diet training module 1 ckd basics 508

U.S. Department of Healthand Human Services

National Institutes of Health

Module 1: Chronic Kidney Disease Basics

Epidemiology, Identification and Monitoring, Medical Nutrition Therapy

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 changes in the laboratory community that yield more accurate, reliable, and accessible test results.

To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from NIDDK, please visit: http://www.niddk.nih.gov.

Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.

Ms. Kuracina is the lead author of the American Dietetic Association’s CKD Nutrition Management Training Certificate Program and NKDEP’s nutrition resources for managing patients with CKD.

Ms. Kuracina has more than 20 years of experience in clinical dietetics with the Indian Health Service (IHS). She is a senior clinical consultant with the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. She also serves as a diabetes dietitian and coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico, a role in which she routinely counsels patients who have chronic kidney disease (CKD).

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 (NIH). Prior to joining NIH in 2006, he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Via telemedicine from NIH, he continues to provide care for IHS patients who have chronic kidney disease. A highly recognized nephrologist and public servant, Dr. Narva has served as a member of the Medical Review Board of ESRD Network 15 and as chair of the Minority Outreach Committee of the National Kidney Foundation (NKF). He serves on the NKF Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Diabetes and is a member of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Expert Panel.

Meet our presenters

Participants will be able to:

1. Burden of chronic kidney disease (CKD) and kidney

failure

2. Identify and monitor CKD

Renal anatomy, physiology, and functional

assessment

3. Medical nutrition therapy for CKD

Brief review

Chronic kidney disease basics

THE BURDEN OF CHRONIC KIDNEY DISEASE AND KIDNEY FAILURE

United States Renal Data System

Burden of CKD

Burden of end-stage renal disease (ESRD)

Topics

National data system funded by the National

Institutes of Health, National Institute of Diabetes

and Digestive and Kidney Diseases (NIDDK)

Collects, analyzes, and distributes information about

ESRD (since 1989) and CKD (since 2008)

U.S. Renal Data System (USRDS)

Atlas of Chronic Kidney Disease

− Estimates the number of people with CKD

Biochemical data from the National Health and Nutrition

Examination Survey (NHANES)

Diagnosis codes

− Medicare sample (5% = 1.2 million people)

− Employer Group Health Plans ( 12 million people)

Atlas of End-Stage Renal Disease

− Provides actual number of people on dialysis or with

kidney transplants

USRDS uses different data sources to determine numbers and rates

Reference:USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, http://www.usrds.org/adr.aspx

Chronic Kidney Disease

− Kidney function

Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 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

CKD is reduced kidney function and/or kidney damage

Reference: National Kidney Foundation Kidney Disease Outcome Quality Initiative (KDOQI). Clinical practice guidelines for chronic kidney disease: evaluation,

classification, and stratification. Amer J Kid Dis 2002; 39(2 suppl 1):S18–S266.

Kidneys cannot maintain homeostasis.

Kidney failure is associated with fluid, electrolyte,

and hormonal imbalances and metabolic

abnormalities.

ESRD means the patient is on dialysis or has a

kidney transplant.

Kidney failure is an eGFR < 15

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

Incidence vs. prevalence

More than 20 million, aged 20 years or older

More than 10% of U.S. adults may have CKD

Reference: http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm (CDC, 2010)

Increase proportion of persons with CKD Baseline Target

CKD 2: who know they have impaired renal function

7.3% 11.3%

CKD 4.1: who receive recommended medical evaluation with serum creatinine, lipids, and microalbuminuria

25.8% 28.4%

CKD 4.2: with type 1 or type 2 diabetes and CKD who receive recommended medical evaluation with serum creatinine, microalbuminuria, HbA1c, lipids, and eye exams

23.1% 25.4%

Reduce proportion of persons with CKD

CKD 6.1: who have elevated blood pressure 74.1% 66.7%

CKD 6.2: who have elevated lipid levels 29.6% 26.6%

Healthy People 2020 includes CKD objectives that Registered Dietitians (RDs) may impact

Too few people receive counseling prior to dialysis

Reference: Adapted from USRDS Annual Data Report (NIDDK, 2010)

The general Medicare population with

“recognized CKD” was 9.8% in 2007.

