chronic renal failure - timely referral guide

8/8/2019 chronic renal failure - timely referral guide

http://slidepdf.com/reader/full/chronic-renal-failure-timely-referral-guide 1/47

Timely Referral in Chronic Renal

Failure

Guidelines in Context



How much renal failure is out there?

In 1998 there were 30,000 ESRF patients in theUK. (520 pmp)

Current take on rates for dialysis are approx 90-100 pmp

Future needs for the UK predicted as 120pmp or more

If no increase in take on rate there will still be40,000 ESRF patients by 2010

Potential 100% increase by 2010 if take onincreases





Incidence of Chronic Renal

Failure East Kent Study of unreferred CRF

± Opportunistic study of all creatinines from lab

± Males >180, females >135 (GFR <30-40)

± Excluding ARF and patients known to renal unit

± Prevalence 6400pmp, 85% unknown to renal

± cf renal unit patients- significantly older

70% of patients <80 with CRF are unknown to

renal unit



Who to refer and when?

I don¶t know

Not 6400pmp but more than at present?



PACE Guidelines for diabetes Refer when proteinuria >1g/24hours or

creatinine >150

Similar to renal association guidelines and

likely to be in the NSF

Likewise any unexplained renal failure

should be referred



Advantages of early referral to Nephrology

Delayed referral is associated with a

worse dialysis outcome

Complications of chronic renal failure need

careful multi-disciplinary management

Is dialysis preventable?



Late referral Referral within 4 (6) months of the need to

start dialysis

Common and the incidence is not falling

13/35 patients in Bradford 2001

µMany patients suffer a needlessly rough

journey on the road to dialysis¶

± Eadington, Nephrol Dial Transplant 1996



Late Referral QJM 2002

Bristol and Portsmouth 1997-8

38% new RRT patients referred late

Nearly half were µavoidable¶ late referrals

Poorer clinical state at start of RRT andlikely worse outcome



Late Referral Longer duration of predialysis

nephrological care does improve outcome

± Jungers et al 2001

How long is longer?



What are the benefits of earlier

referral?

or



Unadjusted 2yr survival of all dialysis patients in 97-98

40

50

60

70

80

90

10 0

N V G B X O D H T W C All

Centre

% s u

r v i v a l

AllUnadj2 yrsurvdial97-98



The DOPPS Study

To what extent does vascular access

account for mortality on dialysis?



Bradford Pre-dialysis audit 2001 13/35 patients referred late

Only 8/35 patients had their first dialysis

using a fistula

Late referrals seem more likely to be older,

diabetic, Asian




Delayed referral is associated with a worse

dialysis outcome

Complications of chronic renal failure

need careful multi-disciplinary

management




Complications of Chronic renal Failure

Anaemia

Bone Disease

Acidosis

Malnutrition

H

ypertension







Consequences of anaemia in

renal disease Symptoms

Increased cardiovascular morbidity and

mortality

Decreased quality of life

Impaired cognitive function

Decreased immune responsiveness



Left Ventricular Hypertrophy and

Survival

Silberg 1989



Pre-dialysis epo When should patients start epo therapy?

When they start dialysis?

± After months of anaemia and with LVH

When they become anaemic pre-dialysis?

Could we prevent anaemia from ever

developing?



Bone Disease

Hypocalcaemia due to reduced active Vitamin D Hyperphosphaemia due to reduced renal clearance

Leads to Hyperparathyroidism

Management: Dietary intervention

Calcium supplements/ phosphate binders

1E-calcidol

Exercise

± Beware of hypercalcaemia, ? New phosphate binders

Calcium Phosphate product

± Last (not uncommon) resort is surgery



Nutrition Poorer nutritional status especially if elderly

Reduced absorption

Shift from protein to carbohydrate

Reduced fluid intake

Indices of nutrition are linked to poorer survival

Management must be aggressive Dieticians

1g/kg/day protein

Energy

Relax dietary restrictions if patients at risk

Intra-dialytic TPN

Supplements

Earlier start to dialysis




Delayed referral is associated with a worse

dialysis outcome

Complications of chronic renal failure need

careful multi-disciplinary management




Is Dialysis Preventable Reversible causes of renal failure

Can we do anything about µnon-reversible¶

causes

± In other words challenge the notion that they

are non-reversible

± Type 2 Diabetes Is Type 2 diabetes preventable?



