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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 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 • ‘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 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 • 1a-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 case of 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 disease Ruggenenti, 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
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