The general Medicare expenditures on CKD were

27.6% of total cost in 2007.

The Medicare population with CKD is growing

Reference: http://www.usrds.org/2009/pdf/V1_09_09.PDF

Prevalent dialysis population

− Increased 3.6% in 2008

− Up 34.7% since 2000

Transplant population


Incident population


ESRD patient counts, by modality2008

Reference: USRDS Annual Data Report (NIDDK, 2010)

Incidence of ESRD is increasing (and appears to be following obesity trends)


Diabetes is the leading cause of ESRD, followed by hypertension

Reference: Adapted from USRDS Annual Data Report (NIDDK, 2011)

African Americans have the highest incidence rates of ESRD


The elderly population has the highest incidence rates of ESRD


Renal replacement therapy (RRT)

1. Hemodialysis

In-center or home

2. Peritoneal dialysis

3. Kidney transplantation

Conservative management

4. Active medical management without RRT

The four options for treating kidney failure

High mortality rates during the first year of hemodialysis are a big challenge


Hemodialysis $19.4 billion Peritoneal Dialysis $ 1 billon Transplantation $ 2 billion

*ESRD data do not include Medicare Part D cost

ESRD is costly


Total Medicare ESRD expenditures by modality

Temporary access (emergent)

− Many patients are not prepared for dialysis prior to

initiation (much more expensive)

Hemodialysis

− Vascular access

Peritoneal dialysis

− Peritoneal access

Transplantation

RRT requires surgery(planned or emergent)

First months of treatment are the most costly; many are not prepared for dialysis


Annual treatment costs are increasing, too

Reference: adapted from USRDS Annual Data Report (NIDDK, 2010)

Recently, ESRD incidence rates have stabilized


Medical nutrition therapy may slow CKD progression.

Medical nutrition therapy may help manage CKD

complications.

Potential cost savings for delaying dialysis for one

year for one patient could exceed a dietitian’s salary.

Delaying the need for RRT may be cost-effective

CKD and ESRD are increasing.

Diabetes and hypertension are the leading causes of ESRD.

Too few patients receive nutritional intervention prior to renal replacement therapy.

Burden of RRT is significant on individuals and our society.

Summary

IDENTIFY AND MONITOR CKD

Renal anatomy, physiology, and functional assessment

Basic anatomy

Kidney functions

Chronic kidney diseases

Glomerular disease

Functional assessment to identify and monitor

− Estimated glomerular filtration rate (eGFR)

− Urine albumin-to-creatinine ratio (UACR)

Topics

Kidneys

Ureters

Bladder

Urethra

Kidneys and collecting system

Glomerulus

Proximal tubule

Loop of Henle

Distal tubule

Collecting duct

The nephron

We have a large physiologic reserve.

Slow, progressive loss of functioning nephrons may

not be noticeable.

The person with CKD may not feel different.

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

noticeable

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.

The nephron functions to maintain balance

The specialized capillary tufts are located between

the afferent and efferent arterioles.

Pressure differences result in a gradient

and movement of solutes across the semipermeable

glomerular basement membrane.

Glomeruli generate ultrafiltrate via specialized capillary tufts

Filtration is based on size and charge.

− Small solutes cross readily.

− Larger substances are generally restricted.

− Negatively charged molecules are restricted.

Volume of ultrafiltrate = 135–180 liters(L)/day

99% water reabsorbed -> 1–1.5 L urine excreted

Ultrafiltration of plasma is the main function of the glomeruli

Reabsorption and secretion of substances occurs

within the tubules.

Examples:

− Potassium is reabsorbed from and secreted into the

urine by the tubules.

− Sodium is generally reabsorbed by the tubules.

− Organic acids are secreted into the urine.

