Saudi Journal of Kidney Diseases and Transplantation

REVIEW ARTICLE
Year
: 2011  |  Volume : 22  |  Issue : 3  |  Page : 419--427

The value of pre-dialysis care


Ayman Karkar 
 Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, Dammam, Saudi Arabia

Correspondence Address:
Ayman Karkar
PhD, FRCP, Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, P.O. Box 11825, Dammam
Saudi Arabia

Abstract

Chronic kidney disease (CKD) is one of the major health care burdens worldwide, with a significant increase in the number of patients and a huge increase in the financial demands in recent years. Patients with CKD usually progress through different stages before they reach end-stage renal disease. The rate and speed of renal function deterioration are variable, but uncontrolled hypertension and diabetes mellitus are major risk factors. Pre-dialysis care, with change of life style, blood pressure and glycemic control, the use of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, lipid-lowering agents and management of anemia and mineral bone disorder can improve quality of life, preserve functioning nephrons and reduce cardiovascular morbidity and mortality with significant reduction in management costs. Early referral of patients with CKD to the nephrologist allows for adequate exposure to educational programs, psychosocial preparation, participation in the decision of type of renal replacement therapy (RRT), pre-emptive kidney transplantation, early creation of dialysis access and adequate training in selected modality of RRT. The degree of involvement and interaction must be individualized according to the needs of the patient and the type of RRT planned. A multi-disciplinary team is crucial for the implementation of a variety of strategies and to intervene more effectively in meeting the health care needs of CKD patients.



How to cite this article:
Karkar A. The value of pre-dialysis care.Saudi J Kidney Dis Transpl 2011;22:419-427


How to cite this URL:
Karkar A. The value of pre-dialysis care. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Sep 16 ];22:419-427
Available from: http://www.sjkdt.org/text.asp?2011/22/3/419/80473


Full Text

 Introduction



Chronic kidney disease (CKD) is characterized by a gradual and sustained decline in renal clearance or glomerular filtration over many years, resulting in permanent kidney failure. The Kidney Disease Improving Global Outcomes (KDIGO) statement has defined CKD as either kidney damage or glomerular filtration rate (GFR) of <60 mL/min/1.73 m [2] for ≥3 months. [1] Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Furthermore, the KDIGO has classified CKD into five stages, [1] from kidney damage with normal or increased GFR to end-stage renal disease (ESRD), as shown in [Table 1].{Table 1}

CKD constitutes a worldwide health problem with significant morbidity and mortality and financial burden. [2] The number of patients with ESRD continues to rise, at least in part, due to the increased incidence of diabetes mellitus and hypertension, aging population and improved dialysis technology and availability. [3],[4] In the United States (US), it is estimated that 26 million people have CKD or albuminuria. [5] The Kidney Early Evaluation Program (KEEP) screened 100,000 participants and showed that 28.7% have CKD, most of them in Stage-3. [6] The recent US Renal Data showed that more than 480,000 people are on dialysis therapy or living with kidney transplant, and projected that nearly 800,000 prevalent patients with ESRD will be receiving RRT and more than 150,000 new patients will begin treatment by 2020. [7] The prevalence of CKD in Europe is probably similar to that of the US, but with varying figures among different European countries. [3] In the United Kingdom, a large primary care study (practice population of more than 160,000) suggests an age-standardized prevalence of Stage-3-5 CKD of 8.5%, [8] and the number of patients per million population starting dialysis each year is 498. [9] In a recent screening study in Mexico (3,734 participants), 15.8% had Stage-3-5 CKD, with 43.5% having diabetes mellitus and 62% having hypertension. [10] Another recent screening study in China, Nepal and Mongolia (11,394 participants) showed that 7.3%-14% had Stage-3-5 CKD. [11] An earlier Australian study (AUSDIAB) showed that the prevalence of renal impairment was 12.1% (defined by a calculated GFR of <60 mL/min), and this study indicated that 18% of the adult Australians had at least one indicator of CKD. [12] Data on the burden of CKD in the Arab world remains poorly understood. Most of the available statistics in the Kingdom of Saudi Arabia are about prevalence of treated ESRD. The recent estimated prevalence of CKD in the young Saudi population was 5.7%. [13] The annual incidence of treated ESRD patients is 172/million population/year, and the annual prevalence of treated ESRD is 753/million population/year. The current number of patients on dialysis is about 11,000, and it is expected to exceed 15,000 by the end of 2015. [14]

Patients at risk of developing CKD include those with family history of renal disease [15] and patients with diabetes mellitus, hypertension, kidney stones, chronic urinary tract infections as well as people in the older age-group. [1] Patients at risk of CKD need to be screened and monitored yearly for blood glucose, blood pressure, urine analysis for micro-albuminuria, serum creatinine and renal function, which should be expressed as estimated GFR (eGFR) using the Modification of Diet in Renal Disease (MDRD) equation. [16] The risk of progression of CKD is increased in patients with poor glycemic and blood pressure control and in patients with high levels of proteinuria. [1],[17],[18] Early detection of CKD, change of life style, which includes cessation of smoking, weight reduction, proper diet and physical fitness, and management of modifiable risk factors can slow the progression of both CKD and the attendant cardiovascular disease. [18],[19]

