A Healthier Future for West Virginia - Healthy People 2010

4 - Chronic Kidney Disease

Objectives | References

Background

Anyone can develop kidney disease, and eventually ESRD. Diabetes and high blood pressure are two of the leading causes of kidney disease. Diabetes accounts for 42% of the new cases of kidney failure in the United States, while high blood pressure contributes to 26% of the new cases.

According to the latest U.S. statistics available at the time of publication, the overall incidence rate of ESRD was 318.46 cases per one million persons in 1998. In the Mid-Atlantic Renal Coalition (MARC) Network 5 region, which includes West Virginia, Virginia, Maryland, and Washington, DC, the ESRD incidence rate was 376.57 per million people in that year. In West Virginia, the rate was 337.91 per million. Nearly all of these individuals became permanently dependent on renal replacement therapy (RRT) to stay alive.

RRT is a life-saving process that artificially replaces the function of diseased kidneys and aids patients suffering from ESRD. Two primary options exist for RRT patients: dialysis or kidney transplantation. In 1999, West Virginia had 1,303 people actively receiving some form of dialysis, and over 20% of adult dialysis facility patients were awaiting transplantation.

There are two types of dialysis: hemodialysis and peritoneal dialysis. Hemodialysis involves removing blood from the body and filtering it into a machine that continuously draws blood, cleanses it and removes excess fluids, and then returns the blood to the patient. Hemodialysis requires a person to have a three-to-four-hour treatment three times a week, typically in a treatment facility. Peritoneal dialysis is an internal or in- body dialysis in which a blood-cleansing solution is injected into a peritoneal cavity, extracting toxins and excess fluids and then drained from the body cavity. Peritoneal dialysis is performed each day and is usually performed at home.

Many patients also benefit from a kidney transplant. A functioning transplant will end the need for dialysis. Donated organs from cadavers or living donors who match the patient are used for transplantation.

The importance of early referral for patients with ESRD cannot be overstated. Studies from the U.S. and abroad have shown that earlier patient referrals may lead to fewer complications, shorter hospital stays, and decreased medical costs. Today, there are new and better treatments choices for ESRD patients. Learning about treatment choices can assist patients in determining the treatment that works best for them. No matter what treatment is chosen, the patient will experience lifelong changes. The addition of adequate nutritional counseling, treatment choices, and social services before renal replacement therapy can help ensure the patient leads the fullest life possible.

Predialysis referral to a renal team consisting of a nephrologist, nurse, dietician, and social worker provides time to establish a working relationship to acquaint the patient/family with the various modes of renal replacement therapy, and to determine what is the optimal therapy, both medically and psychosocially, for the individual. Should hemodialysis be the therapy of choice, early intervention with the renal team also provides the necessary time for referral for the creation and subsequent maturation of the arteriovenous (AV) fistula.

Nutritional education and intervention are also of utmost importance in the maintenance of optimum protein/albumin and electrolyte levels. Early referral allows the medical team to help prevent acceleration of renal function loss by ensuring the avoidance of situations such as the use of potentially nephrotoxic drugs and dehydration states. Including patients in decisions involving their care and encouraging their active participation will help empower patients to be proactive in learning about their care with the goal of decreasing morbidity ultimately related to noncompliance.

The Objectives

FLAGSHIP OBJECTIVE
OBJECTIVE 4.1. Slow the rate of new cases of end-stage renal disease (ESRD) by 10%. (Baseline: 337.91 per million West Virginia population in 1998)

Data Source: Mid Atlantic Renal Coalition (MARC)

According to preliminary MARC data, 583 new cases of ESRD were diagnosed in 1999; of these, the primary causes were diabetes, 49%; hypertension, 26%; glomerulonephritis, 12%; cystic kidney disease, 3%; and other causes, 10%. Some warning signs may include high blood pressure, swelling in the face and ankles, eye puffiness, rusty or brown urine, back pain just beneath the rib cage, or frequent urination.

OBJECTIVE 4.2. Increase to 40% the proportion of new hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access. (Baseline: 18.9%)

Data Source: National Kidney Foundation, Dialysis Outcomes Quality Initiative (DOQI), Vascular Access for In-Center Hemodialysis Patients: Preliminary Finding, 1999

Primary AV fistulas should be constructed in at least 40% of all new patients electing to receive hemodialysis as their initial form of RRT. The AV fistula is established by surgically attaching a person's artery to a vein. The increased pressure in the vein causes the vein to swell and the walls of the vein to strengthen. This provides the site to insert hemodialysis needles (fistula needles). Despite drawbacks in terms of cardiac load on the heart, the AV fistula is considered the "gold standard" of blood access. A primary AV fistula using the cephalic vein confers the best permanent access with the fewest complications, requires fewer interventions compared to other access types, and has a sufficient patency rate.

