Transcript Treatment Options for End Stage Kidney Disease

Treatment Options for
End Stage Kidney
Disease
Dr Vipula De Silva
Chronic Kidney Disease
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Very Common
Usually does not progress
Increases cardiovascular risk
K-DOQI Classification of CKD
Stage GFR
Description
(ml/min)
1
> 90 1
2
60-89
3
4
5
30-59
15-29
< 15
1
Kidney damage with
normal or GFR
Kidney damage with
mild GFR
Moderate GFR
Severe GFR
Kidney failure
Prevalence
(%)
3.3
3.0
4.3
0.2
0.2
Most CKD patients are stable
Rate of GFR decline (ml/min/1.73m2/year)
<2.0
2.0-2.9 3.0-3.9 4.0-4.9 >5.0
Age (years)
<70 (%)
82
70-80 (%)
80
>80 (%)
77
4
5
6
5
4
3
5
3
4
5
7
10
All (%)
5
4
4
8
79
Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization
among 1,120,295 Ambulatory Adults, According to the Estimated GFR
Go, A. S. et al. N Engl J Med 2004;351:1296-1305
But a small proportion do progress
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Renal function declines with time
Develop the complications of renal disease
Renal Anaemia
 Renal Bone Disease
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Approach End Stage Kidney Disease
Identifying ESKD
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Symptoms
Nausea / vomiting
 Poor appetite / weight loss
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Signs
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Biochemistry
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Fluid overload
High potassium, acidosis, high phosphate
Declining eGFR
Treatment Options for ESKD
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Haemodialysis (HD)
Peritoneal Dialysis (CAPD or APD)
Renal transplantation
Conservative Pathway
How do we choose?
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Careful patient education
Patient education programmes
 Expert patients
 Visits to dialysis units
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Medical best advise
Some patients will tolerate dialysis poorly – e.g.
cardiovascular problems
 Some abdominal surgery can make CAPD
impossible
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Dialysis History
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Thomas Graham coined the
term dialysis in 1861
Crystalloids diffuse through
vegetable parchment coated
with albumin
First Dialysis Machines
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George Haas performed
the first successful
human dialysis in 1924
The first practical human
haemodialysis machine
was developed by WJ
Kolff and H Berk in
1943 (Rotating Drum)
Haemodialysis
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Blood is removed from the
patients and cleaned in an
extracorporeal circuit
Requires high flow access to
circulation – AV fistula or large
diameter dialysis line
Usually centre or satellite unit
based
Usually 4 hours, 3 times a week
An AV fistula with dialysis needles
A Dialysis Catheter
Disadvantages of HD
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Centre based – travel to unit 3 times a week
Access complications
Line infections
 AV Fistula thromboses
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Cardiovascular trauma
Blood borne virus infection risk
Anticoagulation
Peritoneal Dialysis
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Involves the use of the patients peritoneal
membrane as a dialysis membrane
Dialysis fluid is put into peritoneal space via
catheter
Left in for 6 hours and drained out
Immediately replaced by more fluid
Continuous Ambulatory Peritoneal Dialysis
Peritoneal Dialysis
Automated Peritoneal Dialysis
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APD machine moves fluid in and out of
peritoneal space while the patient is asleep
More convenient for many
Often avoids many day time exchanged
May provide more efficient dialysis
APD Machine
Disadvantages of PD
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Risk of peritonitis
Not as efficient a dialysis as HD – not suitable
for very large patients
Glucose load to diabetics
Bloated feeling
Dependent on regular bowel movements
Transplantation
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First successful kidney transplant between identical
twins was performed by Joseph E. Murray and J.
Hartwell Harrison in 1954
Very effective form of renal replacement therapy
About 50% of people in UK with ESRD kept alive by a
working transplant
New immunosuppression means excellent 1 year and 5
year survival
Careful and very frequent follow up in the first year
Renal Transplantation
Transplantation
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Number of patients needing kidneys is
increasing steadily
Cadaveric organ availability is falling gradually
Live related programme slowly expanding
Number of transplants per year – at best stable
Disadvantages of Transplants
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Infection risk
Bacterial
 Viral
 Fungal
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New Onset Diabetes After Transplant
(NODAT)
Malignancy
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Skin tumours, lymphoma
Conservative Pathway
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Based on patient choice
Aim to control symptoms of progressive renal
decline
Close links with palliative care teams
Emphasis on trying to take care to patients
homes
Increasing awareness that this provides better
quality of life for many patients
Spectrum of treatment available
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Patient may start with CAPD
Then may get a transplant
10 years later transplant fails – start HD
5 years on HD, may decide on withdrawing
treatment and opting for conservative care
The demand for RRT
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Expanding at 7-8% each year in the UK
We are treating and increasingly elderly
population
Co-morbidity burden is increasing
Expansion of dialysis capacity is constant
challenge
Our Aim
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To identify those needing RRT early
To prepare them physically, psychologically and
socially for end stage kidney disease
To identify the best treatment option for them
as an individual