Timely Referral in Chronic Renal Failure Guidelines in Context

How much renal failure is out there? In 1998 there were 30,000 ESRF patients in the UK. (520 pmp) Current take on rates for dialysis are approx pmp Future needs for the UK predicted as 120pmp or more If no increase in take on rate there will still be 40,000 ESRF patients by 2010 Potential 100% increase by 2010 if take on increases

Should take on rates increase Indo-Asians have 4-7 x incidence of ESRD Increased incidence of ESRD with age Geographical inequalities still exist –Distance from renal unit has an inverse relationship with referral rate The impending Type 2 diabetes epidemic

Incidence of Chronic Renal Failure East Kent Study of unreferred CRF –Opportunistic study of all creatinines from lab –Males >180, females >135 (GFR <30-40) –Excluding ARF and patients known to renal unit –Prevalence 6400pmp, 85% unknown to renal –cf renal unit patients- significantly older 70% of patients <80 with CRF are unknown to renal unit

Who to refer and when? I dont know Not 6400pmp but more than at present?

PACE Guidelines for diabetes Refer when proteinuria >1g/24hours or creatinine >150 Similar to renal association guidelines and likely to be in the NSF Likewise any unexplained renal failure should be referred

Advantages of early referral to Nephrology Delayed referral is associated with a worse dialysis outcome Complications of chronic renal failure need careful multi-disciplinary management Is dialysis preventable?

Late referral Referral within 4 (6) months of the need to start dialysis Common and the incidence is not falling 13/35 patients in Bradford 2001 Many patients suffer a needlessly rough journey on the road to dialysis –Eadington, Nephrol Dial Transplant 1996

Late Referral QJM 2002 Bristol and Portsmouth % new RRT patients referred late Nearly half were avoidable late referrals Poorer clinical state at start of RRT and likely worse outcome

Late Referral Longer duration of predialysis nephrological care does improve outcome –Jungers et al 2001 How long is longer?

What are the benefits of earlier referral? or

The DOPPS Study To what extent does vascular access account for mortality on dialysis?

Bradford Pre-dialysis audit /35 patients referred late Only 8/35 patients had their first dialysis using a fistula Late referrals seem more likely to be older, diabetic, Asian

Advantages of early referral to Nephrology Delayed referral is associated with a worse dialysis outcome Complications of chronic renal failure need careful multi-disciplinary management Is dialysis preventable?

Complications of Chronic renal Failure Anaemia Bone Disease Acidosis Malnutrition Hypertension

Consequences of anaemia in renal disease Symptoms Increased cardiovascular morbidity and mortality Decreased quality of life Impaired cognitive function Decreased immune responsiveness

Left Ventricular Hypertrophy and Survival Silberg 1989

Pre-dialysis epo When should patients start epo therapy? When they start dialysis? –After months of anaemia and with LVH When they become anaemic pre-dialysis? Could we prevent anaemia from ever developing?

Bone Disease Hypocalcaemia due to reduced active Vitamin D Hyperphosphaemia due to reduced renal clearance Leads to Hyperparathyroidism Management: Dietary intervention Calcium supplements/ phosphate binders 1 -calcidol Exercise –Beware of hypercalcaemia, ? New phosphate binders Calcium Phosphate product –Last (not uncommon) resort is surgery

Nutrition Poorer nutritional status especially if elderly Reduced absorption Shift from protein to carbohydrate Reduced fluid intake Indices of nutrition are linked to poorer survival Management must be aggressive Dieticians 1g/kg/day protein Energy Relax dietary restrictions if patients at risk Intra-dialytic TPN Supplements Earlier start to dialysis

Advantages of early referral to Nephrology Delayed referral is associated with a worse dialysis outcome Complications of chronic renal failure need careful multi-disciplinary management Is dialysis preventable?

Is Dialysis Preventable Reversible causes of renal failure Can we do anything about non-reversible causes –In other words challenge the notion that they are non-reversible –Type 2 Diabetes Is Type 2 diabetes preventable?

