than 25 years of clinical dietetics experience focused on diabetes and CKD with the Indian Health Service (IHS). Until her retirement in 2017, she served as a co-coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico. For more than 9 years, she has supported NKDEP with expertise regarding medical nutrition therapy for diabetes and CKD patients, first as a member of the NKDEP’s Coordinating Panel and more recently as a senior clinical consultant for the Program. Slide 3 of 80

Meet our Presenters Andrew S. Narva, M. D. , F. A. C. P. Dr.

Meet our Presenters Andrew S. Narva, M. D. , F. A. C. P. Dr. Narva is the Director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. Prior to joining the NKDEP in 2006, he served as Director of the Kidney Disease Program for the Indian Health Service (IHS). Dr. Narva continues to serve as the Chief Clinical Consultant for Nephrology for IHS and to provide care for patients at Zuni Pueblo through a telemedicine clinic. Dr. Narva is a member of the American Board of Internal Medicine Nephrology Subspecialty Board. He has served as a member of the Eighth Joint National Committee (JNC 8) Expert Panel, the National Quality Forum Renal Steering Committee, the Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Kidney Disease, and the Medical Review Board of End Stage Renal Disease Network 15. Slide 4 of 80

Participants will be able to: 1. Associate kidney function with estimated glomerular filtration rate

Participants will be able to: 1. Associate kidney function with estimated glomerular filtration rate (e. GFR) and understand significance and limitations of e. GFR in assessing individual patients. 2. Associate kidney damage with urine albumin-to-creatinine ratio (UACR) and understand significance and limitations of UACR in assessing individual patients. 3. Use e. GFR and UACR when counseling patients. 4. Define the glomerular filtration rate that qualifies Medicare beneficiaries for medical nutrition therapy referral. Slide 5 of 80

Chronic kidney disease basics • Risk factors for CKD and how nutrition may play

Chronic kidney disease basics • Risk factors for CKD and how nutrition may play a role in prevention and treatment • Burden of chronic kidney disease and kidney failure • Identify and monitor CKD § Renal anatomy, physiology, and functional assessment • Medical Nutrition Therapy for CKD Slide 6 of 80

Risk factors for CKD • Diabetes • Hypertension • Family history of kidney disease

Risk factors for CKD • Diabetes • Hypertension • Family history of kidney disease • Cardiovascular disease • Obesity • Acute kidney injury USRDS 2016 Slide 7 of 80

Diabetes and hypertension are the leading causes of kidney failure in the United States

Diabetes and hypertension are the leading causes of kidney failure in the United States Reference: CDC National Chronic Kidney Disease Fact Sheet, 2017 Slide 8 of 80

Incidence vs. Prevalence Incidence = number of new patients during a given time/total population

Incidence vs. Prevalence Incidence = number of new patients during a given time/total population at risk Prevalence = number of patients with specific disease/total population at a designated time Slide 9 of 80

Incidence (new cases) of obesity and diabetes is increasing Obesity 1994 <14% 2000 14

Incidence (new cases) of obesity and diabetes is increasing Obesity 1994 <14% 2000 14 -17. 9% 18 -21. 9% 4. 5 -5. 9% 6. 0 -7. 4% 22 -25. 9% 2010 ≥ 26% Diabetes (diagnosed) <4. 5% Slide 10 of 80 7. 5 -8. 9% ≥ 9. 0%

Incidence of end stage renal disease (ESRD) appears to follow the same trends Adjusted

Incidence of end stage renal disease (ESRD) appears to follow the same trends Adjusted Incidence Rates of ESRD, 2011– 2015 Reference: USRDS Annual Data Report (NIDDK 2017) Slide 11 of 80

Weight management may play a role in CKD prevention and treatment • In 2009

Weight management may play a role in CKD prevention and treatment • In 2009 -2012, 65% of women and 73% of men were overweight or obese. • About half of all adults have abdominal obesity. • Rates of diabetes, hypertension and abnormal lipid levels are higher in adults with abdominal obesity. • Obesity related glomerulopathy (ORG) is associated with decline in renal function. Reference: http: //health. gov/dietaryguidelines/2015/guidelines/ D’Agati et al. Nat Rev Neph 2016; 12: 453 -471. Slide 12 of 80

Nutrition care may be an important component of prevention and treatment • Healthy eating

Nutrition care may be an important component of prevention and treatment • Healthy eating patterns and physical activity may reduce chronic disease risk. • Lifestyle interventions to prevent diabetes or hypertension may prevent or delay CKD onset. • Lifestyle modifications are part of initial treatment interventions for prediabetes, hypertension and cardiovascular disease. • Once CKD is identified, dietary interventions are a key part of management. Slide 13 of 80

Nutrition care is impacted and complicated by CKD • Risk for hypoglycemia may increase.

