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Treatment Options for End Stage Kidney Disease

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

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  1. Treatment Options for End Stage Kidney Disease Dr Vipula De Silva

  2. Chronic Kidney Disease • Very Common • Usually does not progress • Increases cardiovascular risk

  3. 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

  4. Most CKD patients are stable

  5. 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

  6. 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

  7. Identifying ESKD • Symptoms • Nausea / vomiting • Poor appetite / weight loss • Signs • Fluid overload • Biochemistry • High potassium, acidosis, high phosphate • Declining eGFR

  8. Treatment Options for ESKD • Haemodialysis (HD) • Peritoneal Dialysis (CAPD or APD) • Renal transplantation • Conservative Pathway

  9. 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

  10. Dialysis History • Thomas Graham coined the term dialysis in 1861 • Crystalloids diffuse through vegetable parchment coated with albumin

  11. 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)

  12. 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

  13. An AV fistula with dialysis needles

  14. A Dialysis Catheter

  15. 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

  16. 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

  17. Peritoneal Dialysis

  18. 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

  19. APD Machine

  20. 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

  21. 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

  22. Renal Transplantation

  23. 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

  24. Disadvantages of Transplants • Infection risk • Bacterial • Viral • Fungal • New Onset Diabetes After Transplant (NODAT) • Malignancy • Skin tumours, lymphoma

  25. 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

  26. 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

  27. 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

  28. 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

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