Ideally, caring for CKD patients requires an integrated and systematic approach from an integrated renal team. [20],[21] The role of a multi-disciplinary team, which includes the primary healthcare physician, nephrologist, renal nurse, dietitian, social worker and psychologist/psychiatrist, is quite essential in approaching and preparing CKD patients during different stages of the disease. [22] The renal team should be well trained and should have adequate exposure to social, psychological and medical concepts of CKD, the specific needs of these patients at different stages of their disease and indications and advantages of different modalities of RRT. [23],[24] Equally important is the participation of the next of kin/family as understanding the chronicity of the disease and its demanding needs is vital in providing and maintaining care and support. [25]

Over the past few decades, there have been impressive advancements made in peritoneal and hemodialysis technologies for the management of patients with ESRD. These innovations have improved the quality of dialysis and the wellbeing of patients, but have failed to achieve any improvement in survival rates, and continue to drain health budgets and may not be easily affordable by many countries. [26] Optimal pre-dialysis care, however, remains an attractive and effective measure in reducing the morbidity and mortality, and constitutes a valuable cost-effective option. [27],[28],[29] The aim of this narrative review is to outline the value of pre-dialysis care and the benefits of early referral of patients with CKD to the nephrologist and to demonstrate the invaluable role of the multi-disciplinary team in approaching, preparing and supporting CKD patients in the pre-dialysis stage.

 Late Referral of Patients with CKD



Late referral to the nephrologist (<3 months before initiation of dialysis) will deprive patients with CKD from adequate control of diabetic and hypertensive nephropathy, management of anemia, mineral and bone disorder, lipid abnormalities and malnutrition; measures that may preserve functioning nephrons or slow down the deterioration of renal function and possibly avoid or reduce the risk of cardiovascular morbidity and mortality. [30],[31],[32],[33] An earlier survey showed that 70% of the patients referred late suffered major complications. [34] A case-controlled study showed that CKD patients referred late had greater acidosis, hypocalcemia, hyperphosphatemia, anemia, hyper-tension and fluid overload than patients referred early. [35] Late referral of patients with CKD has also been associated with more hospitalizations for symptomatic uremia [33] and increase in management costs. [36] Furthermore, with late referral, there is not only less chance of selection of self-care dialysis modality [37] but also an increased need for urgent initiation of dialysis, which enforces temporary percutaneous catheter insertion. [38] Temporary catheters are associated with an increased risk of luminal thrombosis, infection, inadequate blood flow rates and central venous stenosis. [39],[40] Tunneled catheters have been associated with a 39% increased risk of death. [41] The consequences of late referral of patients with CKD to a nephrologist are summarized in [Table 2].{Table 2}

 Pre-Dialysis Care



Pereira [42] and Obrador and Pereira [43] described the components of optimal care of patients with CKD. These include delaying progressive loss of kidney function, modifying the risk for developing co-morbid conditions, preventing complications of progressive CKD, improving quality of life and ensuring adequate preparation for RRT. On the recent 60 th birthday of the US National Kidney Foundation (NKF), one patient with CKD stated "I am Stage-3 and am seeing my doctor tomorrow. If it hadn't been for NKF, I never would have caught it this early." -Connie O.[44]

 Screening for CKD and its Risk Factors



The change of lifestyle worldwide with less physical fitness, increase in smoking and consuming unhealthy diet together with significant increase in the incidence of obesity, diabetes mellitus and hypertension has largely contributed to the increased incidence and prevalence of CKD. [45] Screening of the general public is a crucial step in identifying modifiable and non-modifiable risk factors and those at increased risk of developing kidney disease. [46] These include the presence of positive family history of kidney disease, hypertension and diabetes mellitus and the early detection of increased body mass index, elevated blood pressure, presence of microalbuminuria, glycosuria and/or elevated blood sugar, hyperlipidemia, elevated serum creatinine and reduction in eGFR. Recent screening programs in different countries have detected a high prevalence of patients with hypertension, diabetes mellitus, proteinuria and patients with Stages 3-5 CKD. [6],[10],[11],[16] These screening programs not only play an important role in educating the public and increasing awareness of the disease, its burden and complications and ways of prevention but also in creating an opportunity for timely nephrology consultation, especially with progressive or more severe nephropathies. [6],[19],[29],[46]

 Early Referral of CKD Patient



Most of the consequences of late referral can be avoided or alleviated if patients with CKD are referred early to a nephrologist. Ifudu et al [47] found that 43% of the patients who had received care from a nephrologist had shorter hospital days at the start of their dialysis, lower mean serum creatinine levels, less severe metabolic acidosis and the need for fewer temporary vascular accesses. Early referral of patients with type II diabetes mellitus with early diabetic nephropathy resulted in better preservation of renal function and better control of blood pressure. [48] Early referral of CKD patients has also been shown to achieve better control of severe hypertension, lower prevalence of uremic symptoms, lower risk for pulmonary edema, avoidance of the need for urgent dialysis therapy, satisfactory preparation and placement of an arteriovenous fistula, greater chance of choosing peritoneal dialysis and receiving a renal transplant. [19] Moreover, it has been repeatedly shown in retrospective studies that patients with ESRD referred early to a nephrologist had lower morbidity and mortality. [27],[34],[35],[43],[49] In addition, early referral has been confirmed in different studies to be more cost-effective than late referral. [28],[29],[36],[50]