Advantages of AV Fistulas are:
Longest functional life
Lowest rate of infection and thrombosis
Predictable performance
Supported by a large body of literature

OBJECTIVE 4.3. Increase the proportion of dialysis patients awaiting transplantation to 50%. (Baseline: 21.4% of all ESRD patients in WV were awaiting transplantation in 1998)

Data Source: MARC data

Patient survival rates for kidney transplantation continue to increase. According to the United Network of Organ Sharing (UNOS) Annual Report, 1998 data reveals kidney survival rates at one year of 88% for cadaveric recipients and 94% for living donor recipients. UNOS reports that patient survival rates at one year at 94% for cadaveric recipients and 98% for living donor recipients. The cost of care for those patients who have a successful kidney transplant is significantly lower compared to ESRD patients on long-term dialysis.

Transplant referrals are monitored and reported by MARC annually. Of the 78.6% of all WV ESRD patients who were not awaiting a kidney transplant in 1998, 19.6% had been referred for evaluation, 19.1% had refused referral, 28.2% were medically unsuitable, and 11.7% were not established. In 1999, MARC Network 5 sent facility specific Transplant Referral Pattern reports to each dialysis provider. Each was asked to determine the need for educational programs or internal assessment to deliver complete transplant information to every medically eligible patient. It was noted that many patients in WV may have limited access to these services due to geographic location. There are currently only two UNOS transplant centers located in the state (Charleston and Morgantown).

OBJECTIVE 4.4. (Developmental) Increase the proportion of persons with Type 1 or Type 2 diabetes and proteinuria who receive recommended medical therapy to reduce progression to chronic renal insufficiency. (Baseline data available in 2001)

Data Source: West Virginia Primary Care Chart Audits from 1997 and 2000

The West Virginia Primary Care Chart Audits were performed by Marshall University Center for Rural Health in 1997 and 2000. Data exist on the 15 selected primary care clinics audited these years. These data were collected in order to compare diabetes care in West Virginia to data analyzed in 11 clinics in 1997. The sample group followed in 1997 was not the same sample group followed in 2000. A total of 1,200 charts were reviewed in 2000 compared to 991 charts in 1997. Health center staff, using a protocol developed by Marshall University, performed these chart reviews. Data were collected on annual foot and eye checks, flu shots, HbA1c x 2/year, lipid checks, average HbA1c value (actual value), lipid profile (actual value), tobacco use, and cessation offered.

Meeting the Objectives

Health Promotion Channels for Achieving Objectives:

• Worksites
• Schools
• Public Health Programs
• Networks
• Health Care System
• Higher Education

Some of the offices and organizations that are helping to lead the initiatives to reach the objectives include:

Diabetes Control Program, West Virginia
Bureau for Public Health (WVBPH)

National Kidney Foundation of the Virginias

Charleston Area Medical Center (CAMC)

Work Group Members

Carla VanWyck, RN, CNN, Nurse Manager, Renal Services, CAMC
Tammie Mitchell, RN, CNN, Clinical Management Coordinator, Renal Unit, CAMC
Karen Miller, RN, BSN, CNN, Program Director, Renal Services, CAMC
Peggy Adams, RNC, MSN, CDE, Diabetes Control Program Manager, Division of Health Promotion, WVBPH
Dr. Julian Espiritu, Jr., nephrologist, Charleston
Dr. Charles Schade, Medical Epidemiologist, West Virginia Medical Institute
Samantha Mullins, Regional Director, National Kidney Foundation of the Virginias
Dr. Mary Emmett, Camcare Health Education and Research Institute, CAM
Jennifer Bragg, MSW, Renal Transplant Social Worker, CAMC
Roy "Clint" Stover, Diabetic Transplant Recipient
Beverly Mann, Renal Services Dietician, CAMC

References/Resources

American Society of Nephrology.
www.asn-onine.org

Mid-Atlantic Renal Coalition. 1999 Annual Report Mid-Atlantic Renal Coalition ESRD Network 5. June 2000.

National Kidney and Urologic Disease Information Clearinghouse.
www.niddk.hih.gov

U.S. Department of Health and Human Services. Tracking Healthy People 2010. Washington, DC: U.S. Government Printing Office, November 2000.

For More Information

Diabetes Control Program
Office of Epidemiology and Health Promotion
350 Capitol Street, Room 319
Charleston, WV 25301-3715
Phone: (304) 558-0644; Fax: (304) 558-1553

This page was last updated June 12, 2001.
For additional information about HP2010, contact Chuck Thayer at (304) 558-0644 or Chuck.E.Thayer@wv.gov