IQ:CKD Spring 2009

There’s a sort of Zen-like quality about

Dr. Eric Gardner as he discusses what he

does for a living and why he does it.

Having renounced the glamour of per-

forming cardiovascular surgery, he now

spends three days a week performing a sur-

gery that makes life more bearable for pa-

tients needing dialysis. He is a vascular

surgeon who specializes in performing arte-

riovenous fistula (AVF) placement.

In 2007 Gardner moved his Collierville,

Tenn., practice’s focus to be strictly on pa-

tients needing vascular surgery, primarily

AVFs. “When you focus on one niche, you

end up getting very good at it,” he said.

“I saw a need where dialysis patients

were getting upset, because most of the sur-

geons performing dialysis access surgery typ-

ically had more pressing operations that took

priority, often resulting in long patient wait

times for appointments and ultimately sur-

gery,” he said. “The Mid-South has a tremen-

dous population of dialysis patients with

untreated hypertension and the gamut of

renal disease. No one really focused on these

patients in giving them the attention and serv-

ice that they deserve.”

Patient EducationMost patients who arrive at Gardner’s of-

fice know why they are there. Their nephrol-

ogist has prepped and educated them on the

need for dialysis. Once there, Gardner dis-

cusses access options and preliminary steps

that need to be taken.

“A fistula is always the first goal,” he

said, when it comes to discussing access op-

tions with patients.

He reviews the various placement op-

tions for a fistula, but prefers to place a fistula

as far from the heart as possible. He explains

to patients that an access further away from

the heart (such as at the wrist) prolongs lives

by saving the bigger veins and allows for

more “real-estate” for future access needs.

Gardner typically sees 30 patients a day,

twice a week and spends the remainder of the

week doing surgery. Of those 30 patients, 8

to 12 are new patients. Most of these patients

are going into surgery for fistula placement.

Fistula creation usually takes Gardner an

average of 30 minutes and is an outpatient

procedure. “I usually tell my patients they

can resume their normal activities later that

day,” he said, with an average total time of 4

to 8 hours including surgery and recovery.

One of the hardest parts of what he does

is getting patients to understand and accept

what is happening and overcome their fear.

It is also one of the best parts. He usually

does a comparative analysis of a patient with-

out a fistula and another patient with a fistula.

“Patients who receive their first dialysis

treatment with a fistula live longer, have a

better quality of life, have fewer hospital vis-

its, fewer infections and less costs,” he said.

“That usually convinces them. That and the

fact that fistula placement is usually a simple

procedure to recover from quickly.”

Fistulas are preferred to catheters, he

said. Catheters extend outside the body, lead

to infection and need replacement.

“Having a catheter or graft is less desir-

able than having a fistula,” he said, in regards

to fistulas being considered the “gold stan-

dard” for vascular access. “I’m able to do the

complete range of dialysis access procedures,

but knowing how important access strategy

is for a dialysis patient, I try to exhaust all

possibilities for a fistula before I put in a

catheter or graft. It’s a quality of life factor.

The patient with a fistula typically has fewer

complications and dialysis is more effective

and efficient.”

Draw a MapThe biggest challenge he and most vas-

cular surgeons face is locating a suitable site

for fistula placement as many patients who

make their way to his office have often had

2 IQ:CKD Spring 2009

multiple vein punctures. Nephrologists are

good about identifying patients that may

need dialysis and educating patients on sav-

ing their arms and/or veins. The non-domi-

nant arm is usually the one chosen for

fistula access.

“Many elderly patients or those that

have (vascular) trauma from multiple punc-

tures for IVs and blood draws typically will

have scarred or nonexistent veins, making

it that much more difficult to create dialysis

access and have a fistula,” he said.

The key to Gardner’s success is having

an ultrasound unit in the exam room with

the patient. He is able to examine the pa-

tients’ veins and arteries to make sure they

are suitable for a fistula and to identify any

kind of abnormalities that may exist preop-

eratively that might otherwise have resulted

in postoperative failure.

