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Renal Replacement Therapy-What The PCP Needs To Know PowerPoint Presentation

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This medical PowerPoint presentation is about Renal Replacement Therapy (RRT), the medical treatment used to replace the normal functions of the kidneys when they are unable to do so. RRT is typically used in patients with end-stage kidney disease (ESKD) or acute kidney injury (AKI).

The three main types of RRT are Hemodialysis (HD), Peritoneal dialysis (PD) and Kidney transplant.

Tags : Renal Replacement Therapy, kidneys, end-stage kidney disease, ESKD, acute kidney injury, Hemodialysis, Peritoneal dialysis, Kidney transplant, Nephrology, Nephrology PowerPoint presentation

Published on : Jun 07, 2023 | Views : 1128 | Downloads : 3

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Slide 1-

Renal Replacement Therapy: What the PCP Needs to Know
Slide 2-

Learning Objectives Describe treatment options for renal replacement therapy to improve awareness and understanding. Use evidence-based strategies to manage patients with kidney failure in need of renal replacement therapy to improve outcomes. Manage patients receiving dialysis or living with a kidney transplant, from a primary care perspective.
Slide 3-

Question 1 A patient with progressive CKD has opted for hemodialysis for renal replacement therapy. Which type of vascular access is associated with better outcomes in hemodialysis patients? A. Central venous cuffed catheter B. Arteriovenous graft C. Arteriovenous fistula D. Temporary central venous catheter
Slide 4-

Question 2 Another patient with progressive CKD is considering a kidney transplant. Which one of the following statements is correct? A. CKD patients can be referred to a transplant center when their GFR is < 20 mL/min/1.73m2 B. Pre-emptive and live kidney transplants are associated with better graft survival C. Most common cause of kidney transplant loss is death with a functional transplant D. All of the above
Slide 5-

Renal Replacement Therapy Overview and Considerations for the PCP
Slide 6-

Indications for Renal Replacement Therapy Hyperkalemia Metabolic acidosis Fluid overload (recurrent CHF admissions) Uremic pericarditis (rub) Other non specific uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attentiveness, and cognitive tasking, …
Slide 7-

Treatment Options for Renal Replacement Therapy ESRD Hemodialysis Kidney Transplant Peritoneal Dialysis Comfort Care
Slide 8-

Treatment Options for Renal Replacement Therapy ESRD Hemodialysis Kidney Transplant Peritoneal Dialysis Comfort Care
Slide 9-

Dialysis Options Dialysis Hemodialysis Peritoneal Dialysis In-Center HD (3 x week) Home HD (short daily, nocturnal) Manual (CAPD) Cycler (CCPD) Home
Slide 10-

Incident Patient Counts (USRDS)by 1st Modality USRDS 2013 ADR
Slide 11-

Total Medicare ESRD expenditures, by modality Period prevalent ESRD patients. USRDS 2013 ADR
Slide 12-

Refer patients early, when eGFR < 30 ml/min/1.73 m2 Education about types of renal replacement therapy: Hemodialysis (vascular access +++) Peritoneal Dialysis (QOL advantage +++) Kidney Transplantation Refer when eGFR < 20 ml/min/1.73 m2 Living kidney transplant (family, friends) Build time on list before dialysis initiation Even transplant before dialysis initiation (pre-emptive) No PICC lines for patients with eGFR < 45 mL/min/1.73m2 Referral and Education for Patients with Progressive CKD
Slide 13-

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
Slide 14-

Medical Health and Wellness: Components of Multidisciplinary Care in Progressive CKD Education and counseling about different RRT modalities, transplant options, and vascular access surgery Protocols for laboratory and clinic visits; with attention to CKD and CVD-associated comorbidities (e.g., high blood pressure) Ethical, psychological, and social care (e.g., social bereavement, depression, anxiety) Dietary counseling and education on other lifestyle modifications (e.g., exercise, smoking cessation) Vaccination program KDIGO Transplant Guidelines
Slide 15-

