Management of CKD Stages 4 and 5: Preparation for Transplantation, Dialysis, or Conservative Care



Management of CKD Stages 4 and 5: Preparation for Transplantation, Dialysis, or Conservative Care


Ajay Singh

Jameela Kari



Once a patient has reached stage 4 chronic kidney disease (CKD), with size-adjusted estimated glomerular filtration rate (eGFR/1.73 m2) of <30 mL/min, he or she should be under a nephrologist’s care. Ideally, the patient should also be a part of a multidisciplinary predialysis program that includes patient and family education, early choice of appropriate renal replacement modality, and, if dialysis is being considered, elective creation of dialysis access. The advantage of a programmatic approach to care is a planned outpatient initiation of dialysis in a patient who is both mentally and physically prepared. It is likely that this approach results in fewer hospital days in the first month after beginning dialysis and substantial cost savings.

I. CHOICE OF MODALITY

A. Patient education. Of key importance is patient education about the various treatment options available in the event that renal replacement therapy will become necessary. Would the patient best benefit from some form of dialysis, from preemptive transplantation, or from continued conservative management? In some cases, due to extreme patient debility or other reasons, dialysis may not be an appropriate option, and conservative management may be the best choice. These discussions are best initiated once a patient is still in stage 4 CKD, and well before stage 5 has been reached.

B. Options for renal replacement therapy (Table 2.1)

1. Preemptive transplantation. Transplantation offers survival superior to the standard forms of dialysis being offered today. Transplantation may not be indicated, however, for a patient who has severe problems with compliance in terms of medications. Preemptive transplantation has a higher success rate in general than when transplantation is initiated after hemodialysis (Kallab, 2010), and for this reason, discussions about the feasibility of transplantation and transplantation workup should begin well in advance of any need for dialysis, usually when eGFR/1.73 m2 is still well above 10 mL/min (Kupin, 2011).









TABLE 2.1 Treatment Options in Patients Who Need Renal Replacement Therapy













































Modality


Description


Advantages


Disadvantages


Preemptive transplantation


Live or cadaver donor transplant before ever needing dialysis


Improved patient survival relative to conventional dialysis; lower long-term costs.


Logistics of finding a suitable donor; need for compliance with immunosuppressive drugs.


Home hemodialysis


3-6 times per week, either during the day or at night. Usually assisted by a relative or caregiver; uncommonly, by a paid health-care professional


When given more than 3 times per week, or when given as 8-10-hour treatments, 3-3.5 nights per week, evidence suggests better quality-of-life and better control of phosphate and blood pressure; may also reduce left ventricular hypertrophy


Home is changed into a hospital; partner burnout; with some home therapies, modification to home water systems is required; waste disposal; expense


Home PD


Automated cycler, with most exchanges done during the night


Independence, relative simplicity


Need for delivery of large volumes of PD fluid; exposure to high amounts of glucose


In-center nocturnal hemodialysis


Three 7-9-hour nocturnal treatments per week (or uncommonly, every other night) given incenter (either staff assisted or self-care)


Marked increase in weekly dialysis time with better control of phosphate, blood pressure, and anemia. Home does not need to be converted into a clinic. Dialysis time spent sleeping


Leaving home unattended on dialysis nights; travel to unit; relatively inflexible schedule


In-center conventional hemodialysis


Either staff assisted (the norm) or self-care


Short amount of time spent on dialysis. Staff does all the work


Travel to unit; relatively inflexible schedule. May be inadequate amount of dialysis


Postponing dialysis


Very-low-protein diet plus ketoanalogues, careful fluid management


May work to postpone dialysis for about 1 year in elderly patients with few comorbidities (no heart failure, diabetes)


Expense of ketoanalogues


Palliative


care Conservative management without dialysis


Good for those patients for whom dialysis is not expected to prolong life to a significant extent or in whom overwhelming comorbidities are present


Potentially reduced life expectancy


Modified from Tattersall JE, Daugirdas JT. Preparing for dialysis. In: Daugirdas JT, ed. Handbook of Chronic Kidney Disease Management. Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins, 2011:511-523.



2. Dialysis: Home versus in-center therapy. Among the end-stage renal disease (ESRD) therapies, the choices made will depend on what is available in the local community. One of the main decisions to be made is whether the patient will be coming in to a clinic for regular dialysis (hemodialysis in this case), or whether he or she would prefer the independence of dialyzing at home, using either a home hemodialysis system or peritoneal dialysis (PD). Obviously transportation issues are very important here, as is the status of a patient’s home, the amount of support available through interested family members who might assist as caregivers, and technical issues such as available water quality and electricity.

In observational studies, mortality rates are lower in home hemodialysis patients than in in-center hemodialysis patients, sometimes dramatically so, even after adjustments for common comorbidities and at similar total weekly dialysis times. Some of this home dialysis advantage may be due to unaccounted for patient selection bias, as patients undertaking the responsibility to dialyze at home usually have a strong positive attitude, good compliance, and strong caregiver and/or family support structure, factors which are associated in their own right with increased survival. Mortality rates for in-center hemodialysis are similar to those for home PD, so the selection of home versus in-center modality should be based primarily on patient preferences versus any anticipated survival benefit.

3. “Short daily” hemodialysis. Normally, whether done at home or in-center, hemodialysis therapy is offered 3 times per week, usually 3-5 hours per session. When the same amount of dialysis time is broken up into five or six sessions per week, some observational studies have shown better control of blood pressure, better nutrition (weight gain, increased appetite and albumin), and better control of anemia. In the only moderate-sized randomized trial that has been
done, the FHN trial, where patients were randomized to get 6 treatments per week but in fact averaged only 5, those assigned to more frequent dialysis for 1 year were found to have reduction in left ventricular hypertrophy, improved physical functioning (those were the two primary outcomes of the FHN trial), a reduced severity of hypertension, and marginally improved control of serum phosphorus. There was no improvement in serum albumin, nutritional measurements, or control of anemia (FHN Trial Group, 2010). The details of various “short daily” hemodialysis regimens are discussed in Chapter 16. Usually frequent hemodialysis is done at home and is only rarely offered in-center or in self-care units. “Short daily” hemodialysis is gaining in popularity, especially with the availability of easy-to-use machines dedicated to delivering such therapy in the home setting.

Jun 16, 2016 | Posted by in NEPHROLOGY | Comments Off on Management of CKD Stages 4 and 5: Preparation for Transplantation, Dialysis, or Conservative Care

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