Nutrition care is impacted and complicated by CKD • Risk for hypoglycemia may increase. • Blood pressure may be harder to control. • Reduced urinary excretion of waste products may lead to hyperkalemia and metabolic acidosis. • Anemia may develop. • Abnormalities in vitamin D, phosphorus and calcium may impact bone strength and lead to vascular and soft tissue calcification. • Nutrition care recommendations change when the kidneys fail based on the chosen renal replacement therapy (RRT). Slide 14 of 80

Healthy People 2020 includes CKD objectives that RDNs may impact Increase proportion of persons

Healthy People 2020 includes CKD objectives that RDNs may impact Increase proportion of persons with CKD Baseline Target 9. 4 13. 4% CKD 4. 1: who receive recommended medical evaluation with serum creatinine, lipids, and microalbuminuria 25. 7% 28. 3% CKD 4. 2: with type 1 or type 2 DM and CKD who receive recommended medical evaluation with serum creatinine, microalbuminuria, Hb. A 1 c, lipids, and eye exams 23. 0% 25. 3% CKD 6. 2: over age 50 who currently take statins to lower their cholesterol 21. 6% 25. 6% 22. 7% 17. 6% CKD 2: who know they have impaired renal function Reduce proportion of persons with CKD 6. 1: who have uncontrolled blood pressure https: //www. healthypeople. gov/2020/topics-objectives/topic/chronic-kidney-disease/objectives Slide 15 of 80

Too few people receive counseling prior to dialysis Reference: Adapted from USRDS Annual Data

Too few people receive counseling prior to dialysis Reference: Adapted from USRDS Annual Data Report (NIDDK, 2010) Slide 16 of 80

The burden of chronic kidney disease and kidney failure Slide 17 of 80

The burden of chronic kidney disease and kidney failure Slide 17 of 80

CKD is reduced kidney function and/or kidney damage Chronic Kidney Disease Kidney function Glomerular

CKD is reduced kidney function and/or kidney damage Chronic Kidney Disease Kidney function Glomerular filtration rate (GFR) < 60 m. L/min/1. 73 m 2 for > 3 months with or without kidney damage AND/OR Kidney damage > 3 months, with or without decreased GFR, manifested by either • Pathological abnormalities • Markers of kidney damage, i. e. , proteinuria (albuminuria) - Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Slide 18 of 80 Reference: Kidney International Supplements, 2013; 3(1): 5 -14

Kidney failure is defined as e. GFR < 15 • The kidneys cannot maintain

Kidney failure is defined as e. GFR < 15 • The kidneys cannot maintain homeostasis. • The four options for treating kidney failure include: Renal replacement therapy (RRT) 1. Hemodialysis • In-center or home 2. Peritoneal dialysis 3. Kidney transplant Supportive Management 4. Active medical management without RRT Slide 19 of 80

U. S. Renal Data System (USRDS) • USRDS is a national data system funded

U. S. Renal Data System (USRDS) • USRDS is a national data system funded by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). • USRDS collects, analyzes, and distributes information about the actual number of people with end-stage renal disease (ESRD) on dialysis or with a kidney transplant and the estimated number of people with CKD. Slide 20 of 80

Thirty million U. S. adults may have chronic kidney disease Reference: CDC National Chronic

Thirty million U. S. adults may have chronic kidney disease Reference: CDC National Chronic Kidney Disease Fact Sheet, 2017 Slide 21 of 80

The Medicare population with CKD is growing; more are identified earlier Reference: USRDS Annual

The Medicare population with CKD is growing; more are identified earlier Reference: USRDS Annual Data Report (NIDDK, 2017) Slide 22 of 80

Trends in ESRD prevalence by modality, 1980 -2015 Reference: USRDS Annual Data Report (NIDDK,

Trends in ESRD prevalence by modality, 1980 -2015 Reference: USRDS Annual Data Report (NIDDK, 2017) Slide 23 of 80

Diabetes is the leading cause of ESRD, followed by hypertension Reference: USRDS Annual Data