The ultrafiltrate is modified by the tubules

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

The kidneys maintain homeostasis

Hormone 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)2D (active vitamin D)

Metabolic function

− Gluconeogenesis

− Metabolize drugs and endogenous substances

(e.g., insulin)

The kidneys have other functions

CKD usually means fewer functioning nephrons

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)

Reduced catabolism

− Examples: Insulin, glucagon, drugs

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 as well

Fewer nephrons disrupt the balance

Diabetes

Hypertension

Family history of kidney disease

Cardiovascular disease

Recurrent urinary tract infections

HIV infection

Autoimmune diseases

Risk factors for CKD

Historical cohort study (Kaiser) found that body

mass index (BMI) > 25 is an independent predictor

for ESRD.

A retrospective 20-year study in Norway found the

risk for CKD increases for pre-hypertensive patients

with BMI > 30.

Overweight may be an independent risk factor for CKD

References: Hsu et al. Ann Intern Med 2006; 144(1):21–28; Munkhaugen et al. Am J Kid Dis 2009; 54(4):638–646.

Inflammation may contribute to:

− Decline in kidney function with aging

− Albuminuria

− Cardiovascular disease

− Malnutrition

− Anemia

− Metabolic acidosis

Causes reduced clearance and/or increased

production of pro-inflammatory cytokines

Obesity may be an inflammatory state

Inflammation is a possible risk factor for CKD

Primary disease

Secondary to systemic disease

Anatomic

Genetic

Immunologic

Metabolic

CKD may be a primary or secondary process

Glomerular disease is the most common type of

kidney disease.

With disease progression, the vascular tuft is

replaced by scar tissue and function is lost.

Glomerular injury

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

United States

Reference: NIH Publication No. 10-3895

Damage to the filter allows larger molecular weight

substances such as albumin into the ultrafiltrate.

Increased urine protein may be a cause as well as a

sign of kidney injury.

Glomerular injury may result in urinary excretion of larger molecules

The composition of the urine changes.

Most people do not notice any difference in urine

volume.

Slow, progressive loss of function may not be

noticeable.

People with CKD still make urine

FUNCTIONAL ASSESSMENTIdentify and monitor CKD

Chronic kidney disease

− Kidney function

Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for > 3 months

with or without kidney damage

AND/OR

− Kidney damage



− Markers of kidney damage, e.g., albuminuria


This definition does not account for age-related GFR decline.


Reference: National Kidney Foundation, 2002


− Kidney function

Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for > 3 months

with or without kidney damage

AND/OR

− Kidney damage







KIDNEY FUNCTIONUse estimated GFR to assess and monitor

The eGFR is the estimated glomerular filtration rate.

The eGFR provides an estimate of how much blood

is filtered by the kidneys each minute.

Use eGFR to assess and monitor kidney function

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 (eGFR) gives a rough measure

of the number of functioning nephrons.

What is the glomerular filtration rate (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 mL/min

x Filtration Fraction of 20% = 120 mL/min

What is the GFR?

Reference Table for Population Mean eGFR from NHANES III

Kidney function and eGFR decline with age

Reference: http://nkdep.nih.gov/professionals/gfr_calculators/gfr_faq.htm

Age (years) Mean eGFR (mL/min/1.73 m2)

20–29 116

30–39 107

40–49 99

50–59 93

60–69 85

70+ 75

eGFR is not the measured GFR.

The formula to estimate GFR was derived from a

population-based study.

eGFR is based on serum creatinine levels.

Previous methods to estimate kidney function also

are based on serum creatinine.

Creatinine assays are now standardized.

− Isotope Dilution Mass Spectrometry (IDMS)

eGFR estimates the measured GFR

The Modification of Diet in Renal Disease (MDRD) Study equation is widely used for estimating GFR.

The variables are serum creatinine, age, race, and gender.

The estimate is normalized to body surface area.

Use an estimating equation for eGFR

eGFR (mL/min/1.73 m2) =

175 x (Scr)–1.154 x (Age)–0.203 x (0.742 if female) x (1.212 if African American)

References: Stevens et al. J Am Soc Nephrol 2007; 18:2749-2757; Poggio et al. Am J Kid Dis 2005; 46:242-252; Verhave et al. Am J Kid Dis 2005; 46:233-241

The National Kidney Disease Education Program

(NKDEP) recommends reporting MDRD estimates

greater than or equal to 60 as “> 60” rather than a

numeric value.

