Improving Chronic Kidney Disease in the Bronx
Thomas H. Hostetter, MD and Carolyn Ann Bauer, MD
Chronic kidney disease (CKD) affects 26 million of our nation’s adults, with millions of others at increased risk. In the Bronx, over 100,000 residents are affected by CKD, and many more are at risk or in the disease’s beginning stages. As the provider of half of the borough’s healthcare services, Montefiore Medical Center established a comprehensive Chronic Kidney Care Program addressing cardiac risk factors and complications of kidney disease. In its early stages of operation, the program has shown promising outcomes in reducing in morbidity, mortality, and healthcare costs associated with CKD and end-stage renal disease (ESRD).
Chronic kidney disease is the gradual loss of kidney function over time. There is currently no cure for CKD, and many patients are not diagnosed until they have lost much of their kidney function. Left untreated, most patients with CKD will progress to ESRD, the final stages when the kidneys no longer function independently.
The Bronx’s unusually high rate of CKD may be partly due to its high African American and Hispanic populations (minority groups at increased risk for the disease), as well as its burgeoning rates of diabetes and hypertension, common causes of kidney complications. As the borough’s primary healthcare system providing over half of its healthcare services, Montefiore Medical Center, Einstein’s teaching hospital, admits as many as 50,000 patients with CKD and ESRD each year.
Patients who have developed chronic kidney disease from years of uncontrolled diabetes and hypertension present complex health issues, and the best treatment approach is often unclear. As physicians, we do our best to treat these patients’ diabetes, hypertension, and lipids; we support their smoking cessation; and we put them on aspirin to address their cardiovascular disease. But the story doesn’t end there: even when all of these risk factors are controlled, our patients still have high rates of cardiovascular disease and kidney disease.
The National Kidney Foundation and other organizations have issued guidelines addressing how to treat complications and causes of kidney disease. Intensive “guideline care” is a broad multidisciplinary effort which includes a number of best practices:
- monitoring patients’ creatinine, lipids, calcium, phosphorus, and parathyroid hormone levels
- ensuring that patients get regular flu vaccininations
- administering an A1C (for patients with diabetes)
- prescribing ARBs and ACE inhibitors for blood pressure control
- nutrition counseling
- patient education
- follow-up phone calls from a nurse
- starting patients who are nearing ESRD safely on dialysis as outpatients (renal dialysis is costly, with a significant portion of the expense involved in admitting and beginning the procedure on inpatients)
- encouraging patients to receive dialysis through an arteriovenous fistula to decrease risk of complications like infection and venostenosis (blockage)
- getting ESRD patients on the kidney transplant list as early as possible to increase their chances of being matched with a donor and/or time to prepare live donors
Studies have shown that patients who are cared for under these guidelines have improved cardiovascular and renal outcomes, prolonged kidney function (measured by glomerular filtration rates), and mortality rates associated with ESRD. Additionally, by delaying dialysis and beginning the process on an outpatient basis, this model of care saved significant healthcare costs.
The Montefiore Chronic Kidney Care Program, part of the Einstein Division of Nephrology, provides comprehensive care to address cardiac risk factors and complications of kidney disease. Our Program’s goal is to educate patients to improve their understanding of the disease and adherence to medication, and encourage them to take ownership in their medical care. Additionally, the Program strives to safely transition patients to ESRD and provide cost-effective care. Funded by Montefiore’s managed care organization, the Program’s multifaceted care team, including a dietician, social worker, nurse, coordinating secretary, and nephrologist, offers:
- dietary counseling and nutrition classes geared toward diabetes, high blood pressure, electrolyte imbalances, and bone health
- patient education classes that introduce kidney disease and discuss ESRD treatment options
- full medical care including intensive blood pressure management and regular vaccinations
While the Bronx leads the nation in chronic kidney disease, we at Einstein/Montefiore strive to lead in providing excellence in renal care. In its first year of operation, our Comprehensive Kidney Program has shown promising outcomes in outpatient dialysis starts, stabilizing patients’ blood pressure, and use of ACE and ARBs to treat high blood pressure and possibly delay dialysis. Moving forward, we will focus on increasing our number of patients with arteriovenous fistulas. Appropriate treatment of CKD and preparation for ESRD saves morbidity, mortality, and healthcare costs, and a multidisciplinary approach like we have started at Montefiore has clear advantages.
This article was adapted from a recent Department of Medicine Grand Rounds presentation. The post-lecture webcast is available at www.medicinegr.org. For the access code contact Mildred Rodriguez, firstname.lastname@example.org.