Treatment Options Treatment Options for End Stage for End Stage

Kidney DiseaseKidney Disease

Dr Vipula De SilvaDr Vipula De Silva

Chronic Kidney DiseaseChronic Kidney Disease

Very CommonVery Common Usually does not progressUsually does not progress Increases cardiovascular riskIncreases cardiovascular risk

K-DOQI Classification of K-DOQI Classification of CKDCKD

Stage GFR(ml/min)

Description Prevalence(%)

1 > 90 1 Kidney damage withnormal or GFR

3.3

2 60-89 1 Kidney damage withmild GFR

3.0

3 30-59 Moderate GFR 4.34 15-29 Severe GFR 0.25 < 15 Kidney failure 0.2

Most CKD patients are Most CKD patients are stablestable

Rate of GFR decline (ml/min/1.73m2/year) <2.0 2.0-2.9 3.0-3.9 4.0-4.9 >5.0 Age (years) <70 (%) 82 4 5 5 5 70-80 (%) 80 5 4 3 7 >80 (%) 77 6 3 4 10 All (%) 79 5 4 4 8

Go, A. S. et al. N Engl J Med 2004;351:1296-1305

Adjusted Hazard Ratio for Death from Any Cause, Cardiovascular Events, and Hospitalization among 1,120,295 Ambulatory Adults, According to the Estimated GFR

But a small proportion do But a small proportion do progressprogress

Renal function declines with timeRenal function declines with time Develop the complications of renal Develop the complications of renal

diseasedisease Renal AnaemiaRenal Anaemia Renal Bone DiseaseRenal Bone Disease

Approach End Stage Kidney DiseaseApproach End Stage Kidney Disease

Identifying ESKDIdentifying ESKD

SymptomsSymptoms Nausea / vomitingNausea / vomiting Poor appetite / weight lossPoor appetite / weight loss

SignsSigns Fluid overloadFluid overload

BiochemistryBiochemistry High potassium, acidosis, high phosphateHigh potassium, acidosis, high phosphate

Declining eGFRDeclining eGFR

Treatment Options for Treatment Options for ESKDESKD

Haemodialysis (HD)Haemodialysis (HD) Peritoneal Dialysis (CAPD or APD)Peritoneal Dialysis (CAPD or APD) Renal transplantationRenal transplantation Conservative PathwayConservative Pathway

How do we choose?How do we choose?

Careful patient educationCareful patient education Patient education programmesPatient education programmes Expert patientsExpert patients Visits to dialysis unitsVisits to dialysis units

Medical best adviseMedical best advise Some patients will tolerate dialysis Some patients will tolerate dialysis

poorly – e.g. cardiovascular problemspoorly – e.g. cardiovascular problems Some abdominal surgery can make Some abdominal surgery can make

CAPD impossibleCAPD impossible

Dialysis HistoryDialysis History

Thomas Graham coined Thomas Graham coined the term dialysis in the term dialysis in 18611861

Crystalloids diffuse Crystalloids diffuse through vegetable through vegetable parchment coated with parchment coated with albumin albumin

First Dialysis MachinesFirst Dialysis Machines

George Haas George Haas performed the first performed the first successful human successful human dialysis in 1924dialysis in 1924

The first practical The first practical human haemodialysis human haemodialysis machine was machine was developed by WJ Kolff developed by WJ Kolff and H Berk in 1943 and H Berk in 1943 (Rotating Drum)(Rotating Drum)

HaemodialysisHaemodialysis

Blood is removed from the Blood is removed from the patients and cleaned in an patients and cleaned in an extracorporeal circuitextracorporeal circuit

Requires high flow access Requires high flow access to circulation – AV fistula to circulation – AV fistula or large diameter dialysis or large diameter dialysis lineline

Usually centre or satellite Usually centre or satellite unit basedunit based

Usually 4 hours, 3 times a Usually 4 hours, 3 times a weekweek

An AV fistula with dialysis An AV fistula with dialysis needlesneedles

A Dialysis CatheterA Dialysis Catheter

Disadvantages of HDDisadvantages of HD

Centre based – travel to unit 3 times Centre based – travel to unit 3 times a weeka week

Access complicationsAccess complications Line infectionsLine infections AV Fistula thrombosesAV Fistula thromboses