Interlaboratory differences in calibration of

creatinine assays and the imprecision of

measurements have their greatest impact in the

near-normal range and, therefore, lead to greater

inaccuracies for values ≥ 60.

Estimating equations are less reliable at higher GFR

Normal: ≥ 60 mL/min/1.73 m2

Kidney disease: 15–59 mL/min/1.73 m2

Kidney failure: < 15 mL/min/1.73 m2

How to explain eGFR results to patients

If your lab reports do not include eGFR, use an

online calculator.

Visit http://www.nkdep.nih.gov/ to find the GFR

calculators.

Most lab reports include eGFR with serum creatinine

Do not use 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

Creatinine-based estimates of kidney function have limitations

Creatinine is a product of muscle creatine

catabolism and is produced daily in proportion to

muscle mass.

Serum levels transiently increase after eating

protein.

Creatinine is filtered by the glomerulus and is

secreted into the urine by the tubule.

Serum creatinine levels increase as kidney function declines

Serum creatinine levels reflect:

− Muscle mass

− Age

− Gender

− Race

What is the “normal” serum creatinine level?

A typical “normal” reference range of

0.6–1.2 mg/dL 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 eGFR > 60.

A 78-year-old white woman with serum creatinine of

1.2 has an eGFR of 43.

“Normal” serum creatinine may not be normal

Stable eGFR levels may mean non-progressive

disease or current therapy is working.

A rapid decline in eGFR may indicate rapid

progression of kidney disease.

Monitor the eGFR trends

Use NKDEP’s eGFR calculator to determine eGFR for

various levels of creatinine, different genders and

races.

− eGFR < 60 = CKD

− eGFR < 15 = kidney failure

GFR Calculator can be found at:

http://nkdep.nih.gov/professionals/gfr_calculators/ind

ex.htm

Activity

Age, Race, Gender of Patient Serum Creatinine eGFR

35-year-old African American male 1.2 > 60

35-year-old White female 1.2 51

58-year-old Asian American female 1.2 46

58-year-old White male 2.4 28

58-year-old African American male 2.4 34

58-year-old African American female 2.4 25

80-year-old Hispanic female 2.4 19

Age, Race, Gender of Patient Serum Creatinine eGFR

35-year-old African American male 1.2 ≥ 60

35-year-old White female 1.2 51

58-year-old Asian American female 1.2 46

58-year-old White male 2.4 28

58-year-old African American male 2.4 34

58-year-old African American female 2.4 25

80-year-old Hispanic female 2.4 19

Explaining GFR


− Kidney function

Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for >

3 months with or without kidney damage

AND/OR

− Kidney damage

> 3 months, with or without decreased GFR, manifested by

either




CKD is reduced kidney function and/or KIDNEY DAMAGE


KIDNEY DAMAGE

Use urine albumin-to-creatinine ratio (UACR) to assess and monitor

NHANES 1988–1994 participants

Albuminuria is associated with mortality


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.

Urine albumin is a marker for kidney damage

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)

− Used to monitor and guide therapy

Tool for patient education and self-management (such

as A1C or eGFR)

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

Low-molecular-weight proteins cross the glomerulus.

High-molecular-weight proteins do not cross the

glomerulus normally.

Negatively charged molecules usually are restricted

from crossing the glomerulus.

Proteins are filtered based on size and electrical charge

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.

− Proteins may exceed tubules’ ability to reabsorb.

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

Currently accepted “normal” level ≤ 30 mg/g

− Albumin is a medium-size molecular-weight protein

with a negative charge.

− Most is reabsorbed by the tubules.

Normal urine protein is < 150 mg/day

− Includes albumin and other proteins.

Very little albumin or protein normally is excreted into urine

Reference: Danziger J. Mayo Clinic Proceedings 2008; 83(7):806–812

UACR uses a spot urine sample.

In adults, ratio of urine albumin to creatinine correlates

closely to total albumin excretion.

Ratio is between two measured substances (not dipstick).