“I’m looking for scarred veins, veins

that are too small or areas of the vein that

won’t dilate,” he said.

Gardner says he draws pictures to

“map” his operation out, so he knows what

he is doing for a particular patient. Fistula

failures have occurred because surgeons did

not do vein-mapping or use ultrasound to

determine vein integrity. Nationally, the

failure rate of fistulas has decreased.

Many of his patients have been told by

other physicians that they have exhausted

all options for vascular access. However,

there have been very few patients he has

had to turn away because of a lack of viable

choices.

“Having preoperative studies and ultra-

sounds has raised my rate of success

tremendously,” he said. “The fact that I’m

doing it myself is so much more valuable.”

The Challenging PartWhat could prove even more valuable

to the success of an AVF is identifying pa-

tients in the early stages of CKD.

Many of his patients have been referred

beyond the time needed to appropriately

allow for fistula placement because many

of these patients were not aware that their

kidneys were failing prior to their need for

dialysis.

However, the trend is changing thanks

to the Fistula First Initiative and the Kidney

Disease Outcomes Quality Initiative

(KDOQI) Guidelines. The Guidelines di-

rect physicians on providing appropriate

care for all stages of CKD, related compli-

cations and dialysis. Gardner said he is now

seeing more patients earlier with Stage 3

and Stage 4 CKD instead of receiving them

at the final stage (Stage 5).

Early detection and prevention is the

key to a patient’s care, especially if the pa-

tients are on a path to eventually see him.

“I mostly get referrals from nephrolo-

gists,” he said. “But I would like to see

PCPs (primary care physicians) refer pa-

tients as well.”

According to Gardner, one main reason

PCPs aren’t making referrals is that they

may not know what to look for in terms of

renal function. When a CKD patient’s cre-

atinine clearance is 15 to 30 percent, the pa-

tient needs to be referred to a surgeon as

this signifies that patients have entered

Stage 3 and Stage 4 of the disease.

Gardner encourages physicians to take

preventative steps by monitoring the con-

ditions that can lead to CKD — such as di-

abetes and hypertension. Patient education

is necessary in the early stages.

Not About MoneyWhile a fistula may be the “gold stan-

dard” for dialysis access, it hasn’t been a

gold mine for physicians.

Historically, those surgeons who have

placed fistulas have made less, because

Medicare paid less for them even though

they are harder to perform and work better,

Gardner said.

Reimbursement for fistulas is not as

much as a graft or a catheter. The downside

is that complications resulting from grafts

and catheters can lead to more procedures

to correct new problems.

However, Medicare has recently in-

creased reimbursement of fistula placement

by 30 percent which may result in an in-

crease of surgeons who perform the proce-

dure.

“I’m much happier doing the right

thing for the patient and not compromising

my beliefs that fistulas are the right thing

to do,” he said. “It’s not the glamorous sur-

gery, but my workday is done by 3 p.m., I

spend more time with my family and I have

healthy and happy patients.”

IQ:CKD Spring 2009 3

An apple a day for chronic kidney disease (CKD)

patients could have more benefit than Benjamin

Franklin first supected when he wrote the saying in

the Poor Richard’s Almanac.

Good nutrition is essential to a CKD patient’s

overall health and chomping on an apple (or other

healthy food) can make all the difference when

preparing for a fistula and after its placement.

Early Placement Early fistula placement can have a major impact

on nutritional outcomes in the early stages of dialy-

sis for several reasons, as malnutrition is a major

factor contributing to morbidity and mortality

among CKD patients.

The proportion of CKD patients that have protein

energy malnutrition is substantial. Several studies

have documented that 20 to 60 percent of patients

on hemodialysis are malnourished, especially in the

first 90 days of treatment. Malnourished patients

suffering from a lack of appetite, a manifestation of

uremia, initiate dialysis with a higher risk of hospi-

talization and mortality.