Cardiovascular traumaCardiovascular trauma Blood borne virus infection riskBlood borne virus infection risk AnticoagulationAnticoagulation

Peritoneal DialysisPeritoneal Dialysis

Involves the use of the patients Involves the use of the patients peritoneal membrane as a dialysis peritoneal membrane as a dialysis membranemembrane

Dialysis fluid is put into peritoneal Dialysis fluid is put into peritoneal space via catheterspace via catheter

Left in for 6 hours and drained outLeft in for 6 hours and drained out Immediately replaced by more fluidImmediately replaced by more fluid Continuous Ambulatory Peritoneal Continuous Ambulatory Peritoneal

DialysisDialysis

Peritoneal DialysisPeritoneal Dialysis

Automated Peritoneal Automated Peritoneal DialysisDialysis

APD machine moves fluid in and out APD machine moves fluid in and out of peritoneal space while the patient of peritoneal space while the patient is asleepis asleep

More convenient for manyMore convenient for many Often avoids many day time Often avoids many day time

exchangedexchanged May provide more efficient dialysisMay provide more efficient dialysis

APD MachineAPD Machine

Disadvantages of PDDisadvantages of PD

Risk of peritonitisRisk of peritonitis Not as efficient a dialysis as HD – Not as efficient a dialysis as HD –

not suitable for very large patientsnot suitable for very large patients Glucose load to diabeticsGlucose load to diabetics Bloated feelingBloated feeling Dependent on regular bowel Dependent on regular bowel

movementsmovements

TransplantationTransplantation

First successful kidney transplant between First successful kidney transplant between identical twins was performed by Joseph E. identical twins was performed by Joseph E. Murray and J. Hartwell Harrison in 1954Murray and J. Hartwell Harrison in 1954

Very effective form of renal replacement Very effective form of renal replacement therapytherapy

About 50% of people in UK with ESRD kept About 50% of people in UK with ESRD kept alive by a working transplantalive by a working transplant

New immunosuppression means excellent 1 New immunosuppression means excellent 1 year and 5 year survivalyear and 5 year survival

Careful and very frequent follow up in the first Careful and very frequent follow up in the first yearyear

Renal TransplantationRenal Transplantation

TransplantationTransplantation

Number of patients needing kidneys Number of patients needing kidneys is increasing steadilyis increasing steadily

Cadaveric organ availability is falling Cadaveric organ availability is falling graduallygradually

Live related programme slowly Live related programme slowly expandingexpanding

Number of transplants per year – at Number of transplants per year – at best stablebest stable

Disadvantages of Disadvantages of TransplantsTransplants

Infection riskInfection risk BacterialBacterial ViralViral FungalFungal

New Onset Diabetes After New Onset Diabetes After Transplant (NODAT)Transplant (NODAT)

MalignancyMalignancy Skin tumours, lymphomaSkin tumours, lymphoma

Conservative PathwayConservative Pathway

Based on patient choiceBased on patient choice Aim to control symptoms of Aim to control symptoms of

progressive renal declineprogressive renal decline Close links with palliative care teamsClose links with palliative care teams Emphasis on trying to take care to Emphasis on trying to take care to

patients homespatients homes Increasing awareness that this Increasing awareness that this

provides better quality of life for many provides better quality of life for many patientspatients

Spectrum of treatment Spectrum of treatment availableavailable

Patient may start with CAPDPatient may start with CAPD Then may get a transplantThen may get a transplant 10 years later transplant fails – start 10 years later transplant fails – start

HDHD 5 years on HD, may decide on 5 years on HD, may decide on

withdrawing treatment and opting withdrawing treatment and opting for conservative carefor conservative care

The demand for RRTThe demand for RRT

Expanding at 7-8% each year in the Expanding at 7-8% each year in the UKUK

We are treating and increasingly We are treating and increasingly elderly populationelderly population

Co-morbidity burden is increasingCo-morbidity burden is increasing Expansion of dialysis capacity is Expansion of dialysis capacity is

constant challengeconstant challenge

Our AimOur Aim

To identify those needing RRT earlyTo identify those needing RRT early To prepare them physically, To prepare them physically,

psychologically and socially for end psychologically and socially for end stage kidney diseasestage kidney disease

To identify the best treatment option To identify the best treatment option for them as an individualfor them as an individual