Preparation for DialysisCHRISTOPHER PASSERO, MD

UNIVERSITY OF PITTSBURGHOCTOBER 10, 2019

Objectives

u Implement timely education and support for patients at risk for CKD progression

u Prepare for timely placement of dialysis access

u Prepare for timely initiation of dialysis

Introduction

u As reported in 2015, the prior 30 years saw a dramatic increase in patients undergoing dialysis

u In 2010, there were more than 2million chronic dialysis patients worldwide

u Modeling estimates suggest this will double by 2030

u In 2016, there were 124,675 newly reported cases of ESRD in the United States.

u In 2016, there were 726,331 prevalent cases of ESRD

u The number of prevalent ESRD cases has continued to rise by about 20,000 cases per year

u Based on 2013 data, the lifetime risk of being diagnosed with ESRD from birth was 4.0% in males and 2.9% in females.

u Improved survival of the general population, reduction in mortality of dialysis patients, increased incidence of CKD, greater access to dialysis

u But are patients adequately prepared to start dialysis? Are they starting dialysis under optimal conditions?

Optimal Conditions to start RRT

u As outlined by Saggi SJ et al Nature Reviews 2012:

u 1) Patients should not require hospitalization for the management of untreated acute or chronic complications of uremia

u 2) Patients should have a thorough understanding of the different treatment options

u 3) Patients should have a permanent functioning access for the dialysis therapy of their choice

Pre-ESRD Nephrology Care in Incident ESRD Cases

u From the US Renal Data System:

u CHARACTERISTICS OF INCIDENT ESRD CASES

u In 2016, 20.8% of patients starting ESRD therapy were reported on the CMS 2728 form as not having received nephrology care before ESRD onset

u 14.6% had an unknown duration of pre-ESRD nephrology care.

u Suspected up to 35.4% of new ESRD cases received little or no pre-ESRD nephrology care

Data Source: Special analyses, USRDS ESRD Database. Population only includes incident cases with the form CMS 2728. Values for cells with 10 or fewer patients are suppressed. Abbreviations: ESRD, end-stage renal disease; Neph, nephrology.

Nephrology care >12 months

u Nephrology care >12 months vs no care:

u Prevalence of dietary care was 12.9% in patients with >12 months of pre-ESRD nephrology care and only 0.3% in patients with no such care.

u Prevalence of ESA use was 22.7% in patients with >12 months of pre-ESRD nephrology care and only 1.9% in patients with no such care.

u Prevalence of starting RRT early (≥15 ml/min/1.73 m2) and late (<5 ml/min/1.73 m2) was greatest for patients with no pre-ESRD nephrology care (12.4% and 19.8%, respectively).

u Use of a catheter only for vascular access was strongly and inversely associated with duration of pre-ESRD nephrology care, being 35.6% for patients with >12 months of pre-nephrology care and 80.1% for patients with no such care.

u AV fistula use was much more common for patients with >12 months of pre-ESRD nephrology care (25.4%) than for patients with no such care (2.3%).

Current Trend in Treatment Choice for RRT

u From the US Renal Data System:u TREATMENT MODALITIESu In 2016, 87.3% of incident individuals began renal replacement therapy with

hemodialysis (HD), 9.7% started with peritoneal dialysis (PD), and 2.8% received a preemptive kidney transplant

u On December 31, 2016, 63.1% of all prevalent ESRD patients were receiving HD therapy, 7.0% were treated with PD, and 29.6% had a functioning kidney transplant. Among HD cases, 98.0% used in-center HD, and 2.0% used home HD

u There is a trend in increased use of home modalities over the past several years.

u An older study (Goovaerts 2005) estimated that with appropriate pre-dialysis support and training up to 50% patient would attain self care dialysis.

Benefits of Patient Preparedness

u Urgent start dialysis is associated with lower survival and higher morbidity

u Home modalities (home hemodialysis and peritoneal dialysis) improve patients’ perceptions of autonomy

u Use of AVF and/or AVG compared to central venous catheter is associated with lower mortality, fewer complications, and lower costs.

