Try the all-new QuickBooks Online for FREE.  No credit card required.

chronic renal failure timely referral guide ppt PowerPoint anaemia

Document Sample
chronic renal failure timely referral guide ppt PowerPoint  anaemia Powered By Docstoc
					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