Renal Replacement Therapy – What the Non-Nephrologist Should Know

1. Renal Replacement Therapy – What the Non-Nephrologist Should Know Bernard G. Jaar, MD, MPH, FASN,FNKF Johns Hopkins Medical Institutions Nephrology Center of Maryland

2. Why is this topic relevant to you?

3. Kidney Disease is a Public Health Problem Trends in Kidney Disease Burden …

4. Prevalence of CKD Stages in US Adults Aged 20 Years or Older: NHANES 1988-1994 and NHANES 1999-2004 Coresh, J. et al. JAMA 2007;298:2038-2047

5. 3.0 2.0 1.0 0 2.2 million (60% diabetic) 1.3 million 0.7 million 0.4 million 1978 2000 2010 2020 2030 Year ESRD Prevalence – The Forecast Projected growth overall ESRD prevalence (5% / yr) Number of patients (millions) 618,160 pts (2011) Gilbertson et al. JASN 2003

6. Objectives • Describe treatment options for renal replacement therapy • Understand the general principles of dialysis modalities & compare their outcomes • Importance of residual renal function • Describe kidney transplantation process

7. Case Presentation (I) • 39 y/o AA man • PMHx: none • Routine physical exam: • BP 142 / 100 • LE edema • 4+ proteinuria (dipstick)

8. PE: Unremarkable, except: Weight 230 lbs (BMI 33) BP 138 / 85 2+ LE edema Treatment: ACE inhibitor Thiazide diuretics Case Presentation (II) Initial Nephrology Clinic Visit

9. Case Presentation (III) Initial Laboratory Data • Labs: Albumin 2.5 T. cholesterol 398 mg/dL Serology w-u (-) UA: protein 4+, 0-2 RBC, 0-2 WBC Spot u. prot. / creat. 413 mg/dL / 41 mg/dL  10 12.3 141 107 18 7490 333 95 3.6 28 2.4 41.0 eGFR 37 cc/min/1.73m2

10. CKD Progression  ESRD “Uremic” ESRD Kidney Bx: FSGS RRT Initial presentation: HTN, CKD, proteinuria

11. Indications for Renal Replacement Therapy • Hyperkalemia • Metabolic acidosis • Fluid overload (recurrent CHF admissions) • Uremic pericarditis (rub) • Other non specific uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attentiveness, and cognitive tasking, …

12. What are the Treatment Options for Renal Replacement Therapy for our Patient?

13. ESRD Treatment Options ESRD Comfort Care Peritoneal Dialysis Hemodialysis Kidney Transplant

14. ESRD Treatment Options ESRD Comfort Care Hemodialysis Peritoneal Dialysis Kidney Transplant

15. Dialysis options Dialysis Hemodialysis Peritoneal Dialysis In-Center HD(3 x week) Home HD (short daily, nocturnal) CAPD CCPD Home

16. Incident Patient Counts (USRDS)by 1st Modality USRDS 2013 ADR

17. CKD Education

18. CKD Progression  ESRD CKD Education “Uremic” ESRD RRT Initial presentation: HTN, CKD, proteinuria

19. CKD Education • Refer patients early, when eGFR < 30 cc/min • Education about types of renal replacement therapy: • Hemodialysis (vascular access +++) • Peritoneal Dialysis (QOL advantage +++) • Kidney Transplantation • Refer when eGFR <20 • Living kidney transplant (family, friends) • Build time on list before dialysis initiation • Even transplant before dialysis initiation (pre-emptive)

20. Early Vaccination for Hepatitis B! • Patients with ESRD have  response to vaccination (2ary to general suppression of immune system) • After Hepatitis B vaccination in ESRD patients: • 50 – 60 % develop antibodies, compared to > 90% in patients without renal failure • Have Lower titers • Have protective levels for shorter duration Too Often Forgotten ! Stevens CE et al. NEJM 1984; 311: 496 Buti M et al. Am J Nephrol 1992; 112: 144

21. Early Vaccination for Hepatitis B! • Patients with ESRD have  response to vaccination (2ary to general suppression of immune system) • After Hepatitis B vaccination in ESRD patients: • 50 – 60 % develop antibodies, compared to > 90% in patients without renal failure • Have Lower titers • Have protective levels for shorter duration Stevens CE et al. NEJM 1984; 311: 496 Buti M et al. Am J Nephrol 1992; 112: 144

