irc outlines 1. new classification of ckd according to kdigo dec 2012 2. prevalence of ckd 3....

Peritoneal Dialysis Forum

Farazan Island, Jizan 27-28 February 2013

PROF. JAMAL ALWAKEELC o n s u l t a n t N e p h r o l o g i s t

K i n g K h a l i d U n i v e r s i t y H o s p i t a lK i n g S a u d U n i v e r s i t y

R i y a d h , K i n g d o m o f S a u d i a A r a b i a

The Role of PD within an Integrated Renal

Care

IRC OUTLINES1. New Classification of CKD according to

KDIGO Dec 2012

2. Prevalence of CKD

3. Prevalence of RRT

4. Description of Integrated Renal Care (IRC)

5. Why PD is the first therapy in IRC

US CKD prevalence (11.0% in 1988 through 1994 and 11.7% in 1999 through 2000).

Was 26 million out of approximately 200 million United States residents aged 20 and older.

Total CKD prevalence in Norway was 10.2%

Saudia Arabia 6%.

Iran 18.9%

Indonesia 8.6%

Of these 65.3 % had CKD stage 3 or 4.

CKD

KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of CKD

We recommend that CKD is classified based on cause, GFR category, and albuminuria category (CGA).

Assign cause of CKD based on presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic findings. (Not graded)

Assign GFR categories as follows (Not Graded)

Staging of CKD

GFR Categories in CKD

GFR category

GFR (ml/min/1.73 m2)

Terms

G1 > 90 Normal or high

G2 60-89 Mildly decreased*

G3a 45-59 Mildly to moderatelyDecreased

G3b 30-44 Moderately to Severely decreased

G4 15-29 Severely decreased

G5 <15 Kidney failure

* Relative to young adult level In the absence of evidence of kidney damage, neither GFR category G1 or G2 fulfill the criteria for CKD.


Using CKD-EPI creatinine question or eGFR cys or eGFRcreat-cys

Assign albuminuria categories as follows (Not Graded): *note that where albuminuria measurement is not available, urine reagent strip results can be

substituted

Category

AER(mg/24 hours)

ACR(mg/mmol)

ACR(mg/g)

TERMS

approximate equivalent

A1 < 30 <3 <30 Normal to mildly increased

A2 30-300 3-30 30-300 Moderately increased*

A3 >300 >30 >300 Severely increased**

Albuminuria categories in CKD

*Relative to young adult level** Including nephrotic syndrome (albumin excretion usually > 2200 mg/24 hours [ ACR .2220/g; >220 mg/mmol])


G1 Normal or high > 90 1 if CKD 1 2

G2 Mildly decreased 60-89 1 if CKD 1 2

G3a Mildly to moderately Decreased

45-59 1 2 3

G3b Moderately to severely decreased

30-44 2 3 3

G4 Severely decreased 15-29 3 3 4+

G5 Kidney Failure <15 4+ 4+ 4+

A1 A2 A3

Normal toMildly

Increased

ModeratelyIncreased

Severely Increased

< 30 mg/g< 3 mg/mmol

30-300 mg/g3-30 mg/mmol

>300 mg/g>30

mg/mmol

Persistent albuminuria categoriesDescription and range

GFR categories (ml/

min/1.73 m2

Descriptio

n and

Range

Guide to Frequency of Monitoring

(number of times per year) by

GFR and Albuminuria Category

Green low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk.


ESRD Patients 2, 786, 000

Thereof HD 1,929,000

Thereof PD 235,000

Thereof Tx 622,000

World Population 7.0 Billion

Annual Growth Rates

World population 1.1%

ESRD 6-7%

HD 6-7%

PD 7-8%

Tx 4-5%

Global: 2, 164,000 dialysis patients

PD 11%

HD 89%

ESRD Patients in 2011; A Global Perspective, Frenesius Medical Care


Comparison of HD and PD patients numbers in the 15 largest countries ranked by total dialysis patient population

Percent Distribution of prevalent Dialysis patients, by modality 2010

PD use World Wide

USRDS 8% of ESRD patients were on PD compared to 92% on hemodialysis.

Data from other centers showed that 22% patients on PD in England 19% in Australia, 35 % in New Zealand Hong kong 78% Mexico 51%

Comparison of CAPD APD Patients Numbers since 2000

2000

2005

2010

2011

CAPD; 76%

CAPD; 69%

CAPD; 66%

CAPD, 65%

APD; 24%

APD; 31%

APD; 34%

APD; 35%


153,000 patients 82,000 patients

Dialysis Population-Current and Projected (1995-2015)

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2013

2015

0

2000

4000

6000

8000

10000

12000

14000

16000

3869

4322 4861

5206 6008

7029 7383

7833 7526 78098482

953310280

11168

1204012633

1335613928

15074

Saudi J Kidney Dis Transplant 2012;23 (4):881-889

Causes of end-stage Renal Disease in HD Patients-2011

Cause of Renal Failure No %

Diabetic Nephropathy 4513 37.3

Hypertensive Nephropathy 4375 36.1

Unknown Etiology 1108 9.2

Primary Glomerular Disease 712 5.9

Obstructive Uropathy 320 2.6

Hereditary Renal Disease 224 1.8

Congenital Malformation 267 2.2

Primary Tubulo-interstitial Disease 148 1.2

Vasculitis 152 1.3

Pregnancy related 66 0.5

Others 231 1.9

Total 12116 100


Renal Replacement Therapy 2011

PD; 1240; 6%

HD; 12116; 58%

Renal Tx. Fol-lowed Up, 7408,

36%

Total= 20, 764 Pts (765 PMP)


