According to reports from the National Health and Nutrition Examination Survey, 20 million people in the United States may have chronic kidney disease (CKD). Anemia is a common complication associated with CKD, and often leads to adverse cardiovascular events and decreased health-related quality of life. Recently, a study evaluating a multidisciplinary clinical treatment approach was undertaken at university-affiliated CKD clinics. The goal of the study was to assess how a reengineered clinic and redefined clinical roles of the health care team could improve the care of patients by meeting the National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI).

In the study, 166 patients with anemia of CKD received darbepoetin alfa dosed on an every-other-week basis, as well as oral iron supplements. Dosage amount and frequency were adjusted to achieve the K/DOQI targets for hemoglobin (>11.0 g/dL) and iron measures (transferrin saturation of 20% or greater; ferritin of 100ng/ml or greater). Primary outcome was measured as the number of patients with at least 30 days of treatment who achieved the target hemoglobin level or greater. Of the patients in the study, 52% were female, and most were Caucasian (50%) or African-American (45%) with a mean age of 62 years. The multidisciplinary team included a clinical pharmacist, a supervising nephrologist, a clinical nurse, a vascular access nurse, and data managers.

Of the original 166 patients, 128 patients received at least 30 days of treatment. In this treatment group, 100 (78%) reached the target hemoglobin level. Also, 99 of the original 128 patients were naïve to previous attempts of recombinant human erythropoietin therapy. Of these 99 patients, 77 (78%) achieved the hemoglobin target in an average of 7 weeks. Furthermore, 60% of patients receiving oral iron administration throughout the 30-day treatment and beyond reached K/DOQI targets in hemoglobin, ferritin, and transferrin levels.

The results of this study show how a reengineered clinical practice using a multidisciplinary treatment team can improve the management of CKD. A multidisciplinary approach can better assure timely therapy with darbepoetin alfa and oral iron, increase the appropriateness of patient referrals, and improve monitoring of laboratory tests. The continuity of care is increased in a multidisciplinary approach because patients tend to see their clinic providers more frequently than their primary care provider and receive prompt dosage adjustments and vigilant monitoring of hemoglobin and iron levels. This approach provides a well-planned and directed clinic that offers improved patient care in not only anemic patients, but in all CKD-related complications.

Reengineering clinical operations in a medical practice to optimize the management of anemia of chronic kidney disease. Joy MS. Candiani C. Vaillancourt BA. Chin H. Hogan SL. Falk RJ. Pharmacotherapy. 27(5):734-44, 2007 May.

NAAC Expert Commentary:
The authors of this publication have provided us with evidence for concepts that would normally be intuitively expected. In this time of evidenced based medical decision making, this type of study is helpful because it turns intuitive assumptions into actual outcome proven facts.

Chronic kidney disease (CKD) affects over 20 million Americans, and the associated co-morbidity of anemia is a common complication, which carries with it the additional increased risk of cardiac compromise and reduced quality of life. The authors' goal of modifying the university-based clinic structure to test the premise that this would improve anemia management was successfully born out.

The study of 166 CKD patients with anemia demonstrates that in a clinical setting where designated staff members have described responsibilities, including attention to anemia care, the patient outcomes improve. The clinical setting described brought to bear an impressive team of healthcare providers whose goal was to monitor and intervene in order to resolve the anemia demonstrated in these CKD patients.

This clinic concept should be helpful to private sector therapists involved in managing CKD anemia. However, modifications to the study approach would likely be required because of the difference in resource availability and the economic realities of private practice patient care. Prospective studies evaluating patient outcomes in private practice clinics where similar efforts were undertaken would be useful in providing evidence which might demonstrate cost savings and encourage third-party payers to adopt and promote similar care models. This study, in order to increase attention, would benefit from a larger patient sampling. This wider audience would increase its care planning impact and the degree of its influence on anemia intervention.

Last Updated: September 1, 2007