Dialysis: outcome and complications

Introduction Outcomes – 20%+ of dialysis patients die each year, 3YS diabetics ~50% Technical complications –PD –Haemo Cardiovascular

Peritoneal dialysis Complications –Technical failure, obesity, operated abdomen Peritonitis ~ 1:24 treatment months –Staph spp –Pseud spp –Candida Scerosing peritonitis

Haemodialysis Access related –Evidence base for starting with secure access, morbidity and mortality 3-5x (nutrition, infection) Outcomes –Haemo more efficient –no superiority of one technique in outcome- based trials

Cardiovascular Risk Foley RN et al. AJKD 1998; 32:S112-S119

38% % UK Registry 2002 Cardiovascular mortality in HD Prevalent HD patients % 7%

Cardiovascular risk in renal patients Conventional risk factors Hypertension Diabetes Age Gender Lipids Smoking Physical activity Specific to renal Hyperparathyroidism Phosphate Vascular calcification Vascular stiffness Renal anaemia Homocysteine Oxidative stress Uraemic factors?

Epidemiology: Cholesterol – do renal patients obey the normal rules? Lowrie AJKD 15,

Hypertension and mortality in HD; the controversy Port F et al AJKD 1999;33:507 RR of mortality to predialysis systolic BP, reference group prevalent HD patients USRDS Charra et al KI 1992:41;1286 Survival rates as a function of Mean arterial pressure at 5, 10, 15 y 445 patients on long-slow HD * * *

Pulse Pressure in Haemodialysis patients Tozawa et al. Kidney International 61, Feb 2002;

Hazard ratio for mortality with Pulse Pressure After adjustment for systolic blood pressure; *p<0.001 * * * * * * * * * * * * * * ** *

Prevalence of Hypertension in hemodialysis % % % Banerjee D et al AJKD 2000;583 Banerjee D et al JASN 2001; % % Gambro Miami Brighton UK; Age,60y

LCC: BP Control at presentation(%)

Blood pressure in the LCC

LCC: Mean number of antihypertensives NEJM 2001: 345;851

BP Control in CKD

Pulse Pressure >80 mm Hg is associated with poorer outcome PP<80 PP>80 Log Rank test p<0.05 PP<80 SGH low clearance clinic n=329

Inhibition of RAAS is associated with improved outcome in CKD 4/5 SGH On ACEI/ARB Log Rank test p<0.05 Not on ACEI/ARB Low clearance clinic at St Georges Hospital n=329 mean follow up 250 days