Dialysis AdequacyPatients with mature fistulas at the initiation of

dialysis will achieve better Kt/V results. According

to the National Kidney Foundation’s Kidney Dialy-

sis Outcomes Qualitity Initiative (KDOQI) Guide-

lines, Kt/V is a number used to quantify

hemodialysis and peritoneal dialysis treatment ade-

quacy. In medical equations, K is dialyzer clearance

of urea, t is dialysis time and V is the patient’s total

body water.

Normalized protein catabolic rate (nPCR) is a

parameter that has been widely used as a marker of

protein intake. Research has shown that protein cata-

bolic rates increase linearly with the Kt/V indicating


patients are more adequately nour-

ished when they are well dialyzed.

The improvement in nutritional

status is likely indicative of an in-

crease in protein intake as a result

of an improved appetite because

the patient’s blood is more thor-

oughly cleaned.

Counseling the patient to in-

crease dietary protein intake will be

ineffective if the patient is receiv-

ing poor dialysis.

It is imperative that a patient

gets a good start with a fistula to

achieve dialysis adequacy, but also

to help fight infection and inflam-

mation.

Inflammation suppresses ap-

petite, increases muscle catabolism,

and can result in progressive

cachexia. Infection and nutritional

status have been shown to be inde-

pendent predictors of hypoalbu-

minemia in dialysis patients.

Infection RateInfection creates a downward

spiraling cycle that affects the nu-

tritional status of the kidney pa-

tient. The increased risk of

infection with catheters will lower

albumin levels in CKD patients and

places them at risk for malnutrition.

In turn, low albumin levels

make it difficult for patients to

fight infection.

For patients initiating dialysis,

a mature fistula affects the infec-

tion/nutrition cycle in a positive

way, due to a lower rate of infec-

tion and improved appetite through

adequate dialysis.

Serum albumin levels are used

extensively to assess the nutritional

status of CKD patients. One of the

most powerful predictors of sur-

vival in the first 90 days of dialysis

treatment is an albumin level of

less than 30 g/l.

This makes hypoalbuminemia

highly predictive of future mortal-

ity risk, both at initiation and

throughout the course of mainte-

nance dialysis.

Best PracticesGetting patients involved in the

maintenance of their health at the

earliest stage possible is very im-

portant. Patients should be encour-

aged to attend annual Kidney Early

Evaluation Program (KEEP)

screenings, CKD options classes

provided by most dialysis compa-

nies and health fairs.

In order for patients to achieve

early fistula placement, early refer-

ral is essential. Primary care physi-

cians should refer their patients to

a nephrologist early upon diagno-

sis. This will allow for vein map-

ping and identifying patients who

are candidates for fistula place-

ment.

Patients are also recommended

to receive nutritional education by

a renal dietician. Dieticians can

help manage comorbidities con-

tributing to kidney failure such as

diabetes and hypertension and en-

sure appropriate intake of calories

and protein to maintain a healthy

weight and prevent malnutrition.

Dieticians can also provide ed-

ucation on sources and optimal in-

take of antioxidants to decrease

inflammation, as well as on chang-

ing sodium, potassium, phosphorus

and fluid needs as the patient pro-

gresses through the stages of CKD.


Nephrologist Dr. Vo Nguyen got his wake-up call about

vascular access in 1996.

Actually, it was a triple wake-up call, according to

Nguyen, medical director of Aberdeen Dialysis Center, Renal

Care Group of the Northwest, Olympia, Wash., and member

of the American Society of Diagnostic and Interventional

Nephrology.

His dialysis group got a warning letter from the Medical

Review Company about a high rate of hemodialysis arteri-

ovenous (AV) graft failure among end stage renal disease pa-

tients on chronic hemodialysis.

Then vascular surgeon partners balked at the need to in-

tervene when AV grafts thrombosed — sometimes at mid-

night after all the day’s scheduled operations were

completed. And he was shaken by the generally poor patient

outcomes from dialysis catheters and grafts, which are more

prone to severe infection.

