Treatment Option in Kidney Failure

The Right Patient, the Right Treatment, and the Right Time

Syakib Bakri
 Definition of Chronic Kidney Disease

Structural or functional abnormalities of

the kidneys for >3 months, as
manifested by either:
1. Kidney damage, with or without decreased
GFR, as defined by
• pathologic abnormalities
• markers of kidney damage, including
abnormalities in the composition of the blood or
urine or abnormalities in imaging tests
2. GFR <60 ml/min/1.73 m2, with or without
kidney damage
Incidence and Prevalence of End-Stage
Renal Disease in the US
 Diabetes and hypertension are
leading causes of kidney failure

Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.

ESRD, end stage renal disease USRDS ADR, 2007

Classification of CKD Based on GFR and Albuminuria
Categories: “Heat Map”

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.

Kidney Int Suppls. 2013;3:1-150.
 Prevalence of CKD and Estimated Number
of Adults with CKD in the US (NHANES 88-94)
Prevalence*
GFR
Stage Description N
(ml/min/1.73 m2) %
(1000s)
Kidney Damage with
1  90 5,900 3.3
Normal or  GFR
Kidney Damage with
2 60-89 5,300 3.0
Mild  GFR

3 Moderate  GFR 30-59 7,600 4.3

4 Severe  GFR 15-29 400 0.2

5 Kidney Failure < 15 or Dialysis 300 0.1

*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated
from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For
Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two
measurements.
 Optimal care of kidney disease patients
Care which, when implemented reliably, is associated with:
• Delay of progression of CKD; thus delay of time to renal
replacement therapy;
• Treatment of other comorbidities;
• Delay of progression of cardiovascukar disease;
• Improve quality of life;
• Reduction in mortality, irrespective of renal replacement therapy.
Strategies to delay progression of kidney disease
• Reduction in blood pressure
• Use of angiotensin converting enzyme inhibitors
or angiotensin receptor blockers
• Reduction of proteinuria
• Glycemic control in diabetics
Treatments of other comorbidities and improve
quality of life
• Treatment of anemia
• Protein restriction
• Dietary phosphate restriction
• Attenuation of abnormalities of parathyroid
hormone
• Maintenance of good nutritional status.
Who Should be Involved in the Patient Safety Approach to CKD?

Kidney Kidney
damage and damage and Moderate Severe Kidney
normal or  GFR mild   GFR  GFR failure
GFR

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

GFR 90 60 30 15
Primary Care Practitioner Internist Nephrologist
Consult?

Patient safety
The Patient (always)
and other subspecialists (as needed)
Advantages of Timely Referral in Patients with
Progressive CKD
• Improves patient preparation for RRT
• Greater use of permanent vascular access
• Avoidance of emergent hemodialysis initiation
• Greater utilization of transplantation and self-care
dialysis (i.e., peritoneal dialysis or home hemodialysis)
• Management of medications which may help to delay
the need for RRT
• Gives the nephrologist adequate time to counsel
patients through this challenging transition in their
lives

KDIGO Transplant Guidelines

Observational Studies of Early vs. Late
Nephrology Consultation

Chan M, et al. Am J Med. 2007;120:1063-1070.

http://download.journals.elsevierhealth.com/pdfs/journals/
0002-9343/PIIS000293430700664X.pdf
KDIGO CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
Treatment Options for Renal Replacement Therapy

ESRD Comfort Care

Hemodialysis Peritoneal Dialysis

Kidney Transplant
Dialysis Options
Dialysis

Hemodialysis Peritoneal Dialysis

In-Center HD (3 x week) Manual (CAPD)

Home HD (short daily, nocturnal) Home
Cycler (CCPD)
 Timing for surgical assessment

• Time for surgical dialysis assessment

- when hemodialysis is anticipated within 6 months
(KDOQI)
- eGFR 15-20 ml/menit (Canadian guidelines)
• Timing for surgical creation
The timing of fistula creation should balance the risk
of an unnecessary procedures; if access is placed
too early vs starting with catheter if the AV access is
placed too late in the progression to ESKD
Patient whose fistula is created early may:
• Never progres to require dialysis and need the access.
• Die before progressing to dialysis (especially in the elderly
population.
• Have prolonged access non-use resulting in higher risk of clotting
and stenosis necessitating additional invasive procedures.
Patient whose fistula is created late may:
• Not have a mature access for cannulation at dialysis start, thus
being exposed to catheter and its high risk of deleterious
complications.
• Prolonged catheter use has been shown to increase venous
sclerosis and reduce the suitability of patients’ vasculature for
fistula creation and maturation.

60% of AV access creations fall either too early or too late

as recommended by national guidelines
Timing of Placement of Vascular Access
• Patients with CKD should be reffered for surgery to
attempt construction of a primary AV fistula when
their creatinin clearance level is < 25 mL/min, their
serum creatinin level is > 4 mg/dL, or within 1 year
of an anticipated need for dialysis
 Summary
• Kidney Failure (CKD stage 5) is an important
issue because of the increasing incidence rates,
high mortality and expensive medical expenses.
• Hemodialysis is the most widely used form of
renal replacement therapy.