Treatment Modality 2011

IPD, 85, 7%

CAPD, 374, 30%

APD/CCPD78163%


Integrated ESRD care

Systematic “managed care” type strategies

Intention of maximizing clinical outcome

Minimizing cost

Integrated ESRD care

Requires nephrologists to take a more integrated approach to their patients

To manage them more systematically from first presentation with CRF through to their course on ESRD

Include treatment with HD, PD and transplantation

Integrated dialysis careHD and PD are complimentary rather than

competitive dialytic therapies.

Every RRT has a technical “drop-out”, it is very likely that a patient will need several modalities during his lifetime and transfer from one technique to another will often be needed.

Patient survival and quality of life are two very important factors in the selection of a dialysis modality

Integrated renal careEarly referral of patients with CKD

Patient education program

Pre-emptive transplantatio

nPD as first option if medically suitable allowing for patient

to choose

PD

Transplant

HD

Integrated Renal Care concept- what does it mean?

The integrated care concept (acc. To Lameire N. et al. PDI, 2000; Van Biesen W.et al. PDI, 2000, Corles G. A. et al. Kidney Int. 1998)

Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapyAdv. Clin.Exp. Med.. 2003, 12,2,243-249

Integrated Renal Care concept- what does it mean?

A broader concept of integrated care (acc. To Mendelssohn D. C., Pierratos A., PDI, 2002)


Waiting List for Renal Transplantation among Dialysis Patients-2011

Waiting List for Work -Up; 2423; 20%Active Waiting List;

3138; 26%

Total 12116


Kidney Replacement Therapy: Modality Choice

Kidney Replacement Therapy: Modality Choice

Most patients are medically eligible for PD.

PD has few absolute medical contraindications

In a large Dutch study, only 17% patients had a medical contraindication to PD; (previous major abdominal surgery).

• In a recent U.S. study, only 23% of ESRD patients had a medical contraindication to PD

• In studies from other countries 17% to 21%.

• 50% of patients preferred PD.

Burden of Therapy

* Typical CHD unit have a very robust infrastructure

Jager KJ etal. Am J Kidney Dis. 2004;43:891‐899

PD-Related Complication Rates Are Decreasing.

* Innovations in connection technologies catheter design use of prophylactic antibiotics improvement in catheter function and peritonitis

and exit site infection rates.

Benefits of PD as the first modality of IRC

Higher survival in the first 3 years of renal replacement therapy (RRT)

Cardiovascular benefits, especially in elderly and diabetic patients

Better preservation of residual renal function (RRF)

Better quality of life (QoL) especially in flexibility and convenience

Better control of anemia


Better post transplanted outcome

Less infection and complications of infection

Lower prevalence of hepatitis C infections

Preserve vascular access

Less expensive than HD especially in the first 3 years of RRT.


Higher survival in first 1-3 years of RRT

Data from the 2008 report suggest that there was no difference in the 60-month survival probability between PD and CHD for the population as a whole

These USRDS observations suggest that patients who start their RRT on PD have a survival advantage over similar patients on CHD.

Survival in non-diabetic and young diabetic patients in the first two years of PD.

Advantage of PD surivival over HD is lost after one to three years of dialysis, especially in older diabetic patients

Survival of patients on CAPD up to 2 years was 84% and 82% on HD.


Mortality Rates:

ERDTA - 149 deaths per 1,000 patient years, USRDS - 125 deaths per 1,000 patient years.

Patient mortality at King Khalid University Hospital was 7.81 % or 95 deaths per 1000 patient years

SCOT

AUSTRALIA

NEW ZEALAND

UK RR

KKUH

10%

12.7%

13.6%

22%

7.81 %

Cardiovascular Benefits especially in elderly and diabetic patients

Superior survival among PD patients over HD patients in first years of RRT

Better control BL pressure ,fluid load, anemia,LVH

Better control of cardiovascular problems with PD is the main reason for transfer HD patients to PD

PD are better arryhthmia control, lower homocysteine level and better anemia control

Better Preservation of RRF Residual renal function

In most CAPD patients RRF is preserved up to 3rd year of therapy.

This is probable the cause of better survival in comparison to PD patients being dialysed longer than 3 years.

Tattersall and co-workers reported better survival and lower hospitalization rate of PD patients with higher RRF


Quality of Life-Related Issues

*Current data do not show a consistent difference between studies in SF 36 ratings between PD and HD overtime.

*There is a consistent trend that favors PD.

*PD patients tend to be more satisfied with their therapy than CHD patients.