Nguyen, who had always considered AV access as the

concern of the surgeon rather than the nephrologist, went to

surgeon Chris Griffith and asked for help. Working with

Griffith and other members of the dialysis team, they created

a program to shift from grafts to fistula as the standard AV

access — an unusual strategy, compared to the standard of

practice in the United States.

Why AV Fistula?Like most nephrologists, Nguyen did not have formal

training in AV fistula creation and had gone with AV grafts

as the default because they are simpler and quicker to create

than fistulae. To create an AV fistula, a surgeon needs a well-

mapped target for joining an artery and a vein, and it typi-

cally takes weeks or months for the fistula to mature before

use.

"Who wants to spend six months waiting?" says Nguyen.

Studies show, however, that AV fistula achieve a higher

survival rate than AV grafts, with less thrombosis and infec-

tion. Nguyen also knew that most European dialysis patients

receive fistula.

Making the transition became a "true passion" for

Nguyen, as he describes it. Griffith helped him understand

the vascular surgeon’s information needs and operating pro-

cedures. Nguyen also read extensively about AV access and

talked with European nephrologists during several visits

there and online with Renaliste, an email distribution list for

Francophone nephrologists. Key nursing staff volunteered

to learn the sometimes forgotten art of cannulating fistula,

including the Buttonhole technique, and trained others.

The program proved highly successful, with all dialysis

patients with failing grafts converted to secondary fistula by

the year 2000 and all new patients starting dialysis with fis-

tulae. A more recent survey showed that 98 percent of

Nguyen’s patients had fistula, with greatly reduced use of

catheters.

Steps for ChangeAs part of the system change process, Nguyen and his

team noted several things that needed to take place for the

new standard to be a success and recommends them for oth-

ers to consider.

Recognize that this is a team effort. It requires collab-

oration and trust, not just between nephrologists and sur-

geons, but with nursing staff, other dialysis team members,


primary care physicians, and patients and their families.

The nephrologist must play a central role. In addition to co-

ordinating the effort, nephrologists must have a thorough under-

standing of Doppler analysis and other vein mapping techniques,

surgical options for creating fistula, and cannulating techniques.

Make a roadmap. Establish an outline for the effort.

Prepare for the fistula long before it is needed. Ideally, a re-

ferral should be made at least six months before dialysis is needed.

Establish a relationship of trust with primary care physicians.

Nguyen’s nephrology group started with a letter sent to local pri-

mary care physicians, to encourage early referrals. Building this re-

lationship, according to Nguyen, is "a lot of work; a simple letter is

not going to do it."

Educate patients and their families. Patients don’t want to

hear about the operation when they do not feel sick and yet early

surgery for fistula is key to success. "I spend a lot of time talking to

patients and their families," Nguyen says. "I always invite the whole

family to come to the first visit. Convince the family, and they will

beat on the patient to do it." It’s important to explain the procedure

in very simple terms, he said. "I tell them the [result] is just like

varicose veins, the uglier the better. A fistula is like car insurance:

we hope that we’ll never need to use it, but we’ll be glad to have it

in case of an accident."

Set expectations properly in case the first operation doesn’t do

the job, since we are dealing with sicker and older patients with

higher risk of fistula failure to mature properly, we tell them that

another surgery may be needed. In addition, patients must learn to

protect all veins that may be needed for future fistula construction:

needle sticks are allowed only in hand veins.

Use new surgical approaches when needed. Patients who are

older or obese may need special procedures, including transposition

of deep upper arm veins. Small anastomosis size helps to prevent

steal syndrome (hand ischemia after fistula creation).

Stop revising failing grafts and convert all existing grafts into

secondary fistulas using long term vascular access planning.

Encourage home peritoneal dialysis. Late referral patients are

encouraged to consider home peritoneal dialysis until the fistula ma-

ture in order to avoid the use of hemodialysis catheters which are

the worst dialysis vascular access.

Maintain a checklist for each patient. The AV Access Check-

list for Nephrologists documents key material for a surgical plan,

including mandatory preoperative vein mapping for all patients.

