Outcomes for unplanned startDr Peter RutherfordMedical Director – Europe, Middle East and Africa, Baxter Healthcare SA, Zurich

Visiting Professor, Glyndwr University, Wales

Outline of talk

Set the scene around the challenges of Unplanned

Start

• Unplanned start to dialysis is still common and a major therapeutic • Unplanned start to dialysis is still common and a major therapeutic

challenge for all renal units

• It is associated with worse outcomes and most patients will remain on

a hospital based therapy and not receive a choice of dialysis

• The use of central venous catheters (CVCs) is a major driver of this

poor prognosis

• Peritoneal dialysis can be a viable alternative to allow patient choice

and improve patient outcomes with unplanned start

Referral – early vs late = patient referred more than 3 months before need for dialysis. Would allow education, access formation/maturation and some biochemical

All talking about the same thing

access formation/maturation and some biochemical control.

Known – known vs unknown = is patient known to have CKD and be referred to nephrologist vs not

Timing – urgent vs emergency = patient needs dialysis within hours for high K, fluid overload or needed within days to 2-3 weeksdays to 2-3 weeks

…is a known or unknown patient starting dialysis in an urgent/emergency way with a temporaryvascular access.

An Unplanned Start patient

vascular access.

� Known patient = known to the nephrology unit 3-6 months prior to dialysisstart

� Unknown patient = unknown to the nephrology unit

� Urgent start: has to start dialysis within the next days- weeks

� Emergency start: has to start dialysis now.

Unplanned still frequent

60

%

Overall n=5.805

Unplanned start to dialysis is still common

24

49

3646 46 44 45

3730

20

30

40

50

Overall n=5.805

2430

0

10

Metcalfe 00 Gorriz 02 Caskey 03 Loos 03 Marron 05 Castellano 06 Buck 07 Couchoud 07 Mendelsshon 09

Mendelsshon; BMC Nephrol 2009

Systematic Review – Navaneethan BMC Nephrology 2008; 9: 3

What are common features of late referred patients?

• Increased mortality and morbidity

• Increased hospitalisation, use of resources and

Consequences of unplanned start

• Increased hospitalisation, use of resources and

cost

• Impact on RRT treatment modality selection

• Increased use of central venous catheters

(CVC)

1. Kazmi et al1

Late Referral (LR) is associated with a 44% higher risk of 1- year mortality compared with Early Referral (ER)

Unplanned start - Clinical outcomes

1- year mortality compared with Early Referral (ER)

2. Metcalfe et al2

Unplanned start patients were 3.6 times more likely to die within 90 days compared to planned start patients.

1.Kazmi W et al, NDT(2004) 19 :1808-1814

2.Metcalfe et al, Kid Int, Vol 57 (2000), 2539-2545

The known patient – unplanned start

Buck et al, NDT 2007

Characteristics and outcome of unplanned patients

4.7

3

4

5

HR for mortality

30

35

40

45

Planned

Unplanned

2.2

4.7

1.1

3.6

0

1

2

Medium risk High risk Unplanned Albumin

42.7

27.8 29.524.8

41.9

33.3

0

5

10

15

20

25

30

Low risk Medium risk High risk

Metcalfe. Kidney Int 2000; 57: 2539

%

Unplanned start – impact on modality and access

Marron B et al: Nephrol Dial Transplant (2006) 21 [Suppl 2]: ii51–ii55

Unplanned start is a main risk factor for CVC at

initiation of RRT

3HR

1.01

1.691.41 1.46 1.31

2.7

0.5

1

1.5

2

2.5

3

0

Age Female Late

referral

Type 2 DM Vascular

disease

Lung

disease

Polkinghorne; J Am Soc Nephrol 2004; 15: 477

A high proportion of ESKD patients still start

RRT with a CVC as a dialysis access

Ethier et al; Nephrol, Dial & Transplant 2008; 23: 2319

Patient survival, HD starters, by access type

80%

100%

Survival probablity

Starting dialysis with a CVC carries significant risk

0%

20%

40%

60%

0 50 100 150 200 250 300 350 400Days

Survival probablity

AVF+AVG

Temp line + Tunnel line

UK Renal Registry, Vascular Access Survey

Unplanned start and CVC impact independently on

survival

Lorenzo et al. Am J Kidney Dis 2004; 43: 999

How to prevent infections in unplanned?

� Be dynamic for education and modality election

Methods to reduce infection risk in unplanned start

• If HD is the choice, get functioning permanent internal access

as soon as possible

• Appropriate use of CVC

• Early and accurate diagnosis of infection

• Timely and effective treatment of infections, including systemic

antimicrobials, antibiotic locks and catheter removalantimicrobials, antibiotic locks and catheter removal

• Consider PD!

Infection-related hospitalizationUSRDS

2525

Hemo

Pediatric Adults

Infection related hospitilisation (USRDS)

23.221.3

10

15

20

Hemo

PD

10

15

20 PD

11.6

6.3

0

5

12 months 36 months

0

5

12 months 36 months

All differences p<0,005Chavers et al. J Am Soc Nephrol 2007; 18: 952

Unplanned start patient pathway

1.HD within 24-48h

Temporary catheter

2.Need for dialysis within

2-4 weeks, no permanent access.

Unplanned - Emergency Unplanned - Urgent

Referral to identified

educator(s)

Key Step

1

DecisionKey Step

2

Access PlacementKey Step

3

PD HD 18

Unplanned Start Programme

1.Placement of temporary HD

Access (ICU or HD Unit)

Tell patient that this access

is temporary

4. Choose therapy

5.Final access placement

HHD

is temporary

2. HD sessions in HD Unit

HD nurses become key

influencers

3. Education by nurse educator

PD

PD nurse(s)

3. Education by nurse educator

(CKD, PD, other)

•Patient stabilised

(3 days-2 weeks)

•3 meetings min

•Patient and significant other

•Need to make decision

Nephrologist(s)

Nurse Educator

HD nurse(s)

IC HD

Surgeon Nephrologist(s)

Unplanned Start Programme:

Tools

• Choice map: Provided to each

patient including a DVD, a patient including a DVD, a

Treatment Options Booklet and

Patient photo stories

• Treatment Options Flipchart:

to use with the patient. Includes

tips and question for the

educator.

• Guide on patient education

education and decision making.education and decision making.

• Decision aids: to help the

patient making a treatment

option decision.

Outcomes in Unplanned Start

A problem – but some solutions exist

• Unplanned start is still a major problem

• Infection is a major problem and many patients receive no choice of

therapy

• There are alternative approaches to reduce risk and deliver choice

Survival and late referral

Chow et al, PDI, 2008

Curtis et al, NDT, 2005, 147-154

Outcomes better with multidisciplinary education