200 Hours Heamodialysis Training: Patient Selection

Today they were 2-3 other 'mature students'. It was pretty obvious, they were in nursing uniform and like me, just standing and observing while others worked away setting up machines and getting patients on and off the HD machines.

So I asked who they were and they are something to do with diabetes training which involves just one week in the HD unit.

I work well under pressure. As dateline nears and I set new goals, it becomes easier to study the lecture notes. Today's is patient selection.

It makes more sense now, I have a deeper understanding of things. When I saw a patient with a catheter, I just asked out of curiosity why does he not have a fistula, and he showed me his three previous fistulas which failed, one on the right hand and two on the left arm.

Ok, lets start:

Patient selection & evaluation
Dr Keng Tee Chau Dr Keng Tee Chau UMMC

These slides are prepared by
Dr. Lim Soo Kun
MBBS(MAL), MRCP(UK) Consultant Nephrologist & Senior Lecture Consultant Nephrologist & Senior Lecture Division of Nephrology Department of Medicine University Malaya Medical Centre

Outline
•Introduction
•Options of renal replacement therapy
•Contraindications for long term dialysis
•Contraindications for haemodialysis
•Special groups
-diabetic mellitus
-cardiovascular  disease
•Evaluation of dry weight

At the end of this lecture, you should understand
1.Not all the patients with renal failure are suitable for long term renal replacement therapy (RRT). 2.Factors involved in deciding the options of RRT
3.The principle of management for those who are not suitable for chronic dialysis suitable for chronic dialysis
4.Special consideration for patients with diabetes mellitus and cardiovascular disease
5.The basic concept of dry weight and evaluation


Introduction
•Chronic kidney disease (CKD) –definition:
1.Kidney damage for >3 months, as defined by structure or functional abnormalities of the kidney, with or without decreased GFR, manifest by either
-Pathological abnormalities
-Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests.
2. GFR <60 for="" m2="" min="" ml=""> 3 months with or without kidney damage


Natural history of CKD

Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD

Stage                GFR (mL/min/1.73 m2)             Management

1                       ≥ 90                                            Diagnosis & treatment 

                                                                            Treatment of comorbid conditions, Slowing                                                                                             progression,

                                                                            CVD risk reduction

2                       60 –89                                        Estimating progression

3                       30 –59                                        Evaluating and treating complication

4                       15 –29                                        Preparation for kidney replacement therapy

5                      < 15 or dialysis                           Renal Replacement Therapy

Concept of early or timely initiation of dialysis

•KDQI guidelines (2006) recommendation: Dialysis should be initiated at eGFR <15ml div="" m2="" min="" nbsp="">

-irrespective of their diabetic status, or 

-earlier if protein intake is < 0.8g/kg/day, 

or 

-if uraemic   

•Rationale: 

-Better nutritional status 

-Better survival 

(NKF Kidney Disease Outcomes Quality Initiative (NKF KDOQI)™)

Options of renal replacement therapy

Haemodialysis

Peritoneal dialysis

Renal transplantation

Factors to consider –Options of RRT

Medical factors

•Age 

•Co-morbidities 

•Nutritional status 

•Functional status

•Vascular access

Socio-economic factors

•Access to facilities 

•Family support 

•Financial support 

•Patient’s preference

Contraindications to long term dialysis

•Advanced malignancy 

•Advanced AIDS 

•Incapacitating end stage organ failure 

-Dementia 

-Decompensated advanced chronic liver disease 

•Patients with profound neurological impairment 

What can we offer for patients who are not suitable to initiate or continue with long term dialysis ?

Palliative Care 

Palliative care in ESRD

•Definition of Palliative care in general:

“Palliative care is comprehensive, interdisciplinary care of patients and families facing a chronic or terminal illness focusing primarily on comfort and support.”

Billings JA. Palliative Care. Recent Advances. BMJ 2000:321:555-558.

Relevance to ESRD 

-Shortened life expectancy 

-High symptom burden 

-Aging population

Principles of palliative care in ESRD

•Pain and symptom management 

•Communication-Advance care planning -DNR -Advance Directives 

•Psychosocial and spiritual support 

•Psychosocial and spiritual support 

•Hospice referral

Relative contraindications for chronic haemodialysis

•Haemodynamic or circulatory instability 

•Cardiovascular disease 

•Difficult vascular access 

Diabetes mellitus & ESRD 

Diabetic ESRD

•Overall, more than 35% of new patients starting on dialysis are diabetic.

•Morbidity & mortality are higher in diabetic patients maintained on dialysis. 

•Two main cause of death: 

1.Cardiovascular disease 

2.Infection

Projections for number of patients with diabetes initiating ESRD treatment in USA*

Diabetic ESRD –Timing of initiation of dialysis

•Dialysis should be started at higher creatinine clearance (CrCl), usually more than 15 ml/min/1.73m2.

•Rationale: 1.Renal function deteriorates faster in diabetic patients 1.Renal function deteriorates faster in diabetic patients 2.More difficult control of blood pressure when CrCl < 15 ml/min/1.73m2. 3.Earlier manifestation of uraemic symptoms. 4.Fluid overload in those with heavy proteinuria & hypoalbuminaemia.

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