Ideally, there should be a direct collaboration between the primary health care physician and the nephrologist. [19] It is expected that primary health care physicians should refer patients with CKD while in Stage-1 if hematuria or significant proteinuria is present, in Stage-2 if eGFR declines >4 mL/min/year and in Stage-3 for all patients with CKD where eGFR is <60 mL/min/1.73 m 2 . [1],[51] Special attention should also be directed toward early referral of adole scent renal patients. [52] The many valuable benefits of early referral of patients with CKD to the nephrologist are outlined in [Table 3].{Table 3}

 Optimization of Treatment of CKD



Early referral of patients with CKD to the nephrologist/renal team will help in close monitoring of general health and renal function and avoidance and control of CKD and cardiovascular modifiable risk factors. [53],[54],[55] This should include advice and guidance about change of life style with cessation of smoking, weight reduction and dieting and physical fitness. Regular and planned visits to renal clinic will ensure better glycemic and blood pressure control, detection and management of microalbu minuria, treatment and control of proteinuria, appropriate use of ACE-I and/or ARB and lipid-lowering drugs, assessment and management of malnutrition, maintenance of acid-base balance, proper management of anemia and management of mineral and bone disorder. [18],[56],[57] These measures will help in presserving the remaining functioning nephrons, delaying the progression of renal failure and reduce cardiovascular morbidity and mortality by 20%-50%. [16],[36],[51],[58],[59]

 Structured Education Programs



CKD, whether primary or secondary to systemic illness, takes a long course of follow-up and probably the whole of patient's life. It usually passes through different stages until it reaches over years to ESRD, [1] where another journey starts in the form of dialysis-dependent life [either hemodialysis (hospital or home) or peritoneal dialysis (CAPD or APD)], or kidney transplantation. Many patients may fail one or more of these treatment modalities and require changing to another form of RRT. Once they reach ESRD, and if not well prepared, CKD patients usually go through a stage of denial, shock, grief and anger, and if not well managed, it will lead to psychological distress and depression. Depression is common in CKD and ESRD patients, and has been associated with increased risk of morbidity and mortality. [60] It has recently been shown that paying greater attention to improving mood and activity level among patients with CKD and ESRD could help these individuals to maintain employment, along with improving their overall quality of life. [61] Psycho-education and counseling is an important non-pharmacological treatment of depression. [62] A recommended approach to an education program for CKD patient is outlined in [Table 4].{Table 4}

In order to facilitate CKD patients to cope well with their disease and its consequences, it is essential that they understand the normal function of the kidneys, diseases of the kidneys, complications, treatment/medications, diet and fluid control and different options of RRT. Psychological care and education should begin in the pre-dialysis stage with the help and support of the renal (multi-disciplinary) team and the next of kin/close relative at different visits in a specific counseling clinic. [23],[25],[46],[63]-[65] Implementation of effective structured educational programs has been shown to be of great benefit in promoting self-care dialysis modality. [37],[66],[67] This is usually accompanied with an early insertion of a peritoneal catheter or creation of an arteriovenous vascular access where sufficient time allows for access maturation and adequate training. Self-care dialysis can help in providing treatment for more patients with restricted resources, improvement of treatment outcomes, alleviation of anxiety, greater prospect for continued employment and reduction of cost of treatment. [63],[68] Pre-dialysis psychoeducation intervention has been shown to be effective in achieving a meaningful delay in the initiation of maintenance dialysis therapy, and had resulted in a statistically significant survival advantage when compared with usual care. [69] Patients approaching ESRD should also be educated about the possibility of pre-emptive kidney transplantation, where there is sufficient time for completion of pre-transplant work-up and assessment of the suitability of the CKD patient before the appearance of signs and symptoms of uremic toxicity. A recommended approach for preparing a CKD patient for RRT is outlined in [Table 5].{Table 5}

In conclusion, CKD is a worldwide health problem with significant increase in the number of affected patients and increased demands in financial costs. CKD is an illness for which long-term management is required. A well-trained and experienced multi-disciplinary team and the availability of an integrated renal replacement therapy program are vital for providing proper help and support for CKD patients. Improvement of quality of life, reduction of morbidity and mortality and savings in the management costs are some benefits of pre-dialysis care. Pre-dialysis care includes: (a) screening for risk factors and assessment of the incidence and prevalence of CKD, (b) implementation of preventive measures for modifiable risk factors, (c) proper collaboration between primary health care physicians and nephrologists, (d) early referral to a nephrologist for regular follow-up and optimization of medical treatment and (e) implementation of a structured psychoeducational program.

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