22. Hemodialysis (HD)

23. Principle of Hemodialysis Vein Artery

24. Hemodialysis Filter (Dialyzer)

25. Hemodialysis Filter (Dialyzer)

26. Hemodialysis Vascular Access Polytetrafluoroethylene

27. Arteriovenous (AV) Fistula

28. Question 1 • Which type of vascular access is associated with better outcomes in hemodialysis patients? (choose one answer): • Central venous cuffed catheter • Arteriovenous graft • Arteriovenous fistula • Temporary central venous catheter

29. Which Vascular Access and When Should It Be Placed?

30. CKD Progression Vascular Access (AVF) HD Initial presentation: HTN, CKD, proteinuria

31. Adjusted* Relative Risk of Death by Type of Vascular Access Diabetes No Diabetes Cohort: 5,507 patients, followed for 2 years *Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to ambulate and education level. Prevalent diabetic pts: CVC vs. AVG (P = 0.42). Incident diabetic pts: CVC vs. AVG (P = 0.48). Prev. nondiabetic pts: CVC vs. AVG (P < 0.0001). Inc. nondiabetic pts: CVC vs. AVG (P = 0.82). Dhingra RK et al. Kidney Int 2001; 60: 1443–1451

32. Adjusted* Relative Risk of Death due to Infection by VA Type and Diabetes Status Cohort: 5,507 patients, followed for 2 years *Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to ambulate and education level. Prevalent diabetic pts: CVC vs. AVG (P = 0.81) Prevalent nondiabetic pts: CVC vs. AVG (P < 0.13) Dhingra RK et al. Kidney Int 2001; 60: 1443–1451

33. Patients who started using an AV access by timing of first referral to a nephrologist N=356 hemodialysis patients Astor B. et al. Am J Kidney Dis 2001; 38 (3): 494-501

34. VASCULAR ACCESS GUIDELINES • Arm veins suitable for placement of vascular access should be preserved, regardless of arm dominance. Arm veins, particularly the cephalic veins of the non-dominant arm should not be used. • Dorsum of the hand could be used for IV. • A Medic Alert bracelet should be worn to inform hospital staff to avoid IV cannulation of essential veins. • Subclavian vein catheterization should be avoided for temporary access in all patients with CKD ( stenosis  preclude use of ipsilateral arm for vascular access)

35. SAVE the Non-Dominant ARM for Vascular Access • When GFR < 30 mL/min • No BP measurement • No IV • No Blood Draws • Place vascular access within a year of hemodialysis anticipation … On Non-Dominant Arm

36. Peritoneal Dialysis (PD)

37. Principle of PD Treatment

38. Abdominal cavity is lined by peritoneal membrane which acts as a semi-permeable membrane • Diffusion of solutes (urea, creatinine, …) from blood into the dialysate contained in the abdominal cavity • Removal of excess water (ultrafiltration) due to osmotic gradient generated by glucose in dialysate

39. Types of PD Catheters • Overall PD catheter survival : +/- 90% at 1 year • No particular catheter is superior

40. Placement of Peritoneal Dialysis Catheter

41. Placement of PD Catheter Exit Site

42. PD Catheter Exit Site

43. Peritoneal Dialysis (PD) PD Continuous Intermittent

44. Continuous PD Regimens Multiple sequential exchanges are performed during the day and night so that dialysis occurs 24 hours a day, 7 days a week CAPD: Continuous Ambulatory PD CCPD: Continuous Cyclic PD

45. Intermittent PD Regimens PD is performed every day but only during certain hours DAPD: Daytime Ambulatory PD. Multiple manual exchanges during waking hours NPD: Nightly PD. Performed while patient asleep using an automated cycler machine. Sometimes, 1 or 2 day-time manual exchanges are added to enhance solute clearances

46. CCPD Treatment Setup

47. Question 2 • What is the most common cause of technique failure in peritoneal dialysis? (choose one answer): • Ultrafiltration failure • Malnutrition • Peritonitis • Non-adherence to the treatment regimen

48. Cumulative percentage of PD patients by time from 1st dialysis to 1st switch to HD 25% of PD patients switched to HD within 5-7 years Jaar BG et al. BMC Nephrol 2009; 10: 3

49. Causes of PD Technique Failure (Switching from PD to HD) Psychological Issues Abdominal Surgery Peritonitis Malnutrition Ultrafiltration Failure Jaar BG et al. BMC Nephrol 2009; 10: 3

50. Which Dialysis Modality Provides the Best Outcomes?