kidney learning solutions - western nephrology

PROFESSIONAL | CLINICAL RESOURCES Includes many resources to help clinicians further their own knowledge, as well as helpful tools for evaluating and treating patients. Go to www.kidney.org/store

� Clinical Bulletins keep medical professionals informed about new science and recent clinical developments.

� Quick-Reference Cards and Pocket Guides to evaluate and treat patients.

� Speaker’s Guides to educate colleagues through live lectures and grand rounds.

� KDOQI™ Commentaries provide evidence-based clinical practice guidelines for all stages of chronic kidney disease (CKD). www.kidney.org/professionals/KDOQI

CONTINUING MEDICAL EDUCATION (CME/CE)CME/CE activities are available in traditional and innovative educational designs such as “Ask and Answer,” virtual patient platform, confidence-based learning approach, and the new “NKF Kidney Talks” video series. Go to: www.kidney.org/CME. Some current topics:

� Heart-Kidney Interaction and the Role of Vasopressin and Hyponatremia in Heart Failure

� Clinical Aspects of Fibroblast Growth Factor 23 in Chronic Kidney Disease

� Hemoglobin Variability: Individualization of Anemia Management

Providing hundreds of cutting-edge and innovative educational tools and resources.

The Educational Arm of the National Kidney Foundation

KIDNEY LEARNING SOLUTIONS

This activity is supported by an educational grant from

Takeda Pharmaceuticals International, Inc., US Region© 2

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A FREE CME/CE LEARNING ACTIVITY IN AN ON-DEMAND

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Persistent Hyperuricemia:

A Multi-Pronged Approach to the Management of

SERUM URATE LEVELS IN CHRONIC KIDNEY DISEASE

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A FREE CME/CE LEARNING ACTIVITY IN SHORT

VISUALLY ENGAGING VIDEO PRESENTATIONS

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Membranous NephropathyNEW INSIGHTS REGARDING PATHOGENESIS, DIAGNOSIS, AND TREATMENT

NEW! Declaration of Disclosure

It is the policy of the National Kidney Foundation (NKF) to ensure balance, independence, objectivity, and scientific rigor in all CME/CE activities. Any individual who has control over CME/CE content is required to disclose to learners prior to the activity any relevant financial relationship(s) they may have with commercial interests supporting this activity or whose products or devices are discussed in this activity. If, on the basis of information disclosed, a perceived conflict exists, resolution will be achieved based on NKF’s Disclosure and Conflict of Interest Policy.

Unlabeled/Investigational Use During their presentations, faculty may discuss an unlabeled use or an investigational use not approved for a commercial product. Each faculty member is required to disclose this information to the audience when referring to an unlabeled or investigational use.

Disclaimer The faculty, National Kidney Foundation and Questcor Pharmaceuticals, Inc. do not recommend the use of any pharmaceutical, diagnostic test, or device outside of the labeled indications as approved by the FDA. Please refer to the official prescribing information for each product for approved indications, contraindications, and warnings.

Information contained in this National Kidney Foundation (NKF) educational resource is based upon current data available at the time of publication. The information is intended to help clinicians become aware of new scientific findings and developments. This NKF educational resource is not intended to set out a preferred standard of care and should not be construed as one. Neither should the information be interpreted as prescribing an exclusive course of management.Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of information in this NKF educational resource is responsible for interpreting the data as it pertains to clinical decision making in each individual patient.

NKF PRESENTS: KIDNEY TALKS

Supported by an educational grant from Otsuka America Pharmaceutical, Inc. ©

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A FREE CME/CE LEARNING ACTIVITY IN AN ON-DEMAND

WEBCAST PRESENTATION

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Heart-Kidney Interaction & THE ROLE OF VASOPRESSIN & HYPONATREMIA in Heart Failure

1 in 3 American Adults is at Risk for Kidney DiseaseWhat can you do? 1. Know the criteria for chronic kidney disease (CKD)

• Abnormalities of kidney structure or function, present for > 3 months, with implications for health

• Either of the following must be present for > 3 months:

• Markers of kidney damage (one or more)

• GFR < 60 mL/min/1.73 m2

2. Recognize risk factors• Diabetes

• Hypertension

• Family history of CKD, diabetes, or hypertension

• Age 60 years or older

• U.S. ethnic minority status

3. Screen for CKD with two simple tests• “Spot” urine for albumin-to-creatinine ratio (ACR) to detect albuminuria

• Serum creatinine to estimate glomerular filtration rate (GFR)