Diabetes is the leading cause of ESRD, followed by hypertension Reference: USRDS Annual Data Report (NIDDK, 2016) Slide 24 of 80

African Americans have the highest incidence rates of ESRD Reference: USRDS Annual Data Report

African Americans have the highest incidence rates of ESRD Reference: USRDS Annual Data Report (NIDDK, 2016) Slide 25 of 80

ESRD is very costly Reference: USRDS Annual Data Report (NIDDK, 2017) Slide 26 of

ESRD is very costly Reference: USRDS Annual Data Report (NIDDK, 2017) Slide 26 of 80

Delaying the need for RRT may be cost-effective • Medical nutrition therapy may prevent,

Delaying the need for RRT may be cost-effective • Medical nutrition therapy may prevent, delay onset and slow progression of CKD. • Medical nutrition therapy may help manage CKD complications. • Delaying the need for dialysis for even a few patients can have a great impact. Slide 27 of 80

Renal anatomy, physiology, and functional assessment IDENTIFY AND MONITOR CKD Slide 28 of 80

Renal anatomy, physiology, and functional assessment IDENTIFY AND MONITOR CKD Slide 28 of 80

Topics • Basic anatomy • Kidney function • Chronic kidney diseases • Functional assessment

Topics • Basic anatomy • Kidney function • Chronic kidney diseases • Functional assessment to identify and monitor § Estimated glomerular filtration rate (e. GFR) § Urine albumin-to-creatinine ratio (UACR) Slide 29 of 80

Kidneys and collecting system • Kidneys • Ureters • Bladder • Urethra Slide 30

Kidneys and collecting system • Kidneys • Ureters • Bladder • Urethra Slide 30 of 80

The Nephron • Glomerulus • Proximal tubule • Loop of Henle • Distal tubule

The Nephron • Glomerulus • Proximal tubule • Loop of Henle • Distal tubule • Collecting duct Slide 31 of 80

Each kidney has about 1 million nephrons; slow loss may not be noticeable •

Each kidney has about 1 million nephrons; slow loss may not be noticeable • Healthy people have a large physiologic reserve. • Slow, progressive loss of functioning nephrons may not be noticeable. • Often, there are no symptoms until more than three-quarters of kidney function is lost. Slide 32 of 80

Nephrons maintain homeostatic balance The functions include: • Filtration § Glomeruli generate ultrafiltrate of

Nephrons maintain homeostatic balance The functions include: • Filtration § Glomeruli generate ultrafiltrate of the plasma. • Reabsorption § Tubules selectively reabsorb substances from the ultrafiltrate. • Secretion § Tubules secrete substances into the urine. Slide 33 of 80

Ultrafiltration of plasma is the main function of the glomerulus • Volume of ultrafiltrate

Ultrafiltration of plasma is the main function of the glomerulus • Volume of ultrafiltrate = 135– 180 liters(L)/day • 99% water reabsorbed 1– 1. 5 L urine excreted • Filtration of solutes is based on size and charge § Small solutes cross readily. § Larger substances are generally restricted. Slide 34 of 80

The ultrafiltrate is modified by the tubules • Reabsorption and secretion of substances occurs

The ultrafiltrate is modified by the tubules • Reabsorption and secretion of substances occurs within the tubules. Examples: • Potassium is reabsorbed from and secreted into the urine by the tubules. • Sodium and glucose are reabsorbed by the tubules. • Organic acids are secreted into the urine. Slide 35 of 80

The kidneys have many functions • Regulatory function § Control composition and volume of

The kidneys have many functions • Regulatory function § Control composition and volume of blood § Maintain stable concentrations of inorganic anions such as sodium (Na), potassium (K), and calcium (Ca) § Maintain acid-base balance • Excretory function § Produce urine § Remove metabolic wastes § Including nitrogenous waste Slide 36 of 80

The kidneys have many functions • Endocrine function § Produce renin for blood pressure

The kidneys have many functions • Endocrine function § Produce renin for blood pressure control § Produce erythropoietin which stimulates marrow production of red blood cells § Activate 25(OH)D to 1, 25 (OH)2 D (active vitamin D) • Metabolic function § Gluconeogenesis § Metabolize drugs and endogenous substances (e. g. , insulin) Slide 37 of 80