Reversible causes of declining

renal function Urinary tract obstruction

Urinary tract infection

Systemic hypertension Drugs

Cardiac failure

Metabolic abnormalities

± hypercalcaemia

Immunological disease

Pregnancy



Ultrasound is mandatory in any case

of unexplained renal failure



Hypertension

Vicious circle relationship between hypertensionand renal impairment

Optimum control of Blood Pressure delays progression of renal disease (<130/85)

ACE inhibitors seem better than other antihypertensive agents

± Anti-proteinuric ± Anti-fibrogenic

Which leads me onto



Drugs NSAIDS

Diuretics

Interstitial nephritis, especially in the

elderly

ACE Inhibitors



ACE Inhibitors- hero or villain? The typical vascular surgery patient

± Elderly

± Previous CVA and angina ± NIDDM

± On Frusemide, lisinopril and brufen

± Acutely ischaemic leg

± Fasted from admission

± Angiogram

± Nephrology consult

Like most disasters ARF is usually µmulti-hit¶



Nephrology and ACE inhibitor is

a strange relationship Most of our patients should be on them

We must be vigilant, renovascular disease is

common

ACE inhibitors (and diuretics) should often

be suspended in the face of intercurrent

illness



Suggested Guidelines Screen for risk factors

Age, PVD, low cardiac output, NSAIDs, high dose diuretics

Check renal function before and at 7-10 days Check renal function regularly in those with risk

factors (annually)

Assess if intercurrent illness or change in drugs

Consider withdrawal if creatinine increases toabove normal range or by 25% but for some thereis an important risk-benefit question



Immunological diseases causing renal

failure

Can occur at any age

Most have a high liklihood of response to

immunosuppressive therapy Relapses are not uncommon

± Wegeners

± Polyarteriitis

± Lupus ± Rheumatoid

± Goodpastures

Urinalysis will be abnormal in the presence of

active glomerulonephritis



Forget the smallprint

Lets get back to diabetes!



PACE guidelines for Diabetes

2002

Renal/Hypertension



Key Points from the Guidelines Proteinuria/ microalbuminuria

ACE Inhibitors

Early referral

± Creatinine (>150)

± Proteinuria (PCI >1000)



Earlier referral should improve

subsequent mortality/morbidity

of patients with ESRF due todiabetes



Or is there another way?



Is diabetic nephropathy

preventable? Tight control

Blood pressure

Proteinuria

ACE inhibitors

Lipids

Smoking cessation



Blood pressure and proteinuria Reducing blood pressure slows the rate of

disease progression

Superiority of ACE Inhibitors ± Lewis et al NEJM 1993, Captopril

Proteinuria is not just a disease marker but

is pathogenetic Reduction in proteinuria slows progression

± Reviewed in lancet editorial 1999, DeJong et al



Blood pressure and proteinuria Hovind Kidney International 2001

Normal progression of DN 10-12ml/min/year

7 year study of 300 type 1 patients

31% remission

22% regression (GFR decline 1ml/min/year)

Even in this clinic many patients do not achieveBP targets



Smoking and Lipids Meta-analysis suggests that lipid lowering

can preserve GFR

Renal function declines twice as fast in

smokers

± This is under appreciated by patients and

doctors

Progression, remission, regression of chronic renal disease

Ruggenenti, lancet 2001: 357



The final common pathway

We have got to get on the case before this!



W

hy are patients referred late? Ignorance of the value of early referral

± Nephrologist = Dialyser?

Ambivalence about µhigh-risk¶ patients ± At all levels of renal impairment referral rates are

higher for lower risk patients

Under-estimation of severity of renal failure

± 50% of patients with creatinine >500 require dialysiswithin 3 months

High risk patients progress more rapidly andtolerate uraemia less well





Is Dialysis for everyone? The Stevenage experience

Pre-dialysis counsellors make a

recommendation of dialysis or conservative

treatment

Conservative treatment is active

?no difference in outcome



Age does not feature in any guidelines

We would have dialysed if asked

Documents

chronic renal failure - timely referral guide