Educate staff. Proper training in AV access is key for all team

members. That’s a particular issue, in Nguyen’s opinion, because

historically "there’s been no training whatsoever in vascular access

for nephrologists and not much for surgeons." Graft cannulation is

very different from fistula. Dialysis staff are more familiar with graft

cannulation, since the majority of vascular accesses in use in this

country are grafts. Training in fistula cannulation is the key of a suc-

cessful fistula program.

Monitor results as part of a comprehensive quality care control

program. Maintain and analyze statistics on AV access by the

nephrologist, surgeon, and dialysis unit to encourage change in prac-

tice behavior.



The pressure is on for states and providers to adopt health infor-

mation technology (HIT) and the recently passed economic stimulus

package provides at least partial funding.

Under the American Recovery and Reinvestment Act (ARRA),

approximately $19 billion has been allocated to Medicare and Medi-

caid programs for the purpose of increasing reimbursements to hos-

pitals and physicians who become meaningful electronic health record

(EHR) users.

According to the ARRA, if a physician or hospital becomes a

meaningful EHR user after 2014, they are not entitled to any incentive

payments.

In order to become a meaningful EHR user under the Medicare

program and qualify for full payment of stimulus dollars, providers

must demonstrate that they are using certified EHR technology.

The technology must be connected in a manner that provides for

the electronic exchange of health information to improve the quality

of health and they must submit information on clinical quality meas-

ures.

Incentives will begin in 2011, with those achieving meaningful

adoption receiving incentives for up to five years. The maximum

available for those qualifying in 2011 is $44,000. After 2014, anyone

who treats Medicare patients without an EHR will see reimbursements

decrease by 1 percent that year. The pay cut grows to 2 percent in

2016 and 3 percent in 2017 and every year afterwards.

Last year, Congress applied the same carrot-and-stick approach

to e-Prescribing in the Medicare Improvements for Patients and

Providers Act of 2008 (MIPPA). Those who e-Prescribe in 2009 and

in 2010 qualify for a 2 percent raise based on their total Medicare rev-

enue.

The bonus decreases to 1 percent in 2011 and 2012, to 0.5 percent

in 2013, and then disap-

pears (physicians who

receive the EHR bonus

cannot receive the e-pre-

scribing bonus). MIPPA

also imposes a 1 percent

penalty on physicians

who do not begin e-prescribing by 2012. The penalty increases to 1.5

percent in 2013 and to 2 percent in 2014 and beyond.

Details of the Medicaid health IT dollars are not as clear, but

under the Medicaid incentive program, a larger group of medical pro-

fessionals are eligible for the funds, as long as they serve a sufficient

percentage of Medicaid patients.

Unlike Medicare, which only funds doctors and hospitals, eligible

professionals under Medicaid include a physician, dentist, certified

nurse mid-wife, nurse practitioner, and a physician assistant serving

in rural health clinics or federally qualified health centers. Medicaid

payouts are also more significant.

Across five years, practitioners could collect a sum total of

$64,000. This is a maximum total based on paying up to 85% of ex-

penses for an EHR purchase. The first year reimbursement is equiv-

elent to 85% of up to $25,000 for the purchase of an EHR and each

subsequent year (up to 4) is paid at 85% of up to$10,000.

To be eligible for the Medicaid incentive payout, physicians must

have a 30 percent Medicaid patient case load or 20 percent for pedi-

atricians.

According to a U.S. Department of Health and Human Services

report, only 1.5 percent of hospitals nationwide use an EHR and the

number is in line with Tennessee hospital implementation.

However, e-Prescribing or eRx (the ability to electronically order

prescriptions) use in Tennessee has increased by 749 percent since

2006. During 2008, 1,950 Tennessee healthcare providers issued 1.5

million electronic prescriptions, representing 3 percent of all prescrip-

tions written in the state.

“The sheer number of e-prescriptions speaks volumes to the po-

tential for physicians and hospitals that have yet to implement an

EHR,” said Jennifer McAnally, Health Information Technology Pro-

gram Manager for QSource. “In this instance, time literally is money.

