Management of ESRD

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Management of ESRD

• Dr G Paget
• Johannesburg Hospital

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CHRONIC RENAL FAILURE

• 150 cases of CRF per million persons are newly
  diagnosed per year
• Half of these patients go on to require dialysis
  or transplantation
• Mortality is 20

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What is Renal Failure?

• The deterioration of nephrons resulting in loss
  of ability to excrete wastes, concentrate urine,
  and regulate electrolytes.
• Occurs as end stage renal failure (ESRD) at the
  point where function is less than about 10 of
  normal. Function is so low that without dialysis
  or kidney transplantation, death will occur from
  accumulation of fluids and waste products in the
  body.
• ESRD almost always follows chronic kidney
  disease, which may exist for 10 - 20 years or
  more before progression to ESRD.

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Formulae to estimate GFR 1. Cockcroft- Gault
Formula CCr (140-age) X weight (kg)
0.81Xserum creatinine(umol/l) The calculated
clearance is reduced by 15 for women Formula
cannot be applied to ARF 2. MDRD formula GFR
170 X (Scr)-0.999 X (Age)-0.176 X (0.762 if
female) X (1.180 if black) X (BUN) -0.170
X (albumin)0.318
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In South Africa

• Aetiology.
• Hypertension
• Diabetes
• HIV
• Almost any renal disease.
• Chronic GN
• Congenital/Reflux
• Uncertain aetiology

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Chronic Renal Failure

• Incidence.
• Treatment based stats.
• Stats from SA
• SA dialysis and transplant registry - treated
  only, incomplete and dated
• SA majority untreated.
• Money, geography

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Chronic Renal failure

• South Africa.
• Approx. 12 New patients PMP/year
• Geographic variation
• Poor quality stats.
• How big is the problem really ?
• We receive new patients requiring dialysis with
  chronic renal failure weekly
• Increasing incidence of T2DM
• HIV??????

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STAGE DESCRIPTION GFR ml/min/1.73m2 ACTION
  At increased risk 90 (CKD risk factors) Screening CKD risk reduction
1 Kid damage N or ? GFR 90 Diagnosis Treatment CVD risk reduction
2 Kid damage mild ?GFR 60-89 Estimating progression
3 Mod ? GFR 30-59 Evaluate and treat complications
4 Severe ?GFR 15-29 Prepare for renal replacement therapy (RRT)
5 Kidney Failure lt15 or dialysis RRT
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CRF. Management Principles

• Identify reversible factors.
• Preserve residual function.
• Assess for dialysis/transplantation.
• Prepare for replacement (or death).

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CRF. Reversible Factors

• Volume status.
• Fluid depletion
• Fluid overload/heart failure.
• Drugs toxins.
• Aminoglyclosides
• NSAIDS
• Contrast
• Others

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CRF. Reversible Factors

• Blood pressure/cardiac output
• Uncontrolled hypertension (esp malignant phase)
• Hypotension
• Pericardial effusion
• Sepsis
• ATN
• Other effects
• Diagnose and treat Chronic Glomerulonephritis

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Progression Slowing

• Treat hypertension
• Goal 120/80mmHg
• ACE-I / ARB
• Other drugs.
• Reduce Proteinuria
• BP control
• ACE-I / ARB
• Non dihydropyriddine CCB
• Reduce protein intake lt1g/kg/day

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Progression Slowing 2

• Control Glucose
• Other
• Dietary protein restriction
• Phosphate - restriction control
  hyperphosphataemia and secondary
  hyperparathyroidism.
• Metabolic control
• Diabetes
• Hyperlipidaemia.
• Acidosis control

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Progression Slowing 3

• More
• Avoid nephrotoxins
• Maintain hydration
• Early recognition treatment of intercurrent
  illness
• Nutrition calories
• Sodium, potassium, calcium

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When to refer? (NKF)

• GFR lt 50 ml/min (recommended) GFR lt 30 ml/min
  (mandatory)
• Serum creatinine gt 150 µmol/l (on more than 2
  consecutive readings)
• Note 1 At GFR lt50 ml/min interventions to
  retard or prevent the progress of chronic renal
  failure to be instituted
• Note 2 At GFR lt 30 ml/min options for renal
  replacement needs to be considered. Consider
  preparing vascular access
• Note 3 At GFR lt 15 ml/min be vigilant for
  complications such as hypertension, fluid
  overload, electrolyte disturbances and
  malnutrition.