4. Classify CKD to guide testing and treatment • Identify cause of CKD1

• Assign GFR category

• Assign albuminuria category

5. Implement a clinical action plan based on patient’s CKD classification• Consider comanagement with a nephrologist if the clinical action plan

cannot be carried out

• Refer to a nephrologist when GFR < 30 mL/min/1.73 m2 or ACR > 300 mg/g

• Learn more at www.kidney.org/professionals

6. GFR categories in CKD2

Category GFR Terms Clinical Presentations

G1 ≥ 90 Normal or high Markers of kidney damage (nephrotic syndrome, nephritic syndrome, tubular syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic radiologic abnormalities, hypertension due to kidney disease)

G2 60-89 Mildly decreased* • Markers of kidney damage

• Mild to severe complications:

• Anemia

• Mineral and bone disorder

• Cardiovascular disease

• Hypertension

• Elevated parathyroid hormone

• Lipid abnormalities

• Low serum albumin

G3a 45-59 Mildly to moderately decreased

G3b 30-44 Moderately to severely decreased

G4 15-29 Severely decreased

G5 < 15 Kidney failure • Includes all of the above

• Uremia

• Cardiovascular disease

GFR = mL/min/1.73 m2

*Relative to young adult level

In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfill the criteria for CKD.

7. Albuminuria categories in CKD2

Category ACR (mg/g) Terms

A1

A2

A3

< 30

30-300

> 300

Normal to mildly increased

Moderately increased*

Severely increased**

*Relative to young adult level. ACR 30-300 mg/g for > 3 months indicates CKD.**Including nephrotic syndrome (albumin excretion ACR > 2220 mg/g)

1. Cause of CKD is classified based on presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic findings.

2. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Inter. 2013;Suppl.3;1-150.

www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm

www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm

National Kidney Foundation National Kidney Foundation

KDOQI Commentaries available:• KDOQI Commentary on Anemia • KDOQI Commentary on Blood Pressure in CKD• KDOQI Commentary on GN• KDOQI Acute Kidney Injury Commentary• KDOQI Hepatitis C Commentary• KDOQI Mineral and Bone Disorder (CKD-MBD) Commentary• KDOQI Commentary on Care of the Kidney Transplant Patient

Commentaries Coming Soon:• Commentary on CKD, Early 2014• Commentary on CKD Guidelines for PCP, 2014

KDOQI Commentaries available:• KDOQI Commentary on Anemia • KDOQI Commentary on Blood Pressure in CKD• KDOQI Commentary on GN• KDOQI Acute Kidney Injury Commentary• KDOQI Hepatitis C Commentary• KDOQI Mineral and Bone Disorder (CKD-MBD) Commentary• KDOQI Commentary on Care of the Kidney Transplant Patient

Commentaries Coming Soon:• Commentary on CKD, Early 2014• Commentary on CKD Guidelines for PCP, 2014

KDOQI KDOQI

Go to: Go to:

© 2013 National Kidney Foundation, Inc. 02-10-6100_HBD © 2013 National Kidney Foundation, Inc. 02-10-6100_HBD

1. Fistula First Data. Prevalent counts and rate. Fistula First. Available at: http://fistulafirst.org/AboutFistulaFirst/FFBIData.aspx. Accessed 31 July 2013.

2. Akoh JA. Prosthetic arteriovenous grafts for hemodialysis. J Vasc Access. 2009;10:137-147.

3. Lee HW, Allon M. When should a patient receive an arteriovenous graft rather than a fistula? Semin Dial. 2013;26:6-10.

4. O’Hare AM. Vascular access for hemodialysis in older adults: a “pa-tient first” approach. J Am Soc Nephrol. 2013;24:1187-1190.

5. DeSilva RN, Patibandla BK, Vin Y, et al. Fistula first is not always the best strategy for the elderly. J Am Soc Nephrol. 2013;24:1297-1304.

6. Harish A, Allon M. Arteriovenous graft infection: a comparison of thigh and upper extremity grafts. Clin J Am Soc Nephrol. 2011;6:1739-1743.

7. Gulati S, Sahu KM, Avula S, et al. Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail. 2003;25:967-973.

8. U.S. Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD; 2012.

9. Vas SI. Infections related to prosthetic materials in patients on chron-ic dialysis. Minerva Urol Nefrol. 2004;56:259-264.

10. Minga TE, Flanagan KH, Allon M. Clinical consequences of infect-ed arteriovenous grafts in hemodialysis patients. Am J Kidney Dis. 2001;38:975-978.