The longer a hospital or physician chooses to wait to implement HIT,

the less money they could receive. QSource has helped 300 physician

offices implement an EHR and e-prescribing.”

Hospitals and physicians interested in learning more about the

Medicare physician HIT stimulus program can contact McAnally at

[email protected] or 800.528.2655 ext. 2635.

As the chief medical officer for the National Kidney Foundation,

Joseph Vassalotti, MD, FASN, is on a mission to “demystify” Chronic

Kidney Disease (CKD), and he believes QSource can be a valued partner

to aid his cause.

Vassalotti, an associate clinical profes-

sor of medicine at Mount Sinai School of

Medicine, helped systematically develop

the Kidney Foundation Outcomes Quality

Initiative (KDOQI) guidelines to assist

practitioner and patient decisions about ap-

propriate healthcare for CKD.

The KDOQI guidelines have improved

the lives of thousands of kidney patients

since their creation in 1997. However, even

more healthcare professionals need to know

about the guidelines; and, that is where

QSource’s assistance is most needed, he

said.

“I believe the QIOs have a great opportunity,” said Vassalotti.

“QIOs can help educate primary care physicians (and their staff) about

the guidelines and provide technical support for primary care practices’

utilization of the KDOQI guidelines.”

Guidelines Help Providers Improve CareThe KDOQI guidelines, which were initially developed because of

the high mortality of patients on dialysis, were needed because of con-

fusion about the disease and its progression. For example, there were 23

different terms used to describe decreased kidney function in abstracts

submitted in 1998 and 1999 to the American Society of Nephrology

(ASN).

“Obviously this was very confusing — even to someone

who knew the field. These terms would not allow for a con-

certed public health approach to CKD,” said Vassalotti. “If

nephrologists could not agree on what CKD is, what could we

do in terms of a public health approach or a patient awareness

approach?”

He said, after more than a decade since the guidelines were

first published, this “nomenclature mess” has been cor-

rected. There is widespread agreement about the def-

inition of CKD and the association of

complications of the disease with stages 1-5

based on GFR levels estimated from serum

creatinine. The clinical practice guidelines

address evaluation, classification, and strat-

ification.

Challenges Still ExistHowever, there are still significant

challenges with the implementation of

the guidelines. On a recent teleconference,

Vassalotti outlined some of the barriers

QSource may be able to help provider and

partners overcome. He shared research that

illustrated poor utilization of CKD testing.

“There were higher rates of glucose and lipid testing than serum

creatinine. These low creatine testing rates suggest the importance of

more physician education,” he explained.

Vassalotti acknowledged some primary care physicians are still con-

fused about CKD testing. However, evaluation of laboratory measure-

ments for the clinical assessment of kidney disease is occurring now.

“A national standardization program is being undertaken by the Na-

tional Institutes of Health (NIH) to standardize serum creatinine testing,”

he said. “There are so many tests that the physician can pick: the NIH is

trying to standardize not only the laboratory measurements but also this

byzantine list of different tests for urinary albumin which is confusing

for primary care physicians.”

He explained that urinary albumin to creatinine ratio is recom-

mended because it is “more quantitative and more accurate than others.”

The QIO’s specific goal is to increase the adoption of evidence-

based standards to identify CKD in Medicare patients through an annual

urinary microalbumin measurement for individuals with diabetes.

Vassalotti’s recommendations are clear. He stressed that CKD is

poorly inferred from serum creatinine alone. He strongly encourages

clinical laboratories to routinely estimate and report GFR when serum

creatinine is measured. Routinely reporting estimated GFR (eGFR) with

all serum creatinine determinations helps identify reduced kidney func-

tion for providers, and thus facilitates the detection of CKD.

“It is very important that these tests are to be used together. These

are complementary tests — not alternative tests — you can’t substitute

one for the other. GFR is not the

only test,” said Vassalotti.



Documents

IQ:CKD Spring 2009