UACR < 30 mg/g is generally the most widely used cutoff

for “normal.”

Use urine albumin-to-creatinine ratio (UACR) for urine albumin assessment

Reference: http://nkdep.nih.gov/resources/uacr_gfr_quickreference.htm

UACR is a continuous variable.

The term albuminuria describes all levels of urine

albumin.

The term microalbuminuria describes abnormal

urine albumin levels not detected by dipstick test.

• 30 mg/g – 300 mg/g

The term macroalbuminuria describes urine albumin

> 300 mg/g.

UACR quantifies all levels of urine albumin

Dipstick

− Semi-quantitative, screening only

Affected by urine concentration, highly variable

− Detection of urine albumin > 300 mg/day

(1+ approximates albumin excretion of 30 mg/day)

Urine protein/creatinine ratio

‒ All proteins, not just albumin

Urine albumin-to-creatinine ratio (UACR)

‒ Quantifies urine albumin

− Steps toward standardization currently in progress

− Standard for public health, clinical care, and research

Use which urine test?

The NKDEP Laboratory Working Group and the International

Federation of Clinical Chemistry and Laboratory Medicine

are working together to address urine albumin

measurement and reporting.

− Various test options and urine sampling, no international

reference, non-standardized reporting units

Lab cutoffs may change to reflect gender, age, race, level

for CVD risk.

Urine albumin standardization is in process

The currently accepted “normal” UACR level is

≤ 30 mg/g.

Persistent levels > 30 mg/g are considered kidney

damage.

Use a spot urine sample for assessment.

Monitor trends over time.

Use UACR to assess and monitor kidney damage

Explaining urine albumin

Quick Reference on GFR and UACR in Evaluating

Patients with Diabetes for Kidney Disease

http://nkdep.nih.gov/resources/

uacr_gfr_quickreference.htm#uacr

CKD Information

http://nkdep.nih.gov/professionals/

chronic_kidney_disease.htm#definition

NKDEP tools to share with other providers

Follow trends in eGFR

Note differences in timeframes

Follow trends in UACR

Summary: Identify and monitor CKD

Reference: http://nkdep.nih.gov/resources/uacr_gfr_quickreference.htm#uacr

MEDICAL NUTRITION THERAPY

“May help delay disease progression.” The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers and Other Health Care Professionals

Brief definition of medical nutrition therapy (MNT)

Medicare eligibility

Medicare CKD benefit

Coding

Topics

Prescribed by a physician for the purposes of

disease management

Nutritional diagnosis, therapy and counseling

services provided by a Registered Dietitian or

nutrition professional

In-depth individualized nutrition assessment and

interventions

Medical Nutrition Therapy

Medicare Part B costs extra and covers many

outpatient services.

Co-pay does not apply for MNT.

CKD eligibility for MNT referral includes:

− Renal transplant, for up to 36 months after transplant

− Reduction in renal function not severe enough to

require dialysis or transplantation

eGFR 13–50 mL/min/1.73 m2

Must have Medicare Part B for MNT benefit

An initial nutrition and lifestyle assessment

Nutrition counseling

Information regarding diet management

Followup sessions to monitor progress

Individual or group sessions

MNT involves numerous steps

Requires a physician referral with their provider

number on the claim (CMS-1500)

Allows three hours for the first calendar year

− Two hours subsequently

Allows a second referral in the same calendar year

due to change in medical condition, diagnosis, or

treatment

MNT benefits are limited

Reference: https://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf

HCPCS = Healthcare Common Procedure Coding System CPT = Current Procedural Terminology

Use the correct codes for MNT billingHCPCS/ CPT Codes

Descriptors

97802 MNT; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes (NOTE: initial visit only)

97803 Reassessment and intervention, individual, face-to-face with patient, each 15 minutes

97804 Group (two or more individuals), each 30 minutes

G0270 MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen, individual, group (two or more), each 15 minutes

G0271 MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen, individual, group (two or more), each 30 minutes

Stage ICD-9 CM National Kidney Foundation (NKF)

1 585.1 Kidney damage (e.g., proteinuria)• Normal or elevated GFR

• > 90

2 585.2 Kidney damage (e.g., proteinuria) •Mild reduction of GFR

• 60–89

3 585.3 Moderate reduction of GFR • 30–59

4 585.4 Severe reduction of GFR• 15–29

5 585.5 Kidney failure • GFR < 15 (or dialysis)

Note: Staging and coding defined by eGFR only

Medical coding uses staging system developed by National Kidney Foundation

ICD-9 CM = International Classification of Diseases, Clinical Modification

In 2006, RDs were added as providers for telehealth

services.

