Transcript INITIATION OF DIALYSIS IN CHRONIC KIDNEY DISEASE

Marc Richards
Morning Report
November 2nd, 2009




CKD
When to refer to a Nephrologist
Access
When to start dialysis:



Symptoms
Numbers
Pictures of San Diego Zoo animals


Estimated 20 million Americans
HTN + DM = 70%



Others: GN, PCKD, Obstruction, etc…
Decreased renal mass
Nonspecific clinical presentations






1: GFR > 90 (normal to increased)
2: GFR 60-89 (mildly decreased)
3: GFR 30-59 (moderately decreased)
4: GFR 15-29 (severely decreased)
5: GFR <15 (failure)
6: DIALYSIS
(source: National Kidney Foundation, KDOQI)

Often occur late (<6 months before eventual
start of RRT)



~20-50% first referred <4 months (multiple studies)
Due to both patient and physician biases
Studies suggest increased all-cause mortality in
patients referred late.


Suggested for women with SCr > 1.2 and men
with SCr > 1.5, or anyone with CKD 3
Why so early?
 CKD can progress at different rates
 Reversible causes (vasculitis, etc)
 Access
 Management of comorbidities
 Anemia, Bone-Mineral Metabolism…
 Living Donor Allograft
 Dialysis discussions



PermaCath (tunneled line)
AV Fistula
Synthetic Grafts

Referral to Vascular Surgeon:



FISTULAS:






Failed fistula attempt
Mature in 2-6 weeks
Higher risk of infection, thrombosis
LINES:





Mature in 1-6 months
Expected function: 20 years
Very low infectious risk
GRAFTS:


CKD 4
Expected to require RRT in < 1 year
Emergent HD initiation
Awaiting maturation of AVF/AVG or out of access
Lower Q
Highest rate of infection
PD CATHETER





A
E
I
O
U







Refractory Hypertension
Weight Loss/Malnutrition
N/V
Persistent Metabolic Disturbances
Refractory Anemia
“Uremic-Like Symptoms”- depression,
decreased conc, RLS
Pruritis


Currently a topic of contention in the
nephrology world
Cockraft Gault Equation:


Age, weight effects
Loose guidelines now suggested by multiple
entities:


K/DOQI (2006): GFR < 15 (CKD 5)
Europe Best Practices (2005): consider when GFR 810, definitely start when GFR < 6

Why the uncertainty?


Proposed morbitity benefits:



No study to date has effectively proven a survival
benefit with earlier initiation of RRT
Liberal Nutrition
HTN control
IDEAL Trial


Prospective study underway in Australia/NZ
GFR 10 vs 14 when starting RRT





Current (2007)
UpToDate
National Kidney Foundation
IDEAL
San Diego Zoo