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When to consider chronic dialysis?

• Dialysis must be started when the GFR is 6ml/min
  (EBPG) or when the GFR is less than 15 ml/min and
  the patient has one or more of the following
• Symptoms or signs of uraemia
• Diuretic resistant fluid overload
• Poorly controlled blood pressure
• Evidence of malnutrition
• Note 1 Diabetics should be initiated on
  treatment earlier (GFR of 15 ml/min). Note 2
  DOQI guidelines recommend starting dialysis at
  GFR of 10 ml/min or earlier if there are signs
  of malnutrition

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CRF Dialysis Transplantation

• Costly treatment unaffordable to treat all.
• SELECTION
• Need criteria
• Fair
• Easily applicable
• Justifiable.

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CRF - Selection

• National criteria
• Age gt1 lt 60
• Transplantable
• Co-morbid disease
• Psychosocial NB compliance
• Housing/geography transport NOT considered (but
  practically unavoidable)

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Conservative Therapy
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CRF - Selection

• Patients accepted.
• Discuss treatment with patient.
• Prepare for dialysis.
• PD or HD.
• Prepare for transplantation.
• Living donor.
• Cadaver donor.

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Patients not accepted

• Identify those at risk early
• Counsel patient and family
• Advise about medical aid if possible
• Allow death with dignity
• Palliative measures
• High dose diuretics/fluid restriction.
• Potassium?
• Laxatives
• Analgesia and sedation
• Support for family
• Do not over treat

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Dialysis 1

• Factors governing choice.
• Residual function.
• Life style/occupation.
• Housing.
• Geography.
• Personal preference.
• Availability.

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Peritoneal dialysis

• Works by using the body's peritoneal membrane,
  inside the abdomen, as a semi-permeable membrane.
  Solutions that help remove toxins are infused in,
  remain in the abdomen for a certain time period,
  and are eventually drained out. This can be done
  at home on a continuous basis.
• Variants available using automated cyclers

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Peritoneal Dialysis (CAPD)

• Advantages.
• At home.
• Patient responsibility.
• Continuous therapy smooth chemistry.
• Disadvantages.
• Peritonitis.
• Low efficiency.

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Haemodialysis

• Advantages
• Hospital based (home based ?)
• Intermittent (3 x per week for 4 hours)
• Efficient
• Disadvantages
• Vascular access
• Travel etc

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Haemodialysis

• Works by circulating the blood, from an access in
  the body, through a semi-permeable filter in the
  dialysis machine that helps remove toxins. The
  cleansed blood is then returned to the body.
• Typically, most patients undergo hemodialysis for
  three sessions every week. Each session lasts 3-4
  hours
• Patients on hemodialysis are always heparinized
  to prevent clotting of the AV access.

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Transplantation.
Iliac vessels
Graft ureter
Bladder
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Transplantation

• Donor sources.
• Cadaver donors.
• Living donors - genetically related.
• Living donors - genetically unrelated.
• Emotionally related.
• Altruistic strangers.

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Donors - Cadaver

• Brain dead.
• Consent
• Ventilated
• Virology
• Renal function
• Other organs.

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Transplantation

• Cadaver donors. Cause of death Cape Town

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Transplantation Live Donors

• Volunteer donors
• Matching - ABO, HLA
• Health requirements
• Note for genetically unrelated transplant
  Ministerial permission

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Aims of Treatment.

• Survival -
• Rehabilitation
• Return to work/family responsibilities
• Resume community responsibilities
• Normal lifestyle

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To Sum up

• ESRF common in SA and probably on the increase
• Attention to treatment of chronic diseases like
  hypertension and diabetes can improve lifespan of
  these patients and prevent ESRF.
• Dialysis and care for ESRF limited in SA
• Need to refer patients who may develop ESRF early
  so that they can be prepared.
• Transplantation best therapy if patient suitable.