This is a presentation given at the 2006 ASN Conference.

1. Lipid Outcomes and
Statin Use Anemia Outcomes
Blood pressure outcomes
Introduction Discussion
CKD (Chronic Kidney Disease) Clinics Improve Anemia, Lipids and Arrest the Decline of GFR
Gary G. Abud, Jr., Joel M. Topf, MD, Robert Provenzano, MD, FACP • St. John Hospital & Medical Center, Detroit, MI
Conclusion
In this study we documented that during enrollment in a CKD
clinic patients experienced improvement in blood pressure,
hyperlipidemia and anemia. All of these patients additionally were
concurrently treated by primary care physicians and variably
treated by other specialists. An important limitation of this study
was inability to attribute therapeutic changes and clinical
improvement to either the CKD clinic or other physicians.
While we didn’t find increased in the fraction of patients meeting
K/DOQI BP targets we did find dramatic improvements in blood
pressure, especially among patients with the worst blood pressure
readings on their first visit. The improvements in blood pressure
come from specific medications as we had significant increases in
the fraction of patients on ß-blockers, Ca channel blockers and
ACEi/ARB.
The anemia data shows significant increase in use of ESA matched
by a significant decline in the frequency of anemia.
We found increased use of statins in our patients and increased
meeting of K/DOQI lipid goals. The hyperparathyroidism data was
less compelling. PTH did not show much improvement despite
increased use of phosphorous binders and vitamin D.
Most importantly GFR decline approached zero and many patients
had improved renal function. This data is preliminary (less than a
year of follow-up) and it will be important to trace this data
forward to confirm that patients slow progression.
This study demonstrated that patients enrolled in a CKD clinic have
improvement in a broad range of CKD morbidities. Additionally
they show decreased progression of CKD, compared to historic
controls.
Patients enrolled in a CKD clinic had decreased blood pressure,
decreased anemia, and improved lipid profiles.
Hyperparathyroidism was not improved though we were able to
document intensification of treatment.
We conclude that dedicated CKD clinics offer valuable care to
patients with kidney disease that significantly helps them when
measured by objective criteria.
CKD clinics provide comprehensive care for
patients with renal disease. Though clinical
practice guidelines have been published to
systematize the treatment CKD and to
preserve renal function, there is little data on
the effectiveness of CKD clinics.
Knowing the effectiveness of CKD clinics is
important as running a CKD clinic requires
dedication of resources and changes in
practice patterns; without proven efficacy
nephrologists may be reticent to initiate them
and payers reluctant to reimburse them.
Anemia (Hgb<11g/dL) fell from
34% to 21% (P<0.0005).
Severe anemia (Hgb<10g/dL)
fell from 17% to 9% (p=0.002).
Use of Erythropoietic
stimulating agents (ESA)
increased from 12% to 31%
(P<0.0005).
0%
5%
10%
15%
20%
25%
30%
SBP >
150
SBP >
160
SBP >
170
SBP >
180
DBP >
90
DBP >
100
DBP >
110
DBP >
120
SYSTOLIC BP DIASTOLIC BP
First Visit Most Recent Visit
%ofPatients
Statin use increased from 53% to 60% and was
associated with a decrease in mean LDL (106 to
95, P<0.0005).
%ofPatients
%ofPatients
Purpose
We undertook this study to determine
how successful CKD care is in our clinic.
We looked at our success in treating:
We also looked at the overall
progression of renal disease.
Hypertension
 Anemia
 Secondary hyperparathyroidism
 Hyperlipidemia
Methods
Our CKD clinic is staffed by physicians, advanced practice nurses
and physician assistants. We see patients at three clinics in and
around Detroit, Michigan. The clinic incorporates patient
education, clinical practice guidelines, anemia protocols and on
going quality assurance to provide optimal CKD care.
We performed a retrospective analysis of the patients in our CKD
clinic after receiving IRB approval. All patients whose entire
clinical history was captured in an electronic database, and had at
least 2 visits, greater than 30-days apart, were included in the
cohort.
Analysis compared patient characteristics on the first day of clinic
to the same characteristics on the most recent visit.
Though the number of patients
whose blood pressure was at goal did
not change from first to most recent
visit (p=0.08), we did see a general
improvement in blood pressure.
We suspect this is due to the
significant increase in:
• loop (43 to 55%, p=<0.0005)
• ARB (23 to 28%, p=0.027)
• ß-blockers (62 to 66% p=0.032)
• non-dihydropyridine CCB (31 to 36% p=0.025)
2º Hyperparathyroidism
Outcomes
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
First Visit Most Recent Visit
Characterizing the cohort
The cohort was made up of 336 patients who were
diverse with respect to age, gender, race, diabetic
status and renal function.
Avg. Age Male Black Diabetes
CKD Stage 1 54.6 75% 50% 75%
CKD Stage 2 53.2 67% 67% 44%
CKD Stage 3 66.5 60% 31% 47%
CKD Stage 4 69.8 53% 27% 41%
CKD Stage 5 63.5 49% 49% 40%
Active
Vit. D
Calcitriol Hectorol Phos
Binder
On arrival to clinic patients generally had good PTH
levels, with 58% at goal. We were able to increase that
only to 64% primarily through the use of phosphorous
binders and activated vitamin D.
Renal Function Outcomes
We found no significant progression
of renal failure over the 256 days in
clinic with the average MDRD
decreasing by 0.19 mL/min/year
from 32.5 mL/min to 32.3 mL/min.