CKD usually means fewer functioning nephrons Slide 38 of 80

CKD usually means fewer functioning nephrons Slide 38 of 80

Fewer nephrons disrupt the balance • Urine volume may not change § Composition of

Fewer nephrons disrupt the balance • Urine volume may not change § Composition of the urine changes • Reduced waste excretion § May not be apparent until CKD is advanced • Altered hormone production § Anemia (erythropoietin) and mineral & bone disorders (vitamin D) may develop • Reduced catabolism § Examples: Insulin, glucagon, drugs Slide 39 of 80

Fewer nephrons disrupt the balance • Reduced renal clearance and accumulation of: § Advanced

Fewer nephrons disrupt the balance • Reduced renal clearance and accumulation of: § Advanced glycation end products § Pro-inflammatory cytokines § Reactive oxygen species (oxidation) § Metabolic acids • Insulin resistance (even in people without diabetes) § Reduces insulin-mediated glucose uptake in skeletal muscles § May be associated with inflammation Slide 40 of 80

Identify and monitor CKD FUNCTIONAL ASSESSMENT Slide 41 of 80

Identify and monitor CKD FUNCTIONAL ASSESSMENT Slide 41 of 80

CKD is reduced kidney function and/or kidney damage Chronic Kidney Disease Kidney function Glomerular

CKD is reduced kidney function and/or kidney damage Chronic Kidney Disease Kidney function Glomerular filtration rate (GFR) < 60 m. L/min/1. 73 m 2 for > 3 months with or without kidney damage AND/OR Kidney damage > 3 months, with or without decreased GFR, manifested by either • Pathological abnormalities • Markers of kidney damage, i. e. , albuminuria § Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Slide 42 of 80 Reference: Kidney International Supplements, 2013; 3(1): 5 -14

Use e. GFR to assess and monitor kidney function • The e. GFR is

Use e. GFR to assess and monitor kidney function • The e. GFR is the estimated glomerular filtration rate. • The e. GFR provides an estimate of how much plasma is filtered by the kidneys each minute. Slide 43 of 80

What is the glomerular filtration rate (GFR)? • GFR is equal to the sum

What is the glomerular filtration rate (GFR)? • GFR is equal to the sum of the filtration rates in all of the functioning nephrons. • GFR is not routinely measured in clinical settings. • Estimation of the GFR (e. GFR), using serum creatinine level, gives a rough measure of the number of functioning nephrons. Slide 44 of 80

What is the GFR? Cardiac output (CO) = 6 L/min X 20% of CO

What is the GFR? Cardiac output (CO) = 6 L/min X 20% of CO goes to kidneys = 1. 2 L/min X Plasma is 50% blood volume = 600 m. L/min X Filtration Fraction of 20% = 120 m. L/min Slide 45 of 80

e. GFR estimates the measured GFR • e. GFR is not the measured GFR.

e. GFR estimates the measured GFR • e. GFR is not the measured GFR. • e. GFR estimates the measured GFR. • The e. GFR is a good estimate of the risk of having decreased kidney function. • Like other risk predictors, when it is the solitary indicator, it should be used cautiously, especially when “diagnosing” disease. Slide 46 of 80

Estimating equations for e. GFR • The Modification of Diet in Renal Disease (MDRD)

Estimating equations for e. GFR • The Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology (CKD-EPI) equations are most widely used for estimating GFR. • The variables include serum creatinine (Scr), age, race, and gender. • MDRD e. GFR = 175 x (Scr) -1. 154 x (age) -0. 203 x (0. 742 if female) x (1. 212 if African American) • CKD-EPI e. GFR = 141 × min (Scr /κ, 1)a × max (Scr /κ, 1) -1. 209 × 0. 993 age × (1. 018 if female) × (1. 180 if African American) • The estimate is normalized to body surface area. References: Levey et al. Ann Intern Med. 1999; 130: 461– 470; Levey et al. Ann Intern Med. 2009: 150: 604– 612. Slide 47 of 80

Serum creatinine alone is not adequate • Serum creatinine levels reflect muscle mass, age,

Serum creatinine alone is not adequate • Serum creatinine levels reflect muscle mass, age, gender, and race. • A typical “normal” reference range of 0. 6– 1. 2 mg/d. L listed on many lab reports does not account for muscle mass, age, gender, and race. • A 28 -year-old African American man with serum creatinine of 1. 2 has an e. GFR > 60. • A 78 -year-old white woman with serum creatinine of 1. 2 has an e. GFR of 43. Slide 48 of 80