11. Schild AF, Perez E, Gillaspie E, et al. Arteriovenous fistulae vs. arte-riovenous grafts: a retrospective review of 1,700 consecutive vascular access cases. J Vasc Access. 2008;9:231-235.

12. Schutte WP, Helmer SD, Salazar L, Smith JL. Surgical treatment of infected prosthetic dialysis arteriovenous grafts: total versus partial graft excision. Am J Surg. 2007;193:385-388.

13. Bachleda P, Utikal P, Kalinova L, et al. Infectious complications of arteriovenous ePTFE grafts for hemodialysis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010;154:13-19.

14. Lafrance JP, Rahme E, Lelorier J, Iqbal S. Vascular access-related infections: definitions, incidence rates, and risk factors. Am J Kidney Dis. 2008;52:982-993.

15. National Kidney Foundation KDOQI Work Group. KDOQI clinical practice guidelines and clinical practice recommendations for vascular access. Am J Kidney Dis. 2006;48:S176-S322.

16. Sexton DJ. Vascular access infections in patients undergoing dialysis with special emphasis on the role and treatment of Staphylococcus aureus. Infect Dis Clin North Am. 2001;15:731-742.

17. Nassar GM, Fishbane S, Ayus JC. Occult infection of old nonfunc-tioning arteriovenous grafts: a novel cause of erythropoietin resistance and chronic inflammation in hemodialysis patients. Kidney Int Suppl. 2002;(80):49-54.

18. World Health Organization. Clean Care is Safer Care. About SAVE LIVES: Clean Your Hands. Available at: http://www.who.int/gpsc/5may/tools/en/. Accessed on 13 Nov 2013.

19. Lin PH, Brinkman WT, Terramani TT, Lumsden AB. Management of infected hemodialysis access grafts using cryopreserved human vein allografts. Am J Surg. 2002;184:31-36.

20. Matsuura JH, Johansen KH, Rosenthal D, et al. Cryopreserved femoral vein grafts for difficult hemodialysis access. Ann Vasc Surg. 2000;14:50-55.

21. Matsuura JH, Rosenthal D, Wellons ED, et al. Hemodialysis graft infections treated with cryopreserved femoral vein. Cardiovasc Surg. 2002;10:561-565.

22. Multicenter data on file at CryoLife, Inc. (ML0101).

23. Bolton WD, Cull DL, Taylor SM, et al. The use of cryopreserved femoral vein grafts for hemodialysis access in patients at high risk for infection: a word of caution. J Vasc Surg. 2002;36:464-468.

24. Benedetto B, Lipkowitz G, Madden R, et al. Use of cryopreserved cadaveric vein allograft for hemodialysis access precludes kidney trans-plantation because of allosensitization. J Vasc Surg. 2001;34:139-142.

25. Madden RL, Lipkowitz GS, Browne BJ, Kurbanov A. Experience with cryopreserved cadaveric femoral vein allografts used for hemodialysis access. Ann Vasc Surg. 2004;18:453-458.

26. Gallichio MH, Chandolias N, Claudeanos K, et al. Successful utiliza-tion of cryopreserved human femoral vein or bovine carotid artery in the establishment of “button-holes” for hemodialysis. Abstract present-ed at: Vascular Access Society of America XIII Symposium; Orlando, FL, May 9-11, 2012.

A CLINICAL UPDATE ON THE MANAGEMENT OF

FOR THE HEMODIALYSIS PATIENT

DISCLAIMER

Information contained in this National Kidney Foundation educational resource is based upon current data available at the time of publication. Infor-mation is intended to help clinicians become aware of new scientific findings and developments. This resource is not intended to define a standard of care and should not be construed as one. Neither should the information be interpreted as prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of information in this resource is responsible for interpreting the data as it pertains to clinical decision making in each individual patient.

REFERENCES

CARE AFTER CRYOPRESERVED ALLOGRAFT PLACEMENTCannulation of cryopreserved allografts is possible 10-14 days after placement, and when swelling has subsided so that the course of the AVG can be palpated.15, 21 Aseptic technique during cannulation, including standard precautions for hand washing and glove changes, is recommended to minimize risk of access infection. Cannulation techniques should be a hybrid of the techniques for a PTFE AVG regarding depth of the access and the texture of an autogenous vein. It is also necessary to rotate cannulation sites in order to avoid pseudoaneurysm formation.15 A retrospective study using constant cannulation (buttonhole technique) with cryopreserved femoral veins showed good out-comes related to patency and minimal infection risk.26

