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chronic renal failure timely referral guide ppt PowerPoint anaemia

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									Timely Referral in Chronic Renal
        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
• 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
   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
• 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

    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
• 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
• Decreased quality of life
• Impaired cognitive function
• Decreased immune responsiveness
Left Ventricular Hypertrophy and

                    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
                    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
• 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’
  – 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
• 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
• Diuretics
• Interstitial nephritis, especially in the
• 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
• ACE inhibitors (and diuretics) should often
  be suspended in the face of intercurrent
          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
• 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
 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
Or is there another way?
        Is diabetic nephropathy
•   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
   – This is under appreciated by patients and

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
• 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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