Timely Referral in Chronic Renal Failure

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Timely Referral in Chronic Renal Failure

• Guidelines in Context

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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
  more
• 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
  increases

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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

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Incidence of Chronic Renal Failure

• East Kent Study of unreferred CRF
• Opportunistic study of all creatinines from lab
• Males gt180, females gt135 (GFR lt30-40)
• Excluding ARF and patients known to renal unit
• Prevalence 6400pmp, 85 unknown to renal
• cf renal unit patients- significantly older
• 70 of patients lt80 with CRF are unknown to renal
  unit

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Who to refer and when?

• I dont know
• Not 6400pmp but more than at present?

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PACE Guidelines for diabetes

• Refer when proteinuria gt1g/24hours or creatinine
  gt150
• Similar to renal association guidelines and
  likely to be in the NSF
• Likewise any unexplained renal failure should be
  referred

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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?

8
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

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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

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Late Referral

• Longer duration of predialysis nephrological care
  does improve outcome
• Jungers et al 2001
• How long is longer?

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What are the benefits of earlier referral?
or
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The DOPPS Study
To what extent does vascular access account for
mortality on dialysis?
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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

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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?

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Complications of Chronic renal Failure

• Anaemia
• Bone Disease
• Acidosis
• Malnutrition
• Hypertension

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Consequences of anaemia in renal disease

• Symptoms
• Increased cardiovascular morbidity and mortality
• Decreased quality of life
• Impaired cognitive function
• Decreased immune responsiveness

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Left Ventricular Hypertrophy and Survival
Silberg 1989
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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 developing?

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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

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Nutrition

• 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

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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?

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Is Dialysis Preventable

• Reversible causes of renal failure
• Can we do anything about non-reversible causes
• In other words challenge the notion that they are
  non-reversible
• Type 2 Diabetes
• Is Type 2 diabetes preventable?

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Reversible causes of declining renal function

• Urinary tract obstruction
• Urinary tract infection
• Systemic hypertension
• Drugs
• Cardiac failure
• Metabolic abnormalities
• hypercalcaemia
• Immunological disease
• Pregnancy

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Ultrasound is mandatory in any case of
unexplained renal failure
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Hypertension

• Vicious circle relationship between hypertension
  and renal impairment
• Optimum control of Blood Pressure delays
  progression of renal disease (lt130/85)
• ACE inhibitors seem better than other
  antihypertensive agents
• Anti-proteinuric
• Anti-fibrogenic
• Which leads me onto

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Drugs

• NSAIDS
• Diuretics
• Interstitial nephritis, especially in the elderly
• ACE Inhibitors

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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

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Nephrology and ACE inhibitor is a strange
relationship

• Most of our patients should be on them
• We must be vigilant, renovascular disease is
  common
• ACE inhibitors (and diuretics) should often be
  suspended in the face of intercurrent illness

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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

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Immunological diseases causing renal failure

• 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

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Forget the smallprint

• Lets get back to diabetes!

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PACE guidelines for Diabetes 2002

• Renal/Hypertension

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Key Points from the Guidelines

• Proteinuria/ microalbuminuria
• ACE Inhibitors
• Early referral
• Creatinine (gt150)
• Proteinuria (PCI gt1000)

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Earlier referral should improve subsequent
mortality/morbidity of patients with ESRF due to
diabetes
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Or is there another way?
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Is diabetic nephropathy preventable?

• Tight control
• Blood pressure
• Proteinuria
• ACE inhibitors
• Lipids
• Smoking cessation

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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

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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

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Smoking and Lipids

• Meta-analysis suggests that lipid lowering can
  preserve GFR
• Renal function declines twice as fast in smokers
• This is under appreciated by patients and doctors

Progression, remission, regression of chronic
renal disease Ruggenenti, lancet 2001 357
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The final common pathway
We have got to get on the case before this!
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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 gt500 require
  dialysis within 3 months
• High risk patients progress more rapidly and
  tolerate uraemia less well

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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

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Is Dialysis for everyone?

• The Stevenage experience
• Pre-dialysis counsellors make a recommendation of
  dialysis or conservative treatment
• Conservative treatment is active
• ?no difference in outcome

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Age does not feature in any guidelines
We would have dialysed if asked