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INITIATION OF DIALYSIS IN CHRONIC KIDNEY DISEASE

INITIATION OF DIALYSIS IN CHRONIC KIDNEY DISEASE. Marc Richards Morning Report November 2 nd , 2009. PRESENTATION OUTLINE. CKD When to refer to a Nephrologist Access When to start dialysis: Symptoms Numbers Pictures of San Diego Zoo animals. CKD. Estimated 20 million Americans

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INITIATION OF DIALYSIS IN CHRONIC KIDNEY DISEASE

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  1. INITIATION OF DIALYSIS IN CHRONIC KIDNEY DISEASE Marc Richards Morning Report November 2nd, 2009

  2. PRESENTATION OUTLINE • CKD • When to refer to a Nephrologist • Access • When to start dialysis: • Symptoms • Numbers • Pictures of San Diego Zoo animals

  3. CKD • Estimated 20 million Americans • HTN + DM = 70% • Others: GN, PCKD, Obstruction, etc… • Decreased renal mass • Nonspecific clinical presentations

  4. CKD STAGES • 1: GFR > 90 (normal to increased) • 2: GFR 60-89 (mildly decreased) • 3: GFR 30-59 (moderately decreased) • 4: GFR 15-29 (severely decreased) • 5: GFR <15 (failure) • 6: DIALYSIS (source: National Kidney Foundation, KDOQI)

  5. NEPHROLOGY REFERRALS • Often occur late (<6 months before eventual start of RRT) • ~20-50% first referred <4 months (multiple studies) • Due to both patient and physician biases • Studies suggest increased all-cause mortality in patients referred late.

  6. WHEN SHALL WE REFER? • Suggested for women with SCr > 1.2 and men with SCr > 1.5, or anyone with CKD 3 • Why so early? • CKD can progress at different rates • Reversible causes (vasculitis, etc) • Access • Management of comorbidities • Anemia, Bone-Mineral Metabolism… • Living Donor Allograft • Dialysis discussions

  7. ACCESS • PermaCath (tunneled line) • AV Fistula • Synthetic Grafts

  8. ACCESS • Referral to Vascular Surgeon: • CKD 4 • Expected to require RRT in < 1 year • FISTULAS: • Mature in 1-6 months • Expected function: 20 years • Very low infectious risk • GRAFTS: • Failed fistula attempt • Mature in 2-6 weeks • Higher risk of infection, thrombosis • LINES: • Emergent HD initiation • Awaiting maturation of AVF/AVG or out of access • Lower Q • Highest rate of infection • PD CATHETER

  9. WHEN TO INITIATE DIALYSIS:

  10. EMERGENT: • A • E • I • O • U

  11. IN CKD: SYMPTOMS • Refractory Hypertension • Weight Loss/Malnutrition • N/V • Persistent Metabolic Disturbances • Refractory Anemia • “Uremic-Like Symptoms”- depression, decreased conc, RLS • Pruritis

  12. IN CKD: NUMBERS • Currently a topic of contention in the nephrology world • Cockraft Gault Equation: • Age, weight effects • Loose guidelines now suggested by multiple entities: • K/DOQI (2006): GFR < 15 (CKD 5) • Europe Best Practices (2005): consider when GFR 8-10, definitely start when GFR < 6

  13. THE FUTURE: • Why the uncertainty? • No study to date has effectively proven a survival benefit with earlier initiation of RRT • Proposed morbitity benefits: • Liberal Nutrition • HTN control • IDEAL Trial • Prospective study underway in Australia/NZ • GFR 10 vs 14 when starting RRT

  14. REFERENCES: • Current (2007) • UpToDate • National Kidney Foundation • IDEAL • San Diego Zoo

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