Ask the Doctor
Questions about kidney disease? Risk factors? Signs and symptoms? Are you concerned about yourself, a friend or family member? Ask Dr. Spry.
by Peter Juergensen, PA-C
The management of chronic kidney disease—mineral and bone disorder (CKD-MBD) is complicated, but new information has helped with the understanding and possibly the management of this problem. To address this issue, it would be reasonable to understand the recent new physiology findings and the KDOQI and KDIGO recommendations.
Data suggests that as GFR declines, there is a decline in 1,25 Vit D and a gradual reciprocal rise in intact PTH (iPTH). The process most likely starts at a GFR of 50-60 ml/min with definite changes in 1,25 Vit and iPTH by GFR of 40-50 ml/min, yet PO4 and calcium levels remain normal. The old teaching has been that as renal mass declines, 1,25 Vit D levels drop and iPTH increases. The new data suggests that as GFR declines there is an important need to maintain normal PO4 levels. This process is achieved by increasing iPTH and FGF-23 (fibroblast growth factor 23 made by osteocytes). The two hormones stimulate PO4 excretion. Unfortunately FGF-23 inhibits the conversion of 25 Vit D to 1,25 Vit D. The drop in 1,25 Vit D causes a further rise in iPTH. PO4 only starts to rise late in CKD (GFR of 20-25 ml/min) as FGF-23 can no longer enhance PO4 excretion. Elevated PO4 has been found to be potentially detrimental to the vascular tree by enhancing vascular calcification. Data has demonstrated that elevated PO4 and elevated FGF-23 are associated with increased mortality. It may point to the need to control PO4 aggressively at earlier stages of CKD. Elevated FGF-23 may be a better indicator of chronic problems with PO4 control and may be a similar marker of PO4 control as Hemoglobin A1C is for glucose control.
Therapy: Several approaches seem reasonable. First is the need to replace 25 Vit D deficiency at all stages of CKD. There is a plethora of data that indicates deficiency of 25 Vit D adversely affects numerous organ systems of the body. Future studies need to be done to demonstrate that repletion of 25 Vit D can correct some of these problems. Second is tight control of PO4 by restricting PO4 intake early in CKD. Further data is needed to demonstrate if PO4 binders would be of benefit in early CKD (at present these binders are approved only for ESRD). Third, the use of active Vit D products (calcitriol, paricalcitol or doxercalciferol) to control iPTH is reasonable once control is no longer achieved with 25 Vit D repletion or PO4 control. These active agents may increase PO4 absorption, thus attention also needs to be focused on continued adequate PO4 control. Once stage 5 CKD is present, iPTH control maybe achieved by using numerous approaches including PO4 control, active Vit D and calcimimetic therapy. The present KDOQI guidelines accept a gradual rise of iPTH in CKD 3 and 4 with a maximum target iPTH of 150-300 pg/ml in ESRD. KDOQI also suggests PO4 targets of 3.5 to 5.5 mg/dl. These targets have been revisited by KDIGO that suggest a PO4 level “as close to normal as possible” and iPTH values of 2 to 9 times normal range with dialysis patients. The reasons for these less specific goals with KDIGO are due to a paucity of randomized prospective controlled data that support the tighter KDOQI guidelines.
by Kim Zuber, PAC, MSPS
We are in the final stretch of planning for the NKF Spring Clinical Meetings and this year's program looks fantastic! CAP's CE Committee, under Laurie Benton and Elaine Go's direction, has put together an incredible program that covers the breadth and depth of what we, as advanced practitioners, do. Please be sure to thank them when you see them frantically running around the halls at the Gaylord Opryland. The entire CAP Executive Committee is looking forward to seeing you all in Nashville!
The first CAP luncheon (as an official NKF Professional Council) will be held in Nashville on Thursday, March 26 at 12:00 p.m. as part of the 2009 NKF Spring Clinical Meetings. It is free, open to all advanced practitioners (CAP member or not…we want to meet you all!) and a great place to network. We look forward to seeing you there.
CAP granted educational stipends to the following members to assist in defraying the cost of attending SCM09 in Nashville: Beth Ramenofsky, a PA student from Virginia; Laura MacGregor, RN, an ANP student at Stony Brook University in New York; Kirsten Jensen, RN. ANP, who is new to nephrology; and Linda Mixter, MSN, APN-BC, of Michigan. Beth, Laura and Kirsten will be first-time attendees.