A qualified individual should perform a physical examination to detect AVG dysfunction at least monthly. The 3 preferred surveillance techniques for stenosis of AVGs are: 1) intra- access flow using sequential measurements with time analysis; 2) directly measured or derived static venous dialysis; or 3) duplex ultrasound. Other acceptable techniques include physical findings of persistent swelling of the arm, presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in the AVG. Unstandard-ized dynamic venous pressures should not be used.15

A disadvantage of cryopreserved grafts is that they can “sensi-tize” a patient. Transplantation of any allograft tissue can induce an anti-HLA antibody response in the recipient. The possibility that a patient may develop antibodies after allograft tissue transplantation should be considered for any patient who might be a future recipient of allograft tissue, organs, or cells. There-fore, cryopreserved allografts should not be used for hemodialysis access in potential kidney transplant recipients.24

Other advantages and disadvantages of cryopreserved grafts to consider include patency, complications, and cost. Studies show that compared to PTFE grafts, cryopreserved grafts have similar patency, are more resistant to infection, but significantly more susceptible to aneurysms. The researchers concluded that cryopreserved allografts should be monitored aggressive-ly for the development of aneurysms.25 Regarding cost, the initial cryopreserved graft cost is considerably more expensive than PTFE grafts.25 Graft performance, average hospital stay, and overall hospital cost should be considered to determine if the cryopreserved graft using the allograft method may be a cost-effective means of treating infected AVGs.

Infected Arteriovenous Graft (AVG) Access

THE ALLOGRAFT METHOD PRESERVES THE VASCULAR ACCESS AND SAVES POTENTIAL FUTURE AV SITES.

© 2014 National Kidney Foundation, Inc. All rights reserved. 02-10-6071_GBD5 6

Made possible through an educational grant from:

› AVG Access: Demographics and Infection Risk

› Risks and Clinical Consequences of AVG Infection

› Prevention and Management of AVG Infection

› Cryopreserved Allograft

› Allograft Method vs. Graft Excision Method

› Evidence-Based Benefits and Risks Related to Cryopreserved Allograft

› Care After Cryopreserved Allograft Placement

National Kidney Foundation30 East 33rd StreetNew York, NY 10016

A Clinical Update on Dialyzer Membranes State-of-the-Art Considerations for Optimal Care in Hemodialysis

Supported by

› Key features of high performance membrane dialyzers

› Influence of design and chemical composition on membrane performance

› Influence of membrane characteristics on clinical status

› Consideration of membrane features as part of the hemodialysis prescription

PATIENT BROCHURESWide range of topics, including:

� Treatment and prevention of chronic kidney disease, high blood pressure, diabetes, anemia, heart and blood vessel disease, bone and mineral disease, and more!

� Risk factors for kidney disease, including diabetes and high blood pressure

� Complications of kidney disease, such as heart disease, anemia, or bone problems

� Nutrition for kidney disease patients, with information about carbohydrates, protein, sodium, phosphorus, and potassium

� Relevant topics for transplant recipients

SMARTPHONE APPSSmartphone apps are available for patients and professionals at www.kidney.org/apps

� eGFR Calculator. Helps medical professionals estimate kidney function using five separate eGFR calculators, including the CKD-EPI Creatinine 2009 Equation.

� Screening For Albuminuria in Patients with Diabetes. Helps medical professionals assess and treat albuminuria in people with diabetes and other high-risk patients.

� Relative Risk, Monitoring, and Referral in Patients with CKD. Explains how eGFR and ACR are independent risk factors for adverse outcomes.

� H2Overload: Fluid Control for Heart-Kidney Health. Designed for those who need to limit their fluid intake, especially those with kidney failure, heart disease, or hyponatremia.

� Gout Manager. Helps those with gout take control of their health.

� Care After Kidney Transplant App. How to stay healthy with a kidney transplant.

KIDNEY LEARNING SOLUTIONS

Contact us:

Awareness. Prevention. Treatment.www.kidney.org 800.622.9010


Awareness. Prevention. Treatment.www.kidney.org


Awareness. Prevention. Treatment. Awareness. Prevention. Treatment.





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HIGH BLOOD PRESSURE AND YOUR KIDNEYS

www.kidney.org

Dining Out With COnfiDenCeA Guide for Patients With Kidney Disease

www.kidney.org

GLOMERULAR DISEASE: What You Need To Know

www.kidney.org

ARE YOU AT INCREASED RISK FOR CHRONIC KIDNEY DISEASE

URINALYSIS AND KIDNEY DISEASE What You Need To Know

www.kidney.org

KIDNEY TRANSPLANT

www.kidney.org

kidney learning solutions - western nephrology

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