Early Vaccination for Hepatitis B: Too Often Forgotten! Patients with ESRD have  response to vaccination (Secondary to general suppression of immune system) After Hepatitis B vaccination in ESRD patients: 50 – 60 % develop antibodies, compared to > 90% in patients without renal failure Have Lower titers Have protective levels for shorter duration Stevens CE et al. NEJM 1984; 311: 496 Buti M et al. Am J Nephrol 1992; 112: 144
Slide 16-

Other Considerations for Vaccination in Patients with Progressive CKD Influenza vaccine annually, unless contraindicated. Polyvalent pneumococcal vaccine: eGFR <30 ml/min/1.73m2 High risk of pneumococcal infection (e.g., nephrotic syndrome, diabetes, receiving immunosuppression), unless contraindicated. Offer revaccination within 5 years. KDIGO Transplant Guidelines
Slide 17-

High Blood Pressure Common in both dialysis and transplant populations Target blood pressure: Dialysis: Predialysis: <140/90 mm Hg Postdialysis: <130/80 mm Hg Transplantation: 130/80 mm Hg Managing high blood pressure in dialysis requires attention to fluid status and antihypertensive medications, while minimizing intradialytic fluid accumulation Can be impacted by certain immunosuppressants in kidney transplantation recipients. Monitor for adverse effects and drug–drug interactions KDIGO. Am J Transplant. 2009:9(suppl 3):S1-S155. NKF KDOQI. Am J Kidney Dis. 2000; 35(suppl 2):S1-S3. Alborzi et al. Clin J Am Soc Nepohrol. 2007;2:1228-1234
Slide 18-

Hemodialysis (HD)
Slide 19-

Principle of Hemodialysis Vein Artery
Slide 20-

Urea Mass Transfer During Hemodialysis Solids ICF ECF IV HD Harmon W, Jabs K: Hemodialysis (chap 77) in Pediatric Nephrology, 4th ed Barratt, Avner, Harmon (ed) Lippincott, 1999
Slide 21-

Dialyzer
Slide 22-

Hemodialysis Filter (Dialyzer)
Slide 23-

Hemodialysis Vascular Access Polytetrafluoroethylene
Slide 24-

Arteriovenous (AV) Fistula
Slide 25-

Which Vascular Access and When Should It Be Placed?
Slide 26-

Dialysis Access Provides location for easy access to patient’s blood for dialysis Bane of dialysis physician’s existence Higher flows and cannulation can lead to stenosis or thrombosis Maintenance of dialysis access patency is critical, at times life-saving Patency is assessed while patient is on HD by multiple parameters Early detection of stenosis can lead to intervention before thrombosis occurs
Slide 27-

Dialysis Access AV Fistula Vein cross-cut, attached end-to-side to artery High-pressure flow dilates and thickens vein Best alternative: Lowest infectious risk Longest lasting with least thromboses Drawbacks Takes 2-4 months to mature Only about 50% ever mature Goal for all dialysis patients
Slide 28-

Dialysis Access AV Graft Tube made of biocompatible material (gortex) attached end-to-side to artery and vein Often required in patients with vascular disease, occluded distal veins Advantages Ready to use when swelling resolves (~2 weeks) Able to use in most patients Disadvantages High stenosis/thrombosis rate Moderate infectious risk
Slide 29-

Dialysis Access Catheter (IJ most common) Tunnelled under skin to reduce communication from skin flora with blood Advantages Ready for use immediately Disadvantages High infectious risk High thrombosis risk A/W increased mortality Can be a sign of poor pre-dialysis care or extensive vascular disease
Slide 30-

Vascular Access Guidelines Arm veins suitable for placement of vascular access should be preserved, regardless of arm dominance. Arm veins, particularly the cephalic veins of the non-dominant arm should not be used. Avoid PICC lines Dorsum of the hand could be used for IV. A Medic Alert bracelet should be worn to inform hospital staff to avoid IV cannulation of essential veins. Subclavian vein catheterization should be avoided for temporary access in all patients with CKD ( stenosis  preclude use of ipsilateral arm for vascular access)
Slide 31-

