Timely Referral in Chronic Renal Failure

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 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

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 Failure

• 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 knowNot 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 referral?

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Unadjusted 2yr survival of all dialysis patients in 97-98

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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 management

• 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 mortality

• Decreased quality of life

• Impaired cognitive function

• Decreased immune responsiveness

Left Ventricular Hypertrophy and Survival

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 developing?

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• 1-calcidol• Exercise

– Beware of hypercalcaemia, ? New phosphate binders

• Calcium Phosphate product– Last (not uncommon) resort is surgery

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

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’ causes– 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 caseof unexplained renal failure

Hypertension

• 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

Drugs

• NSAIDS

• Diuretics

• Interstitial nephritis, especially in the elderly

• 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 common

• ACE inhibitors (and diuretics) should often be suspended in the face of intercurrent illness

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 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

Forget the smallprint

Lets get back to diabetes!

PACE guidelines for Diabetes 2002

Renal/Hypertension

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 diabetes

Or is there another way?

Is diabetic nephropathy preventable?

• 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 smokers– This is under appreciated by patients and

doctors

Progression, remission, regression of chronic renal diseaseRuggenenti, 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 treatment

• Conservative treatment is active

• ?no difference in outcome

Age does not feature in any guidelines

We would have dialysed if asked