Reversible causes of declining renal function Urinary tract obstruction Urinary tract infection Systemic hypertension Drugs Cardiac failure Metabolic abnormalities –hypercalcaemia Immunological disease Pregnancy

Ultrasound is mandatory in any case of unexplained renal failure

Hypertension Vicious circle relationship between hypertension and renal impairment Optimum control of Blood Pressure delays progression of renal disease (<130/85) ACE inhibitors seem better than other antihypertensive agents –Anti-proteinuric –Anti-fibrogenic Which leads me onto

Drugs NSAIDS Diuretics Interstitial nephritis, especially in the elderly ACE Inhibitors

ACE Inhibitors- hero or villain? The typical vascular surgery patient –Elderly –Previous CVA and angina –NIDDM –On Frusemide, lisinopril and brufen –Acutely ischaemic leg –Fasted from admission –Angiogram –Nephrology consult Like most disasters ARF is usually multi-hit

Nephrology and ACE inhibitor is a strange relationship Most of our patients should be on them We must be vigilant, renovascular disease is common ACE inhibitors (and diuretics) should often be suspended in the face of intercurrent illness

Suggested Guidelines Screen for risk factors Age, PVD, low cardiac output, NSAIDs, high dose diuretics Check renal function before and at 7-10 days Check renal function regularly in those with risk factors (annually) Assess if intercurrent illness or change in drugs Consider withdrawal if creatinine increases to above normal range or by 25% but for some there is an important risk-benefit question

Immunological diseases causing renal failure Can occur at any age Most have a high liklihood of response to immunosuppressive therapy Relapses are not uncommon –Wegeners –Polyarteriitis –Lupus –Rheumatoid –Goodpastures Urinalysis will be abnormal in the presence of active glomerulonephritis

Forget the smallprint Lets get back to diabetes!

PACE guidelines for Diabetes 2002 Renal/Hypertension

Key Points from the Guidelines Proteinuria/ microalbuminuria ACE Inhibitors Early referral –Creatinine (>150) –Proteinuria (PCI >1000)

Earlier referral should improve subsequent mortality/morbidity of patients with ESRF due to diabetes

Or is there another way?

Is diabetic nephropathy preventable? Tight control Blood pressure Proteinuria ACE inhibitors Lipids Smoking cessation

Blood pressure and proteinuria Reducing blood pressure slows the rate of disease progression Superiority of ACE Inhibitors –Lewis et al NEJM 1993, Captopril Proteinuria is not just a disease marker but is pathogenetic Reduction in proteinuria slows progression –Reviewed in lancet editorial 1999, DeJong et al

Blood pressure and proteinuria Hovind Kidney International 2001 Normal progression of DN 10-12ml/min/year 7 year study of 300 type 1 patients 31% remission 22% regression (GFR decline 1ml/min/year) Even in this clinic many patients do not achieve BP targets

Smoking and Lipids Meta-analysis suggests that lipid lowering can preserve GFR Renal function declines twice as fast in smokers –This is under appreciated by patients and doctors Progression, remission, regression of chronic renal disease Ruggenenti, lancet 2001: 357

The final common pathway We have got to get on the case before this!

Why are patients referred late? Ignorance of the value of early referral –Nephrologist = Dialyser? Ambivalence about high-risk patients –At all levels of renal impairment referral rates are higher for lower risk patients Under-estimation of severity of renal failure –50% of patients with creatinine >500 require dialysis within 3 months High risk patients progress more rapidly and tolerate uraemia less well

How to avoid late referral? Education –Progression rates vary –Creatinine is a flawed marker –Management of CRF is a dynamic process –Age is not a criterion Assess high risk patients before they have symptomatic uraemia Integrated follow-up –Primary care –General physician –Geriatrician –Nephrologist –Urologist

Is Dialysis for everyone? The Stevenage experience Pre-dialysis counsellors make a recommendation of dialysis or conservative treatment Conservative treatment is active ?no difference in outcome

Age does not feature in any guidelines We would have dialysed if asked