Renal Take Action Clinic

Chronic Kidney Disease by Numbers

In a world where even the semi health-conscious know their blood pressure and cholesterol numbers, a Central Texas nephrologist would like to see another figure added to the equation: The GFR.

That's the glomerular filtration rate.

"It doesn't roll off the tongue," acknowledged Scott & White Nephrology Division Director, Dr. Charles Foulks. "But that number can help determine if you have chronic kidney disease."

The Renal Take Action Clinic
Dr. Foulks and Scott & White are leading the way when it comes to discovering and treating chronic kidney disease. The nephrology team has devised a program – the Renal Take Action Clinic – that encourages doctors to determine their patients' GFR. This clinic is a result of a national effort by the National Kidney Foundation to inform doctors and the public about this silent killer.

"Chronic kidney disease is a huge epidemic," Dr. Foulks noted. "Thousands of Central Texans are likely in the late stages of the disease and have not recognized the condition – and they certainly have never seen a nephrologist."

The GFR Calculator
The Renal Take Action Clinic, which began in 2004, has placed a GFR calculator in the hands of Scott & White primary care providers. The small device makes easy work of a complex formula that incorporates serum creatinine levels with other body factors like age, weight, race and gender. Calculating the GFR is the best way to determine stages of kidney disease. Amgen and Ortho Biotech, two large companies that provide medicines to patients with chronic kidney disease have supported the distribution of these calculators.

A GFR over 90 is considered normal. As the number falls, so does kidney function.

A Silent Killer
Like other "silent killers," the symptoms of chronic kidney disease, which may include a loss of appetite, weakness, itching and swelling, often don't show until the later stages of the disease. Even then, they are often chalked up to "getting older." What's more, small changes in the creatinine level alone may not signal a red flag among doctors.

But small fluctuations, when taken with other factors, can have a large impact on the GFR. That's why Dr. Foulks continues to push the use of the GFR calculators. "If we can find the disease early we can help you. If we find it late, we can only get you ready to start dialysis."

Diagnosis and Successful Treatment
Handing out the calculators and educating family practitioners has had a major impact on patients. For some, it has saved their life. "This has made a huge difference in finding people who may be in trouble," Dr. Foulks said. Through the routine screening, nine patients, who had not shown any symptoms, were diagnosed with kidney cancer and successfully treated through surgery. "This is something that has not always been available to patients. The patients are being identified earlier in their disease process, educated and treated. Thus preventing many from ever having to make the decision of having to be placed on dialysis to live."

Urgent Need for Nephrologists
To deal with the growing number of patients, the Scott & White program has delved into the education realm to expand the number of providers who can effectively care for them.

"The number of patients is exploding and the number of upcoming nephrologists is decreasing. We nephrologists have faced the unpleasant reality that we won't live forever and it might be nice to retire at some point," Dr. Foulks said.

To boost the level of caregivers, Scott & White started a nephrology fellowship program, but realized that two fellows each year would make only a small dent in the problem. Incorporating mid-level providers, like physician's assistants, registered nurses and nurse practitioners seemed like a logical solution to expand care.

"Unfortunately, there were no formal renal education programs that can prepare mid-level practitioners for a nephrology practice," Dr. Foulks said. With that realization, the group, with the help of some grants, set out to develop an on-the-job training program that would standardize therapy in order to decrease variations in outcomes.

The results have been successful – with Scott & White's dialysis units consistently ranking in the 99th percentile in outcomes. Hospitalization rates are half of the national outcomes.

"It takes hard work by several people to make this a success," Dr. Foulks noted. "It can't be done by a single doctor or primary care provider."

A Model for other Healthcare Organizations
The Renal Take Action Clinic may also serve as a model for other healthcare organizations, Dr. Foulks said. A patient education booklet and the training guidelines already have been well received by other providers and institutions. Dr. Foulks presented the Scott & White model to a meeting of dialysis providers in Chicago last month, and the National Kidney Disease Evaluation Program has expressed interest in the education program and the clinic.

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