Astor B. et al. Am J Kidney Dis. 2001; 38:494-501. Patients who started using an AV access by timing of first referral to a nephrologist N=356 hemodialysis patients
Slide 32-

SAVE the Non-Dominant ARM for Vascular Access When GFR < 30 mL/min No BP measurement No IV No Blood Draws Place vascular access within a year of hemodialysis anticipation … On Non-Dominant Arm
Slide 33-

Peritoneal Dialysis (PD)
Slide 34-

Principle of PD Treatment
Slide 35-

Abdominal cavity is lined by a vascular peritoneal membrane which acts as a semi-permeable membrane Diffusion of solutes (urea, creatinine, …) from blood into the dialysate contained in the abdominal cavity Removal of excess water (ultrafiltration) due to osmotic gradient generated by glucose in dialysate PD Treatment
Slide 36-

Peritoneal Dialysis (PD) PD Continuous Intermittent
Slide 37-

Continuous PD Regimens Multiple sequential exchanges are performed during the day and night so that dialysis occurs 24 hours a day, 7 days a week CAPD: Continuous Ambulatory PD CCPD: Continuous Cyclic PD
Slide 38-

Intermittent PD Regimens PD is performed every day but only during certain hours DAPD: Daytime Ambulatory PD. Multiple manual exchanges during waking hours NPD: Nightly PD. Performed while patient asleep using an automated cycler machine. Sometimes, 1 or 2 day-time manual exchanges are added to enhance solute clearances `
Slide 39-

Is Timing of Dialysis Initiation Important in ESRD Patients?(Controversial)
Slide 40-

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Slide 41-

IDEAL Study: K–M Curves for Time to the Initiation of Dialysis & for Time to Death Cooper BA et al. N Engl J Med 2010;363:609-619 Between July 2000 & November 2008 Australia / New Zealand 828 adults Early start: eGFR 10-14 cc/min Late start: eGFR 5-7 cc/min Mean age 60.4 years 542 men & 286 women 355 with diabetes Median follow-up 3.6 years
Slide 42-

Implications Cooper BA et al. N Engl J Med. 2010;363:609-619. Total of 75.9% of the patients in the late-start group started dialysis when eGFR was > 7.0 mL/min/1.73m2, owing to the development of symptoms! In this study, planned early initiation of dialysis in patients with stage V CKD was not associated with an improvement in survival or clinical outcomes (QOL)  OK to delay initiation of dialysis (eGFR < 7-10 mL/min/1.73m2)  Dialysis initiation should be based upon clinical factors (symptoms) rather than eGFR alone
Slide 43-

Why is Residual Renal Function Important in Dialysis Patients?
Slide 44-

Why is baseline residual renal function important? Remaining GFR at start of dialysis make a significant contribution to the removal of potential uremic toxins Also facilitates regulation of fluid, electrolytes, and may enhance nutritional status and QOL Offers survival advantage in both HD and PD Suda T et al. Nephrol Dial Transplant. 2000; 15:396. Shemin D et al. Am J Kidney Dis.2001; 38: 85. Szeto C et al. Nephrol Dial Transplant 2003;18.7
Slide 45-

Adjusted Hazard Ratio: 0.70 (0.52-0.93) p = 0.02 Shafi T., Jaar B., et al. Am J Kidney Dis. 2010;56:348-58 Cumulative Incidence of All-Cause Mortality in 579 HD Patients by Urine Status at 1 Year (CHOICE)
Slide 46-

Implications Try to preserve residual renal function in dialysis patients!  Less dietary restriction  Better quality of life  Better survival Try to avoid nephrotoxins if your dialysis patient still makes urine!
Slide 47-

Kidney Transplantation
Slide 48-

Principle of Kidney Transplantation Iliac Fossa
Slide 49-

Eligibility Able to be evaluated once GFR <20 mL/min Need just one listing less than 20 mL/min to remain active With GFR 15-19 mL/min- can be transplanted if live donor or if six antigen match If GFR <15 mL/min- open to all offers Why starting early- if certain blood types with long wait time, no potential live donors
Slide 50-

