Timely Referral in Chronic Renal Failure

1. Timely Referral in Chronic Renal Failure Guidelines in Context

2. 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

3. 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

4. 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

5. Who to refer and when? I don’t know Not 6400pmp but more than at present?

6. 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

7. 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

9. 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

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

11. What are the benefits of earlier referral? or

13. The DOPPS Study To what extent does vascular access account for mortality on dialysis?

14. 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

15. 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?

16. Complications of Chronic renal Failure • Anaemia • Bone Disease • Acidosis • Malnutrition • Hypertension

19. Consequences of anaemia in renal disease • Symptoms • Increased cardiovascular morbidity and mortality • Decreased quality of life • Impaired cognitive function • Decreased immune responsiveness

20. Left Ventricular Hypertrophy and Survival Silberg 1989

21. 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?

22. 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

23. 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

24. 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?

25. 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?

26. Reversible causes of declining renal function • Urinary tract obstruction • Urinary tract infection • Systemic hypertension • Drugs • Cardiac failure • Metabolic abnormalities • hypercalcaemia • Immunological disease • Pregnancy

27. Ultrasound is mandatory in any case of unexplained renal failure

28. 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

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

30. 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’

31. 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

32. 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

33. 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

34. Forget the smallprint Lets get back to diabetes!

35. PACE guidelines for Diabetes 2002 Renal/Hypertension

36. Key Points from the Guidelines • Proteinuria/ microalbuminuria • ACE Inhibitors • Early referral • Creatinine (>150) • Proteinuria (PCI >1000)

37. Earlier referral should improve subsequent mortality/morbidity of patients with ESRF due to diabetes

38. Or is there another way?

39. Is diabetic nephropathy preventable? • Tight control • Blood pressure • Proteinuria • ACE inhibitors • Lipids • Smoking cessation

40. 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

41. 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

42. 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

43. The final common pathway We have got to get on the case before this!

44. 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

45. 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

46. 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

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