chronic renal failure - timely referral guide
TRANSCRIPT
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Timely Referral in Chronic Renal
Failure
Guidelines in Context
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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
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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
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Who to refer and when?
I don¶t know
Not 6400pmp but more than at present?
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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
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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?
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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
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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
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Late Referral Longer duration of predialysis
nephrological care does improve outcome
± Jungers et al 2001
How long is longer?
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What are the benefits of earlier
referral?
or
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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
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The DOPPS Study
To what extent does vascular access
account for mortality on dialysis?
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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
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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?
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Complications of Chronic renal Failure
Anaemia
Bone Disease
Acidosis
Malnutrition
H
ypertension
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Consequences of anaemia in
renal disease Symptoms
Increased cardiovascular morbidity and
mortality
Decreased quality of life
Impaired cognitive function
Decreased immune responsiveness
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Left Ventricular Hypertrophy and
Survival
Silberg 1989
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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?
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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
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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
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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?
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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?
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Reversible causes of declining
renal function Urinary tract obstruction
Urinary tract infection
Systemic hypertension Drugs
Cardiac failure
Metabolic abnormalities
± hypercalcaemia
Immunological disease
Pregnancy
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Ultrasound is mandatory in any case
of unexplained renal failure
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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
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Drugs NSAIDS
Diuretics
Interstitial nephritis, especially in the
elderly
ACE Inhibitors
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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¶
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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
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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
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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
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Forget the smallprint
Lets get back to diabetes!
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PACE guidelines for Diabetes
2002
Renal/Hypertension
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Key Points from the Guidelines Proteinuria/ microalbuminuria
ACE Inhibitors
Early referral
± Creatinine (>150)
± Proteinuria (PCI >1000)
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Earlier referral should improve
subsequent mortality/morbidity
of patients with ESRF due todiabetes
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Or is there another way?
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Is diabetic nephropathy
preventable? Tight control
Blood pressure
Proteinuria
ACE inhibitors
Lipids
Smoking cessation
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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
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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
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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
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The final common pathway
We have got to get on the case before this!
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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
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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
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Age does not feature in any guidelines
We would have dialysed if asked