When to prepare? Who to prepare?

u Generally patients nearing or below an eGFR of 30 (CKD stage 4) are offered education regarding death from renal failure and dialysis

u But not all CKD stage 4 patients progress to ESRD

u In a 5 year follow up of a large nonprofit group model HMO, 17% or CKD 4 patients required dialysis and 45% had died before needing any dialysis.

u Canadian study from 2008 suggested of ~4000 CKD stage 4 patients 7% died prior to dialysis and 24% required dialysis support

When to prepare? Who to prepare?

u Certain characteristics to look out for:u Albuminuria: More albuminuria is associated with

progression to dialysisu Declining renal functionu Hard to control hypertensionu Progressive underlying diseaseu CKD complicationsu Age: Advancing age is associated with dying

prior to starting dialysis.u US Veterans with CKD and mean eGFR 18u – 67% of 18-44 year old started dialysis and 22%

died u – 17% of >85 year olds started dialysis and 41% died

From Eckhardt, K et al Kidney Int 2018;93:1281-1292

Can risk be quantified?

u Kidney Failure Risk Equation https://kidneyfailurerisk.com/

u Based on Thirty-one cohorts participating in the CKD Prognosis Consortium, including 721 357 participants with CKD stages 3 to 5 in more than 30 countries spanning 4 continents, were studied. These cohorts collected data from 1982 through 2014.

u They developed 2 kidney failure risk equations:

u - 4-variable utilizing age, sex, eGFR, and ACR

u - 8-variable equation (4-variable + serum calcium, phosphate, bicarbonate, and albumin).

Kidney Failure Risk Equation

Kidney Failure Risk Equation https://kidneyfailurerisk.com/

Risk Factor Calculator

u 2018 Meta-analysis looking at need for kidney replacement therapy, cardiovascular disease events, and death included 28 cohorts of 185,024 individuals with CKD stage 4

u Age and history of cardiovascular disease events were negatively correlated with need for dialysis, but positively related to future cardiovascular disease events and death

u Current smoking was associated with death

u Lower GFR and higher albuminuria were associated with need for kidney replacement therapy

u They generated a risk factor calculator for cardiovascular disease, death and kidney replacement therapy https://kdigo.org/equation/

Risk Factor Calculatoru Scenario of a 60 year old

male with cardiovascular disease, non-smoker, systolic blood pressure 140, diabetes, and estimated GFR 25

u Picture is from Eckhardt, K et al Kidney Int 2018;93:1281-1292

u KRT= kidney replacement therapy

u https://kdigo.org/equation/

CKD Education

Should focus on:health promotionshared decision makingdiscussion of treatment options

Should be iterative – estimated 5 encounters for a patient to understand the message of dialysis needs

Should include psychosocial aspects and coping –individualized and ongoing educational support

Can include education materials in video or written format, tours of dialysis units, meeting patients on dialysis or with transplant

CKD Education

From Saggi et al Nature Reviews 2012;66:1-9

Goal is to have patient making informed decisions and participation in their care

CKD Education

u Progression of CKD patient options:u Incenter hemodialysis

u Home dialysis – peritoneal and hemodialysis

u Transplant – earlier time to referral may allow for pre-emptive transplant

u Conservative Care

Conservative Careu 2011 UK study

u 844 patients studied over an18-year period

u Conservative care patients (18%)were older and a greater proportion had high comorbidity.

u In patients aged > 75 years when corrected for age, high comorbidity and diabetes, the survival advantage from RRT was ~ 4 months, which was not statistically significant. I

u Increasing age, the presence of high comorbidity and the presence of diabetes were independent determinants of poorer survival in RRT patients

Chandna et al. NDT, 2011

Conservative Care

u Planned treatment of advanced kidney disease without dialysis

u Goals:u optimize quality of life

u treat symptoms of kidney failure

u prepare for the future and when appropriate preserve residual renal function

u Renal-Palliative subspecialty physicians

Home Dialysis

u Patient perception of improved freedom, flexibility and well being

u Anxiety and Fear about performing dialysis treatments, lack of ability to perform tasks, and isolation from medical staff Chan et al Kidney International 2019;96:37-47

Preparing for Dialysis Access

u Hemodialysis:

u AVF u – have a high likelihood of failing to mature

u – may take 1-4 months to mature

u – but once mature can last years

u AVGu – lower early failure rate than AVF

u – Usable in 2- 3 weeks

u – generally last about 2-3 years

u Chronic venous catheters – may be used in selected populations

Preparing for Dialysis Access

u Peritoneal dialysis:

u Guidelines generally suggest placement 2 weeks prior to usage to allow for healing

u Buried catheter technique can allow for more flexible timing

u Possible to have urgent start as well

Initiation of Dialysis

IDEAL StudyRandomly assigned 828 patients >= 18 years of age with progressive chronic kidney disease and an eGFR 10-15

Initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause.

