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Timely Referral in Chronic Renal Failure Guidelines in Context.
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Transcript of Timely Referral in Chronic Renal Failure Guidelines in Context.
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 the UK. (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 be 40,000 ESRF patients by 2010
• Potential 100% increase by 2010 if take on increases
Should take on rates increase
• Indo-Asians have 4-7 x incidence of ESRD
• Increased incidence of ESRD with age
• Geographical inequalities still exist– Distance from renal unit has an inverse
relationship with referral rate
• The impending Type 2 diabetes epidemic
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 knowNot 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
• ‘Many 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 ‘avoidable’ late referrals
• Poorer clinical state at start of RRT and likely 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
100
N V G B X O D H T W C All
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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
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?
Complications of Chronic renal Failure
• Anaemia
• Bone Disease
• Acidosis
• Malnutrition
• Hypertension
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• 1-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
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?
Is Dialysis Preventable
• Reversible causes of renal failure
• Can we do anything about ‘non-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 caseof unexplained renal failure
Hypertension
• Vicious circle relationship between hypertension and 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 ‘multi-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 to
above normal range or by 25% but for some there is 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 to diabetes
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 achieve
BP 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 diseaseRuggenenti, lancet 2001: 357
The final common pathway
We have got to get on the case before this!
Why are patients referred late?
• Ignorance of the value of early referral– Nephrologist = Dialyser?
• Ambivalence about ‘high-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 dialysis
within 3 months
• High risk patients progress more rapidly and tolerate uraemia less well
How to avoid late referral?• Education
– Progression rates vary– Creatinine is a flawed marker– Management of CRF is a dynamic process– Age is not a criterion
• Assess high risk patients before they have symptomatic uraemia• Integrated follow-up
– Primary care– General physician– Geriatrician– Nephrologist– Urologist
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