Treatment Options for End Stage Kidney Disease Dr Vipula De Silva

Chronic Kidney Disease Very Common Very Common Usually does not progress Usually does not progress Increases cardiovascular risk Increases cardiovascular risk

K-DOQI Classification of CKD StageGFR (ml/min) DescriptionPrevalence (%) 1> 90 1 Kidney damage with normal or  GFR Kidney damage with mild  GFR Moderate  GFR Severe  GFR 0.2 5< 15Kidney failure0.2

Most CKD patients are stable

Go, A. S. et al. N Engl J Med 2004;351: 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 progress Renal function declines with time Renal function declines with time Develop the complications of renal disease Develop the complications of renal disease Renal Anaemia Renal Anaemia Renal Bone Disease Renal Bone Disease Approach End Stage Kidney Disease Approach End Stage Kidney Disease

Identifying ESKD Symptoms Symptoms Nausea / vomiting Nausea / vomiting Poor appetite / weight loss Poor appetite / weight loss Signs Signs Fluid overload Fluid overload Biochemistry Biochemistry High potassium, acidosis, high phosphate High potassium, acidosis, high phosphate Declining eGFR Declining eGFR

Treatment Options for ESKD Haemodialysis (HD) Haemodialysis (HD) Peritoneal Dialysis (CAPD or APD) Peritoneal Dialysis (CAPD or APD) Renal transplantation Renal transplantation Conservative Pathway Conservative Pathway

How do we choose? Careful patient education Careful patient education Patient education programmes Patient education programmes Expert patients Expert patients Visits to dialysis units Visits to dialysis units Medical best advise Medical best advise Some patients will tolerate dialysis poorly – e.g. cardiovascular problems Some patients will tolerate dialysis poorly – e.g. cardiovascular problems Some abdominal surgery can make CAPD impossible Some abdominal surgery can make CAPD impossible

Dialysis History Thomas Graham coined the term dialysis in 1861 Thomas Graham coined the term dialysis in 1861 Crystalloids diffuse through vegetable parchment coated with albumin Crystalloids diffuse through vegetable parchment coated with albumin

First Dialysis Machines George Haas performed the first successful human dialysis in 1924 George Haas performed the first successful human dialysis in 1924 The first practical human haemodialysis machine was developed by WJ Kolff and H Berk in 1943 (Rotating Drum) The first practical human haemodialysis machine was developed by WJ Kolff and H Berk in 1943 (Rotating Drum)

Haemodialysis Blood is removed from the patients and cleaned in an extracorporeal circuit Blood is removed from the patients and cleaned in an extracorporeal circuit Requires high flow access to circulation – AV fistula or large diameter dialysis line Requires high flow access to circulation – AV fistula or large diameter dialysis line Usually centre or satellite unit based Usually centre or satellite unit based Usually 4 hours, 3 times a week Usually 4 hours, 3 times a week

An AV fistula with dialysis needles

A Dialysis Catheter

Disadvantages of HD Centre based – travel to unit 3 times a week Centre based – travel to unit 3 times a week Access complications Access complications Line infections Line infections AV Fistula thromboses AV Fistula thromboses Cardiovascular trauma Cardiovascular trauma Blood borne virus infection risk Blood borne virus infection risk Anticoagulation Anticoagulation

Peritoneal Dialysis Involves the use of the patients peritoneal membrane as a dialysis membrane Involves the use of the patients peritoneal membrane as a dialysis membrane Dialysis fluid is put into peritoneal space via catheter Dialysis fluid is put into peritoneal space via catheter Left in for 6 hours and drained out Left in for 6 hours and drained out Immediately replaced by more fluid Immediately replaced by more fluid Continuous Ambulatory Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis

Peritoneal Dialysis

Automated Peritoneal Dialysis APD machine moves fluid in and out of peritoneal space while the patient is asleep APD machine moves fluid in and out of peritoneal space while the patient is asleep More convenient for many More convenient for many Often avoids many day time exchanged Often avoids many day time exchanged May provide more efficient dialysis May provide more efficient dialysis

APD Machine

Disadvantages of PD Risk of peritonitis Risk of peritonitis Not as efficient a dialysis as HD – not suitable for very large patients Not as efficient a dialysis as HD – not suitable for very large patients Glucose load to diabetics Glucose load to diabetics Bloated feeling Bloated feeling Dependent on regular bowel movements Dependent on regular bowel movements

Transplantation First successful kidney transplant between identical twins was performed by Joseph E. Murray and J. Hartwell Harrison in 1954 First successful kidney transplant between identical twins was performed by Joseph E. Murray and J. Hartwell Harrison in 1954 Very effective form of renal replacement therapy Very effective form of renal replacement therapy About 50% of people in UK with ESRD kept alive by a working transplant About 50% of people in UK with ESRD kept alive by a working transplant New immunosuppression means excellent 1 year and 5 year survival New immunosuppression means excellent 1 year and 5 year survival Careful and very frequent follow up in the first year Careful and very frequent follow up in the first year

Renal Transplantation

Transplantation Number of patients needing kidneys is increasing steadily Number of patients needing kidneys is increasing steadily Cadaveric organ availability is falling gradually Cadaveric organ availability is falling gradually Live related programme slowly expanding Live related programme slowly expanding Number of transplants per year – at best stable Number of transplants per year – at best stable

Disadvantages of Transplants Infection risk Infection risk Bacterial Bacterial Viral Viral Fungal Fungal New Onset Diabetes After Transplant (NODAT) New Onset Diabetes After Transplant (NODAT) Malignancy Malignancy Skin tumours, lymphoma Skin tumours, lymphoma

Conservative Pathway Based on patient choice Based on patient choice Aim to control symptoms of progressive renal decline Aim to control symptoms of progressive renal decline Close links with palliative care teams Close links with palliative care teams Emphasis on trying to take care to patients homes Emphasis on trying to take care to patients homes Increasing awareness that this provides better quality of life for many patients Increasing awareness that this provides better quality of life for many patients

Spectrum of treatment available Patient may start with CAPD Patient may start with CAPD Then may get a transplant Then may get a transplant 10 years later transplant fails – start HD 10 years later transplant fails – start HD 5 years on HD, may decide on withdrawing treatment and opting for conservative care 5 years on HD, may decide on withdrawing treatment and opting for conservative care

The demand for RRT Expanding at 7-8% each year in the UK Expanding at 7-8% each year in the UK We are treating and increasingly elderly population We are treating and increasingly elderly population Co-morbidity burden is increasing Co-morbidity burden is increasing Expansion of dialysis capacity is constant challenge Expansion of dialysis capacity is constant challenge

Our Aim To identify those needing RRT early To identify those needing RRT early To prepare them physically, psychologically and socially for end stage kidney disease To prepare them physically, psychologically and socially for end stage kidney disease To identify the best treatment option for them as an individual To identify the best treatment option for them as an individual