Only available in rural areas. Requires audio and

video components.

Use telehealth modifiers for billing:

− GT (continental United States)

− GQ (Alaska and Hawaii demo projects)

MNT telehealth services are covered

Reference: MLN Matters Number: MM4204, January 12, 2006

For information on how to become a Medicare provider visit:

http://www.cms.gov/MedicareProviderSupEnroll/downloads/G

ettingStarted.pdf

Becoming a Medicare Provider

MNT may help prevent progression and treat

complications

Must have Medicare Part B

Need physician referral

Use correct codes for billing

Summary

eGFR < 30 (“Stage IV”)

Medicare Part B

− Individual pays 20%, deductible applies

Qualified providers: physicians, physician assistants,

nurse practitioners, and clinical nurse specialists

Covers up to six sessions

Kidney disease education is a Medicare benefit

The topics include the same topics in the certificate program.

The topics include the same topics in this program.

Reference: http://www.medicare.gov/Publications/Pubs/pdf/11456.pdf

CKD and ESRD are increasing.

Diabetes and hypertension are the leading causes of

ESRD.

Too few patients receive nutritional intervention prior

to renal replacement therapy.

Burden of RRT is significant on individuals and our

society.

Take-home messages: Burden of disease

Take-home messages: Identify and monitor CKD

Reference: http://nkdep.nih.gov/resources/uacr_gfr_quickreference.htm#uacr

Patient must have Medicare Part B.

MNT may help prevent progression and treat

complications.

− Need physician referral

− Use correct codes for billing

Kidney disease education may be available from

other qualified providers.

Take-home messages: Medicare covers MNT and kidney disease education

Birn H, Christensen EI. Renal albumin absorption in physiology and pathology. Kidney International. 2006;69(3):440–449.

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, 2010. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention website. http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm Accessed June 13, 2011.

Centers for Disease Control and Prevention. Classification of diseases, functioning, and disability. International Classification of Diseases, 9th revision (ICD-9). Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/icd/icd9.htm Updated September 1, 2009. Accessed June 13, 2011.

References

Centers for Medicare & Medicaid Services. Medicare Helps Cover Kidney Disease Education, 2010. Baltimore, MD: U.S. Department of Health and Human Services. Medicare.gov website. http://www.medicare.gov/Publications/Pubs/pdf/11456.pdf. Accessed February 8, 2012.

Centers for Medicare & Medicaid Services. The Guide to Medicare Preventive Services, 4th Ed, 2011. Baltimore, MD: U.S. Department of Health and Human Services. Medicare.gov website. https://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf. Accessed February 22, 2012.

Choncol M, Lippi G, Montagnana M, Muggeo M, Targher G . Association of inflammation with anaemia in patients with chronic kidney disease not requiring chronic dialysis. Nephrology Dialysis Transplantation. 2008;23(9):2879–2883.

References

Chronic kidney disease (CKD) information. National Kidney Disease Education Program website. http://nkdep.nih.gov/professionals/chronic_kidney_disease.htm#definition. Reviewed February 13, 2011. Accessed June 13, 2011.

Coresh J, Astor BC, McQuillan G, et al. Calibration and random variation of the serum creatinine assay as critical elements of using equations to estimate glomerular filtration rate. American Journal of Kidney Diseases. 2002;39(5):920–929.

D’Amico G, Bazzi C. Pathophysiology of proteinuria. Kidney International. 2003;63(3):809–825.

References

Danziger J. Importance of low-grade albuminuria. Mayo Clinic Proceedings. 2008;83(7):806–812.

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References

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