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Treatment Options for End Stage Kidney Disease. Dr Vipula De Silva. Chronic Kidney Disease. Very Common Usually does not progress Increases cardiovascular risk. K-DOQI Classification of CKD. Stage. GFR. Description. Prevalence. (ml/min). (%). 1. 1. > 90. Kidney damage with. 3.3.
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Treatment Options for End Stage Kidney Disease Dr Vipula De Silva
Chronic Kidney Disease • Very Common • Usually does not progress • Increases cardiovascular risk
K-DOQI Classification of CKD Stage GFR Description Prevalence (ml/min) (%) 1 1 > 90 Kidney damage with 3.3 normal or GFR 1 2 60-89 Kidney damage with 3.0 mild GFR 3 30-59 Moderate GFR 4.3 4 15-29 Severe GFR 0.2 5 < 15 Kidney failure 0.2
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 • Renal function declines with time • Develop the complications of renal disease • Renal Anaemia • Renal Bone Disease • Approach End Stage Kidney Disease
Identifying ESKD • Symptoms • Nausea / vomiting • Poor appetite / weight loss • Signs • Fluid overload • Biochemistry • High potassium, acidosis, high phosphate • Declining eGFR
Treatment Options for ESKD • Haemodialysis (HD) • Peritoneal Dialysis (CAPD or APD) • Renal transplantation • Conservative Pathway
How do we choose? • Careful patient education • Patient education programmes • Expert patients • Visits to dialysis units • Medical best advise • Some patients will tolerate dialysis poorly – e.g. cardiovascular problems • Some abdominal surgery can make CAPD impossible
Dialysis History • Thomas Graham coined the term dialysis in 1861 • Crystalloids diffuse through vegetable parchment coated with albumin
First Dialysis Machines • 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 • 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
Disadvantages of HD • Centre based – travel to unit 3 times a week • Access complications • Line infections • AV Fistula thromboses • Cardiovascular trauma • Blood borne virus infection risk • Anticoagulation
Peritoneal Dialysis • 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
Automated Peritoneal Dialysis • 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
Disadvantages of PD • 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 • 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
Transplantation • 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 • Infection risk • Bacterial • Viral • Fungal • New Onset Diabetes After Transplant (NODAT) • Malignancy • Skin tumours, lymphoma
Conservative Pathway • 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 • 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 • 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 • 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