Absolute contraindications Active malignancy Advanced lung disease Chronic O2 needs FEV 1<1 Ongoing infections Life expectancy less than 2 years Active substance abuse Ischemic Cardiac disease Not amenable to revascularization Severe peripheral vascular disease Liver cirrhosis/primary oxalosis- unless combined liver/kidney Poorly controlled psychiatric illness Minimal rehabilitative potential Morbid obesity – BMI>40
Slide 51-

Trends in Transplantation: patients age 20 years & older USRDS ADR 2012
Slide 52-

Adjusted Relative Risk of Death among 23,275 Recipients of a 1st Cadaveric Transplant Wolfe RA et al. N Engl J Med. 1999;341:1725-1730
Slide 53-

Acute Rejection within the 1st Year Post-Transplant Patients age 18 & older with a functioning graft at discharge. USRDS ADR 2012
Slide 54-

Cumulative incidence of post-transplant diabetes Patients receiving a first-time, kidney-only transplant, 2003–2007 combined. USRDS ADR 2012
Slide 55-

Causes of Death in Kidney Transplant Patients with Functioning Graft 2006–2010 First-time, kidney-only transplant recipients, age 18 & older, 2006–2010, who died with functioning graft. USRDS ADR 2012
Slide 56-

Post-transplant Malignancy Risk is 4X to 100X compared rates of malignancy in the general population (especially skin cancer) No comprehensive reporting system Available data suggesting 2- to 3-fold under-reporting The precise rate is UNKNOWN Accounts for 10% of deaths in kidney recipients with functioning graft  SCREENING is KEY! Threshold for screening should be low.
Slide 57-

Immunization for Kidney Transplant Recipients Recommended Influenza types A and B (yearly) Pneumovax (every 3-5 years) Diphteria-Pertussis-Tetanus Haemophilus influenza B Hepatitis A and B Inactivated polio Meningococcus Not Recommended Varicella zoster Intranasal influenza BCG Live oral typhoid Measles, Mumps, Rubella Oral polio Yellow fever Smallpox Live Japanese B encephalitis vaccine
Slide 58-

Key Concepts Kidney transplantation is the most cost-effective modality of renal replacement Transplanted patients have a longer life and better quality of life Early transplantation (before [pre-emptive] or within 1 year of dialysis initiation) yields the best results Living donor kidney outcomes are superior to deceased donor kidney outcomes Early transplantation is more likely to occur in patients that are referred early to nephrologists Refer for transplant evaluation when eGFR < 20 mL/min/1.73m2
Slide 59-

Key Concepts The most common cause of transplant loss is death with a functional transplant due to Heart disease +++ Infections Malignancies Immunosuppressants are essential to prevent immunological loss of the transplant, but side effects can also lead to potential loss of transplant
Slide 60-

What About No Renal Replacement Therapy Option?
Slide 61-

Starting Dialysis in the Elderly…Or Not? Among patients > 75 yrs with stage 5 CKD who chose NOT to start dialysis: Overall, more likely to die over next 1-2 years But if they had ischemic heart disease or other significant comorbidity  NO DIFFERENCE in survival Active disease management and supportive care may be appropriate without starting dialysis in the ill elderly Must have end-of-life discussions! Murtagh, et al. Nephrol Dial Transplant. 2007; 22(7): 1955-1962.
Slide 62-

The Future …
Slide 63-

Regenerative Medicine … Stem Cell Therapy … Wearable Artificial Kidney
Slide 64-

Additional Online Resources for CKD Learning National Kidney Foundation: www.kidney.org United States Renal Data Service: www.usrds.org CDC’s CKD Surveillance Project: http://nccd.cdc.gov/ckd Dialysis Outcomes and Practice Patterns Study (DOPPS): http://www.dopps.org Organ Procurement and Transplantation Network: http://optn.transplant.hrsa.gov United Network for Organ Sharing: http://www.unos.org