Recent Publication

Original Article:

Quality of life in hemodialysis and peritoneal dialysis patients

in Saudi Arabia

Jamal Al Wakeel, Ali Al Harbi, Magda Bayoumi, Karaem Al-Suwaida, Mohammed Al Ghonaim,

Adel Mishkirye

Ann Saudi Med 2012; 32(6): 570-574

Quality of Life Scores of Hemodialysis and Peritoneal dialysis patients

Quality of life in hemodialysis and peritoneal dialysis patients in Saudi ArabiaAnn Saudi Med 2012; 32(6): 570-574

Better Control of Anemia

Need lower doses of rHUEPO for achievement of appropriate values.

Longer preservation of RRF, peritoneal membrane being more biocompatible dialysing membrane, lower blood losses, no anticoagulation.

Lower doses of intravenous iron.


Transplant-Related Issues

*Multiple retrospective cohort observational studies transplanted form PD, less like to have delayed graft survival.

*Patients transplanted from PD had

>6% lower risk of death ;

> 3% lower risk of graft failure than those transplanted from HD.

InfectionsIn a 3 year study rates are the same, but the types of

infection differ

HD related infections often more severe and lead to higher mortality risks

* Septicaemia incidence 22%, mortality rate 20% * Pneumonia 17% * Exit site 37%

PD related infections have a lower mortality rate

* Peritonitis incidence 24%, mortality rate 2.3% * Pneumonia 3% * Exit site 53%

Morbidity of infections

PD Catheter removal <5% Endocarditis/Osteomyelitis—unmeasurable

HD Catheter (graft) removal 80% Systemic infection—15%

Lower prevalence of hepatitis C infection

Hepatitis C virus is a major cause of morbidity and mortality in RRT patients.

Hepatitis C virus (HCV) infects an estimated 170 million people worldwide.

Prevalence of HCV in hemodialysis (HD) patients ranges from 3 to 23% in developed countries and exceeds 50% in some developing countries.

HCV-infected HD patients have higher mortality rates than noninfected HD patients, with reported relative risks from 1.25 to 1.57.

Clin J Am Soc Nephrol 4: 1449–1458, 2009. doi: 10.2215/CJN.018503

HBsAg and HCV Among HD Patients-2011

Negative, (11653, 96%)

Positive, (463, 4%) Negative,

(9516, 79%)

Positive, (2600, 21%)

HBsAG HCVTotal 12116


Dialysis in the Kingdom of Saudi Arabia

Active Peritoneal Dialysis Patients

Negative; 1212; 98%

Positive, 28, 2%

HBsAg Status- 2011

Total 1240


HCV Antibodies Status- 2011

Negative 1187 96%

Positive 53 4%

HCV Antibodies

TOTAL = 1240


Preservation of vascular access:

33% of all hemodialysis patients use a central venous catheter

Access complications 25% hospitalizations

30% catheter failure rate

high incidence of bacteremia (40%) in hemodialysis patients

Life of AVF 2.5 years

Premature use causes loss of AVF 30%

In the life of a dialysis patient—two-three years is a long time without an access issue

Cost of Utility

Studies on cost utility between PD and HD performed in Europe and North America showed that HD is 10-70% more expensive than PD especially in the first years of dialysis.

Increasing use of APD in recent years diminished cost advantage of PD.


Patient benefits from PD:

Independence and control Dialysis in bed Flexibility around day to day life No travel to hospital No needles Ability to travel Self reported QOL superiority

a) Choose of dialysis should integrate with daily activities such as work, school, hobbies, family commitments and travel for work or leisure.

1.1.9) Offer all people with stage 5 CKD a choice of peritoneal dialysis or hemodialysis, if appropriate but consider peritoneal dialysis as the first choice of treatment modality for:

children 2 years old or younger people with residual function adults without significant

associated comorbidities.

NICE Clinical Guidelines 125-Peritoneal Dialysis

NICE Clinical Guidelines 2011(UK)

1.1.11)Before starting peritoneal dialysis, offer all patients a choice, if appropriate, between CAPD and APD (or aAPD if necessary).

1.1.13)Do not routinely switch patients on peritoneal dialysis to a different treatment modality in anticipation of potential future complications such as encapsulating peritoneal sclerosis. However, healthcare professionals should monitor risk factors such as loss of ultrafiltration and discuss with patients regularly the efficacy of all aspects of their treatment.

NICE Clinical Guidelines 125-Peritoneal Dialysis

NICE Clinical Guidelines 2011

Integrated Care Approach

“ Start renal replacement therapy in ESRD

patients with PD, transfer them to HD when

problems with PD occur, and transplant them

when the possibility exists.”

Lamiere N, et al, Seminar of Uro-Nephrology. (1999)

CONCLUSION:

Lamiere N

Outcome of patients started on PD as first line therapy, compared to

patients transferred from hemodialysis

Saira Usama, Jamal S. Alwakeel, Ahmad H. Mitwalli, Abdulkareem Alsuwaida, Akram Askar

14th Congress of International Society for Peritoneal Dialysis9th -12 September 2012, Kuala Lumpur , Malaysia

Poster Presentation

Thank

YOU

irc outlines 1. new classification of ckd according to kdigo dec 2012 2. prevalence of ckd 3....

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