MIPPA is still on our radar. This new CKD training program for patients will be an update of the NKF program “People Like Us Live! (PLUL!)” that all of us have used over the years. I am excited to see the update. We are currently reviewing modules as they are written. To volunteer, contact me at firstname.lastname@example.org
Peter Juerguensen has joined the CAP Executive Committee as Research Chair. We will be awarding research grants starting with the 2010 fiscal year, just one of the wonderful benefits of membership in CAP. So, when you are approached by Barb Weis to renew your membership, keep that in mind!
by Elaine Go, CNN, NP, CAP CE Co-Chair
People to People Citizens Ambassadors Program organized a Nephrology Nursing delegation to China this past October. The delegation was headed by Lesley Dinwiddie, RN, CNN, MSN, FNP. I had the good fortune of being asked to be the co-leader of the delegation.
The delegation of 25 nephrology nursing professionals from the U.S., Canada and Australia, was put together for the purpose of participating in bilateral exchanges with our nephrology counterparts in China. The U.S. delegation was comprised of clinical nurses, clinical educators, clinical nurse specialists, and nurse practitioners.
In Beijing, we had the opportunity of meeting with the Dean of Capital Medical School of Nursing (one of the larger nursing schools in Beijing), who is a graduate of the University of Alabama at Birmingham Nurse Practitioner program. We learned from this visit that nursing education is similar to that in the U.S., that there is an increase in the number of male nurses and there is also a shortage in nurses and faculty. There are no nurse practitioners in China. We also found, at this particular university, that the cost of education between that of a nurse and a physician is about the same.
Next, we visited Peking University 3rd Hospital and were briefed by their Chief of Renal Division, Dr. Wang Tao, and his team. Dr. Wang was able to increase his PD program, which also focuses on research, from 98 patients to 350 patients. His key concept for retention of PD patients is self management. He claims low peritonitis rates and excellent dialysis adequacy. He also shared with us that late referral is common in China.
The officers of the Chinese Nursing Association (CNA), headed by Secretary General Ms. Feng Yun Hua, also met with our delegation. We were joined by other CNA officers who are Directors at various dialysis centers in Beijing. From this visit, we learned that there are no professional nursing organizations in China, but the different nursing specialties are represented by committees within the Chinese Nursing Association.
Our travels then took us to Guilin, southeast of Beijing, to visit Guilin Traditional Chinese Medicine (TCM) Hospital. Here we had the opportunity of observing how herbs are prepared, as prescribed by a TCM provider for various ailments and dispensed to the patients. We then went to a "township" hospital, which would be an equivalent to rural area community health centers in the U.S. Here, the practice of medicine is at the "grassroots" level-Traditional Chinese Medicine is more popular than Western medicine. Patients with CKD are referred to a higher level of care. They do not stage CKD using GFR but do check for proteinuria.
Our last stop was Shanghai where we visited two hospitals and a dialysis unit. From all the professional meetings, we learned that the primary cause of CKD leading to ESRD is chronic glomerulonephritis. Diabetes followed, and hypertension was the third cause. Nephrology practitioners in China also follow the NKF K/DOQI guidelines. There is a greater prevalence of AV fistula rather than AV graft or tunneled catheters.
We also learned that in the dialysis units, it is required that a nephrologist be physically present at all times while patients are being dialyzed. Some of the units we visited had all their patients dialyze for 4 hours.
Through all our travels, we learned that there are more similarities among peoples of the world than we had previously thought. The problems we face in nephrology and nursing are not unique to the Western world. All in all, this was a great experience, not only in meeting and forging alliances with other nephrology practitioners from the United States, but also those from Canada, Australia and China.
PETER JUERGENSEN, PA-C
Peter has recently joined the CAP Executive Committee in the capacity of Research Chair. Peter is well-qualified for the position and is already hard at work developing a plan for implementing the research aspect of CAP. As the first Research Chair, he has the monumental task of developing criteria for judging proposals and awarding grants to CAP members in good standing. Peter hopes to encourage students to submit proposals.
Born in Columbia, South America, Peter is fluent in three languages. He received his B.S. in Biology from UNC at Chapel Hill and completed the Yale School of Medicine Physician Assistant program. Since graduating, he has been an assistant professor and lecturer in medicine at Yale School of Medicine, Yale School of Nursing and Quinnipiac College Physician Assistant Program. He currently works at Metabolism Associates. His duties include managing hemodialysis and peritoneal patients both in- and outpatient and participation in research studies. His many honors, including the Yale Alumnus of the Year Award, attest to his abilities and contribution to the profession.
Peter is well-known in the nephrology world and has given numerous presentations at conferences. In addition, since 1993 he has presented a poster and lectured at the International Conference on Dialysis. Peter has also authored and co-authored many publications appearing in nephrology journals and handbooks.