Creatinine-based estimates of kidney function have limitations Results may be inaccurate with: • Rapidly

Creatinine-based estimates of kidney function have limitations Results may be inaccurate with: • Rapidly changing creatinine levels • Example: acute kidney injury • Extremes in muscle mass, body size, or altered diet patterns • Medications that interfere with the measurement of serum creatinine • Use of creatine supplements Slide 49 of 80

Decreased kidney function versus kidney disease • Estimating equations are less reliable at higher

Decreased kidney function versus kidney disease • Estimating equations are less reliable at higher GFR. • Kidney function declines with age. • While there is an association between decreased e. GFR and morbidity, even in elderly, this association does not mean causality. • Use diagnostic terms denoting disease with caution, especially in older people without evidence of kidney damage (e. g. elderly with e. GFR 55). Slide 50 of 80

Kidney function and e. GFR decline with age Reference Table for Population Mean e.

Kidney function and e. GFR decline with age Reference Table for Population Mean e. GFR from NHANES III Age (years) Mean e. GFR (m. L/min/1. 73 m 2) 20– 29 116 30– 39 107 40– 49 99 50– 80 93 60– 69 85 70+ 75 In healthy kidney donors the number of glomeruli per kidney decrease 25% by age 60 -69 and GFR declines proportionately. Reference: Coresh et al. Am J of Kidney Dis. 2003; 41(1): 1– 12. Denic et al. J Am Soc Nephrol. 2017; 28(1): 313– 320. Slide 51 of 80

Monitor the e. GFR trends • Stable e. GFR levels may mean nonprogressive disease

Monitor the e. GFR trends • Stable e. GFR levels may mean nonprogressive disease or current therapy is working. • A rapid decline in e. GFR may indicate rapid progression of kidney disease. Slide 52 of 80

Activity • Use NKDEP’s CKD-EPI calculator to determine e. GFR for various levels of

Activity • Use NKDEP’s CKD-EPI calculator to determine e. GFR for various levels of creatinine, different genders and races. § e. GFR < 60 = CKD § e. GFR < 15 = kidney failure • GFR Calculator can be found at: nkdep. nih. gov/gfr-calculator Slide 53 of 80

Serum Creatinine e. GFR Age, Race, Gender of Patient 35 -year-old African American male

Serum Creatinine e. GFR Age, Race, Gender of Patient 35 -year-old African American male 1. 2 blank 35 -year-old White female 1. 2 blank 80 -year-old Asian American female 1. 2 blank 58 -year-old White male 2. 4 blank 58 -year-old African American female 2. 4 blank 80 -year-old Hispanic female 2. 4 blank Slide 54 of 80

Age, Race, Gender of Patient Serum Creatinine e. GFR 35 -year-old African American male

Age, Race, Gender of Patient Serum Creatinine e. GFR 35 -year-old African American male 1. 2 ≥ 60 35 -year-old White female 1. 2 80 80 -year-old Asian American female 1. 2 43 58 -year-old White male 2. 4 29 58 -year-old African American female 2. 4 25 80 -year-old Hispanic female 2. 4 18 Slide 55 of 80

How to explain e. GFR results to patients Normal: ≥ 60 m. L/min/1. 73

How to explain e. GFR results to patients Normal: ≥ 60 m. L/min/1. 73 m 2 Kidney disease: 15– 80 m. L/min/1. 73 m 2 Kidney failure: < 15 m. L/min/1. 73 m 2 Slide 56 of 80

CKD is reduced kidney function and/or KIDNEY DAMAGE Chronic Kidney Disease Kidney function Glomerular

CKD is reduced kidney function and/or KIDNEY DAMAGE Chronic Kidney Disease Kidney function Glomerular filtration rate (GFR) < 60 m. L/min/1. 73 m 2 for > 3 months with or without kidney damage AND/OR Kidney damage > 3 months, with or without decreased GFR, manifested by either • Pathological abnormalities • Markers of kidney damage, i. e. , albuminuria § Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Slide 57 of 80 Reference: Kidney International Supplements, 2013; 3(1): 5 -14

Urine albumin is a marker for kidney damage • Urine albumin measures albumin in

Urine albumin is a marker for kidney damage • Urine albumin measures albumin in the urine. • An abnormal urine albumin level is a marker for glomerular disease, including diabetes. • Urine albumin is a marker for cardiovascular disease and is a hypothesized marker of generalized endothelial dysfunction. • May be associated with increased mortality. Slide 58 of 80

