Timing of Renal Replacement          TherapyInitiation in Patients Approaching End-stage                Renal Disease     ...
192419451960
Goals of Dialysis in ESKD• Prolong life• Improve life         Early start                              Late start       10...
Rosansky et al -
What I thought I learned?Dialysis can restore health, improveappetite, replaces kidney function, and has fewdown sides, an...
What Rosansky labels as CW• Level of clearance is associated with survival and  morbidity, and clearance by dialysis is th...
Dialysis – Does and Doesn’ts• Removes small               • Remove middle and  molecular weight              large MW mole...
Potential downsides to dialysis• More rapid loss of RRF• Possible myocardial ischemia hits• Chronic inflammation and oxida...
What would be some criteria for   determining when to start dialysis?Laboratory findings    Symptoms/Signs• Creatinine    ...
KDOQI• KDOQI, Canadian 1997 - - kT/V urea < 2 /wk  (equivalent to creatinine clearance 10.5 ml/min• KDOQI 2001 essentially...
From early observational studies to        rethinking risk/benefit• 1982 – urea reduction with HD predicts  mortality• 199...
Pan -
Pan -
IDEAL – Initiating Dialysis Early and                     Late•   Randomized controlled trial•   828 adults – Australia an...
When to initiate dialysis ( for the slowly progressive CKD patient)eGFR 5-9 ml/min/1.73M2 and uremia related:• Pericarditi...
But I would add other factors to                include• Rate of kidney function decline – maybe  earlier if rapid decline...
Tamura -
192419451960
Dialysis initiation final
Dialysis initiation final
Upcoming SlideShare
Loading in...5
×

Dialysis initiation final

742

Published on

1 Comment
2 Likes
Statistics
Notes
No Downloads
Views
Total Views
742
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
1
Likes
2
Embeds 0
No embeds

No notes for slide

Dialysis initiation final

  1. 1. Timing of Renal Replacement TherapyInitiation in Patients Approaching End-stage Renal Disease Patrick Gipson, MD January 24, 2013
  2. 2. 192419451960
  3. 3. Goals of Dialysis in ESKD• Prolong life• Improve life Early start Late start 10-15 ml/min/1.73m2 <5-8 ml/min/1.73m2
  4. 4. Rosansky et al -
  5. 5. What I thought I learned?Dialysis can restore health, improveappetite, replaces kidney function, and has fewdown sides, and since diabetics are overallsicker, they should start dialysis earlier.
  6. 6. What Rosansky labels as CW• Level of clearance is associated with survival and morbidity, and clearance by dialysis is the same as clearance by the native kidney• Low albumin means bad nutrition• Nutrition gets better after starting dialysis• Diabetics should start at eGFR < 15, everyone else can wait until 10• Once you get to a GFR of < 15, it is rapidly downhill from there• It is dangerous to wait to an eGFR < 6 to start dialysis
  7. 7. Dialysis – Does and Doesn’ts• Removes small • Remove middle and molecular weight large MW molecules solutes well well (BUN, Cr, H20, Na, K, +/- • Modulate inflammation P) • Balance Ca/Phos/Vit D• Rapidly removes fluid axis (3-4 hours instead of • Immediately benefit 48-72 hours) those without• Provides lifesaving uremia, volume therapy in AKI with overload, or hyperkalemia, volume hyperkalemia overload, uremia
  8. 8. Potential downsides to dialysis• More rapid loss of RRF• Possible myocardial ischemia hits• Chronic inflammation and oxidative stress• Dialysis access issues – infection, thrombosis, procedures• Heparin exposure• Increased ESA dosing• Protein and blood loss
  9. 9. What would be some criteria for determining when to start dialysis?Laboratory findings Symptoms/Signs• Creatinine • Uremia?• BUN (azotemia) • Pericarditis• GFR • Cognitive decline• Hyperkalemia • Volume overload• Albumin • Nausea/loss of appetite• Protein catabolism
  10. 10. KDOQI• KDOQI, Canadian 1997 - - kT/V urea < 2 /wk (equivalent to creatinine clearance 10.5 ml/min• KDOQI 2001 essentially the same, changing tone, still “It is paradoxical that nephrologists have focused on optimizing urea clearance once patients are started on dialysis, but have accepted much lower levels of kidney urea clearance during the pre-dialysis phase of patient management.”• KDOQI 2006 not much different, but more change in tone
  11. 11. From early observational studies to rethinking risk/benefit• 1982 – urea reduction with HD predicts mortality• 1992 – serum albumin predicted survival• 1997 – CANUSA suggests PD = endogenous• 2003-5 – several studies show RRT is the important fact, not urea reduction, and additionally that albumin in dialysis patients more of a marker of inflammation than nutrition
  12. 12. Pan -
  13. 13. Pan -
  14. 14. IDEAL – Initiating Dialysis Early and Late• Randomized controlled trial• 828 adults – Australia and New Zealand• 355 with DM• 65% male• Mean age 60.4 years• Early start GFR 10-14, Late start 5-7
  15. 15. When to initiate dialysis ( for the slowly progressive CKD patient)eGFR 5-9 ml/min/1.73M2 and uremia related:• Pericarditis• Coagulopathy• GI symptoms with N +/- V• Anorexia/unexplained weight loss• Diuretic refractory volume issues• Resistant hyperkalemia Rosansky -
  16. 16. But I would add other factors to include• Rate of kidney function decline – maybe earlier if rapid decline to avoid acute start• Cardiorenal syndrome can greatly increase minimal tolerated eGFR• Hepatorenal syndrome• Certain metabolic issues (hyperoxaluria)• Other co-morbidities, often age related
  17. 17. Tamura -
  18. 18. 192419451960

×