During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis).

Cooper, BA NEJM 2010;363:609-619

Initiation of Dialysis

u Should not be based on eGFRu Often requires close follow up

u Symptoms or signs of kidney failureu Inability to control volume/Blood pressure with medicationsu Deterioration of nutritional status

u Older patientsu Slower level of decline in residual GFRu Tend to die of other causes before needing dialysis

References Cited

u Thomas, B et al Maintenance dialysis throughout the world in years 1990-2010, JASN 2015;26:2621-2633

u US Department of Public Health and Human Services, Public Health Service, National Institutes of Health, Bethesda. United States Renal Data System [online] https://www.usrds.org/2018/view/v2_01.aspx

u Liyange T et al Worldwide access to treatment for ESKD: a systematic review. Lancet 2015;385:1975-1982

u Saggi, SJ et al Considerations in the optimal preparation of patients for dialysis, Nature Reviews 2012;66:1-9

u Goovaerts T et al Influence of a pre-dialysis education programme(PDEP) on the mode of renal replacement therapy, Nephrol Dial Transplant 2005;20:1842-1847

u Hasegawa et al Greater first year survival on hemodialysis in facilities in which pateints are provided earlier and more frequent pre-nephrology visits Clin JASN 2009;4595-602

u Walker et al Patient and caregiver perspectives on home hemodialysis: a systematic review Am J Kidney Dis 2015;65:451-463

u Robinson et al Factors affecting outcomes in pateints reaching ESKD worldwide: differences in access to renal replacement therapy, modality use, and haemodilysis practices Lancet 2106;388:294-306

u Chan et al Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference Kidney International 2019;96:37-47

More References Cited

u Keith et al Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization Arch Intern Med 2004;164:659-663

u Levin, A et al Variability and risk factors for kidney disease progression and death following attainment of stage 4 CKD in a referred cohort. Am J Kidney Dis 2008;52:661-671

u O’Hare, A et al When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration? Kidney Int 2007;71:555-561

u Eckhardt, K et al Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions form a Kidney Disease:Improving Global Outcomes (KDIGO) Controversies Conference Kidney Int 2018;93:1281-1292

u Tangri, N et al A predictive model for progression of chronic kidney disease to kidney failure JAMA2011;305:1553-1559

u Tangri, N et al Multinational Assessment of Accuracy of Equations for Preducting Risk of Kidney Failure: A Meta-analysis JAMA 2016;315:1-11

u Han, D et al CKD Education: an evolving concept Nephrol Nurs J 2009;36:317-319

u Ptacek, J et al Breaking bad news. A review of the literature JAMA 1996;276:496-502

u Chandna, SM et al Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy Nephrol Dial Transplant 2011;26(5):1608-14

More Reference Cited

u Walker, RC et al Pateint and caregiver perspectives on home hemodialysis: a systematic review Am J Kidney Disease 2015;65:451-463

u Morton, RL et al The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies BMJ 2010;340

u Crabtree, HL Selected best demonstrated practices in peritoneal dialysis access Kidney Int 2006;70:S27-S37

u Allion, M et al Current management of vascular access Clin JASN 2007;2:786-800

u Dember, LM et al Effect of clopidogrel on early failure or arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA 2008;299:2164-2171

u Figueiredo, A et al Clinical practice guidelines for peritoneal access. Perit Dial Int 2010;30:424-429

u McCormick, BB et al Use of the embedded peritoneal dialysis catheter: experience and results from a North American Center Kidney Int 2006;S38-S43

u Cooper, BA A randomized controlled trial of early versus late inititation of dialysis NEJM 2010;363:609-619

u Laden, K et al Discussing conservative management with older patients with CKD: An interview study of nephrologists Am J Kidney Dis 2018;71:627-635