Urine albumin results are used for screening, diagnosing, and treating CKD • Standard of

Urine albumin results are used for screening, diagnosing, and treating CKD • Standard of diabetes care (annual screen) • Diagnosis § Forty percent of people are identified with CKD on the basis of urine albumin alone. • Prognosis § Important prognostic marker, especially in diabetes mellitus (DM) • Tool for patient education and self-management (such as A 1 C or e. GFR) Slide 59 of 80

Damaged kidneys allow albumin to cross the filtration barrier into the urine • Increased

Damaged kidneys allow albumin to cross the filtration barrier into the urine • Increased glomerular permeability allows albumin and other proteins to cross the glomerulus into the urine. • Higher levels of protein within the tubule may exacerbate kidney damage. § Level of protein may exceed the tubules’ ability to reabsorb the proteins. Slide 60 of 80

Risk Factors for Albuminuria Known risks Diabetes Hypertension Smoking Obesity Possible risks High sodium

Risk Factors for Albuminuria Known risks Diabetes Hypertension Smoking Obesity Possible risks High sodium intake High protein intake Inflammation Transient increases may be due to: Episodic hyperglycemia Exercise Fever Urinary tract infection References: De Jong et al. Kidney International. 2004; 66: 2109– 2118; Tuttle et al. Diabetes Care; 2014: 37: 2864– 2883 Slide 61 of 80

Use urine albumin-to-creatinine ratio (UACR) for urine albumin assessment • UACR uses a spot

Use urine albumin-to-creatinine ratio (UACR) for urine albumin assessment • UACR uses a spot urine sample. • In adults, ratio of urine albumin to creatinine in a spot specimen correlates closely to albumin excretion in 24 hours. • UACR < 30 mg/g is generally the cutoff for normal. Reference: http: //nkdep. nih. gov/resources/quick-reference-uacr-gfr. shtml Slide 62 of 80

UACR quantifies all levels of urine albumin • UACR is a continuous variable. •

UACR quantifies all levels of urine albumin • UACR is a continuous variable. • The term microalbuminuria has been used to describe abnormal urine albumin levels not detected by dipstick test, 30 mg/g – 300 mg/g. • The term macroalbuminuria has been used to describe urine albumin > 300 mg/g. • Both terms will be replaced by the term urine albumin. Slide 63 of 80

Explaining urine albumin Slide 64 of 80

Explaining urine albumin Slide 64 of 80

Medical Nutrition Therapy • Prescribed by a physician for the purposes of disease management

Medical Nutrition Therapy • Prescribed by a physician for the purposes of disease management • Nutritional diagnosis, therapy and counseling services provided by a Registered Dietitian Nutritionist or other nutrition professional (may be RD eligible) • In-depth individualized nutrition assessment and interventions Slide 65 of 80

MNT involves numerous steps • An initial nutrition and lifestyle assessment • Nutrition counseling

MNT involves numerous steps • An initial nutrition and lifestyle assessment • Nutrition counseling • Information regarding diet management • Follow-up sessions to monitor progress • Individual or group sessions Slide 58 of 80

Medicare Part B Preventive Care Services Eligibility Frequency MNT • Diabetes Individual or •

Medicare Part B Preventive Care Services Eligibility Frequency MNT • Diabetes Individual or • CKD with e. GFR 13 group 50 • Successful kidney transplant in past 3 years. First calendar year 3 hours No co-pay Deductible waived Subsequent year 2 hours http: //qioprogram. org/sites/default/files/editors/141/Medicare%20 DSMT%20 and%20 MNT%20 Requiremen ts%20 for%20 Reimbursement. pdf Slide 67 of 80

MNT telehealth services are covered • Applies only to Medicare-Fee-For-Service Programs in rural areas.