Throughout his career, he has been devoted to the advancement of professional excellence and has served as AANPA (American Association of Nephrology Physician Assistants) president since 2005. His new assignment as CAP Research Chair is challenging, but he intends to still find time for his leisure interests—sports, especially skiing, basketball and baseball, reading and gardening and spending time with family, which includes a daughter pursuing a graduate degree in art in Minneapolis and a son who is a junior at Tufts University.
CAROL WHITE, RN, MN, NP
CAP members are familiar with Carol White's name. She frequently poses questions on the listserv and responds to queries as well. Carol came into nephrology almost by accident. A graduate of the University of Georgia with a Bachelor of Arts in History, she found teaching was not for her. With a degree in history, her options were limited, but a nurse friend made nursing sound exciting. She decided to give it a try and obtained both her BSN and MSN from Emory University in Atlanta, GA. In between, she completed the Enterostomal Therapy program. She began her nursing career in oncology and then moved to critical care. When a job offer arrived to be a kidney-transplant coordinator and CNS at Emory, it proved to be a good fit, so Carol found her home in nephrology.
After completing her post-Masters ANP certification, she followed ESRD patients for four years at multiple centers in western North Carolina, one of which was located on a Cherokee Indian Reservation. She then moved to Chattanooga, TN, and after a brief stint in pain management, was recruited to help spearhead the CKD clinic for Nephrology Associates. The clinic is staffed by three nurse practitioners and 14 nephrologists and sees approximately 4500 CKD patients, primarily stages 3 and 4.
In 2007, she applied for and received a research grant to improve patient awareness of monitoring home blood pressures, improve blood pressure control and improve patient outcomes. Her practice purchased 35 blood pressure monitors which were distributed to patients for home blood pressure monitoring. The study is expected to conclude in 2009 and the results available in the Nephrology Nursing Journal. She is planning to sit for the CNN-NP exam in Nashville this year.
Carol and her husband Frank have two dogs, Turbo and Grendel, and she likes to spend her spare time reading, cooking and bicycling. When not working, studying or monitoring her grant, she volunteers with the Ashville-Buncombe County Christian Ministry and the NKF. She is currently working on a fun project—writing a murder mystery set in a nephrology vascular access center. When it is published, look for a review in the CAP newsletter!
Dolph Chianchiano, JD, MPA
NKF Senior Vice President for Health Policy and Research
In February 2002, the National Kidney Foundation (NKF) Board of Directors passed the following motion: RESOLVED, that the NKF endorse legislation, to be introduced by Rep. Philip Crane (R. IL) and Sen. Blanche Lincoln (D. AR), to create a new Medicare benefit which would reimburse educational services furnished to individuals with chronic kidney disease before they initiate replacement therapy.
This legislative proposal soon became the foundation's highest public policy priority and was ultimately enacted as part of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275 or MIPPA). Coverage will be effective on January 1, 2010, for individuals with stage 4 kidney disease who are enrolled in Medicare. The multi-year advocacy campaign leading to this victory demonstrates the power of commitment, persistence, consistency and, most importantly, grassroots consumer activism.
The statute provides that no individual shall be furnished with more than six sessions of kidney disease education services and that the education should be provided by a physician or a physician assistant, nurse practitioner or clinical nurse specialist. The scope of the classes, as described in the legislation, includes:
Aside from these directives, MIPPA gives the Centers for Medicare and Medicaid Services (CMS) much leeway in determining the conditions for this benefit and how it will be reimbursed. Therefore, we now have to focus our attention on the implementation of this coverage. To start, representatives of the NKF Professional Councils participated in a CMS "Open Door" conference call, and NKF staff attended a forum on kidney disease patient education services organized by the Agency for Healthcare Research and Quality (AHRQ).
NKF's first concern is to ensure balance, comprehensiveness and consistency in the information provided to beneficiaries pursuant to this MIPPA benefit. In order to achieve that goal, NKF has argued that there should be a core curriculum for each of the six sessions. We also want CMS to design the program to maximize learning experience, which means that fundamental decisions should be made concerning:
NKF has urged CMS to develop a system to evaluate the services provided through this coverage: a) to ensure that they meet minimum requirements and b) to determine impact of educational services on patient outcomes.
Finally, NKF wants to be certain that reimbursement is structured to maximize participation by beneficiaries and providers. In that regard, the history of the Medical Nutrition Therapy (MNT) benefit may be instructive. MNT was created by the Benefits Improvement and Protection Act of 2000. At the time, the Congressional Budget Office estimated that MNT coverage would cost the federal government $60 million per year. However, CMS reports that expenditures for MNT were less than $5 million in 2007. Concern about adequacy of reimbursement may have limited access for this benefit.
NKF expects that CMS will publish draft regulations for pre-dialysis education in July of 2009 and that a final rule will be posted by mid-November.