MNT telehealth services are covered • Applies only to Medicare-Fee-For-Service Programs in rural areas. • Must use interactive audio and video telecommunication systems that permits real-time communication. • For individual and group medical nutrition therapy use HCPCS code G 0270 and CPT codes 97802– 97804. Reference: Medicare Learning Network Telehealth Services. ICN 901705 November 2016 Slide 68 of 80

Coding for MNT including Telehealth • • 97802 Initial assessment and intervention, individual, face-to-face

Coding for MNT including Telehealth • • 97802 Initial assessment and intervention, individual, face-to-face with patient, each 15 minutes (NOTE: initial visit only) 97803 Re-assessment and intervention, individual, face-to-face with patient, each 15 minutes 97804 Group (2 or more individuals), each 30 minutes G 0270 Reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen, (including additional hours for renal disease) individual, (face to face) each 15 minutes G 0271 Reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours for renal disease), group (two or more), each 30 minutes HCPCS = Healthcare Common Procedure Coding System https: //www. cms. gov/Medicare/Prevention/Prevntion. Gen. Info/medicare-preventive. CPT = Current Procedural Terminology services/MPS-Quick. Reference. Chart-1. html#MNT Slide 69 of 80

ICD-10 for CKD Chronic kidney disease GFR N 18. 1 Stage 1 Kidney damage

ICD-10 for CKD Chronic kidney disease GFR N 18. 1 Stage 1 Kidney damage with normal GFR >90 N 18. 2 Stage 2 Kidney damage with mildly low GFR 60 -89 N 18. 3 Stage 3 (moderate) 30 -80 N 18. 4 Stage 4 (severe) 15 -29 N 18. 5 Stage 5 (renal failure) <15 N 18. 6 End stage renal disease requiring dialysis (GFR <15) R 80. 9 Proteinuria, unspecified ICD-10 CM = International Classification of Diseases, Clinical Modification Slide 70 of 80

Tips for MNT: diabetic kidney disease • Assess e. GFR and UACR, obtain 2

Tips for MNT: diabetic kidney disease • Assess e. GFR and UACR, obtain 2 nd referral if CKD is identified (change in medical condition, diagnosis). • Intensive glucose control to near normal glucose levels early in the course of diabetes may prevent or delay the onset of CKD. • A 1 C < 8% may be appropriate for advanced CKD. • A 1 C may measure lower in CKD due to increased erythrocyte turnover (shorter lifespan). • Blood pressure control slows CKD progression. • Review sodium intake. • Certain blood pressure medications increase risk for hyperkalemia. Slide 71 of 80

Follow trends in e. GFR Slide 72 of 80

Follow trends in e. GFR Slide 72 of 80

Follow trends in UACR Note differences in timeframes Slide 73 of 80

Follow trends in UACR Note differences in timeframes Slide 73 of 80

NKDEP tools to share with other providers • Explaining Your Kidney Test Results: A

NKDEP tools to share with other providers • Explaining Your Kidney Test Results: A Tear-Off pad for clinical use https: //www. niddk. nih. gov/health-information/professionals/clinical-tools-patient-educationoutreach/explain-kidney-test-results • Quick Reference on GFR and UACR in Evaluating Patients with Diabetes for Kidney Disease https: //www. niddk. nih. gov/health-information/health-communication-programs/nkdep/a-z/quickreference-uacr-gfr/Documents/quick-reference-uacr-gfr-508. pdf • Making Sense of CKD – A concise guide for managing chronic kidney disease in the primary care setting (Guide) https: //www. niddk. nih. gov/health-information/health-communication-programs/nkdep/az/Documents/ckd-primary-care-guide-508. pdf Slide 74 of 80

References Alicic RZ, Rooney MT, Tuttle KR. Diabetic kidney disease: challenges, progress, and possibilities.

References Alicic RZ, Rooney MT, Tuttle KR. Diabetic kidney disease: challenges, progress, and possibilities. Clinical Journal of the American Society of Nephrology. May 2017. doi: https: //doi. org/10. 2215/CJN. 11491116 Bolignano D, Zoccali C. Effects of weight loss on renal function in obese CKD patients: a systematic review. Nephrology Dialysis Transplantation. 2013; 28(Suppl 4): iv 82 -iv 98. Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet: general information and national estimates on chronic kidney disease in the United States, 2017. Atlanta, GA: US Department of Health and Human Services. Centers for Disease Control and Prevention website. https: //www. cdc. gov/diabetes/pubs/pdf/kidney_factsheet. pdf Accessed June 21, 2017. Centers for Disease Control and Prevention. International Classification of Diseases, tenth revision (ICD-10 -CM). Centers for Disease Control and Prevention website. https: //www. cdc. gov/nchs/icd 10 cm. htm Accessed August 18, 2017 Slide 75 of 80

References Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic

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