linical practice guidelines and clinical practice recommendations

8/9/2019 Linical Practice Guidelines and Clinical Practice Recommendations

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linical Practice Guidelines and Clinical Practice Recommendations2006 UpdatesHemodialysis AdequacyPeritoneal Dialysis AdequacyVascular Access

I. C I!ICA PRAC"IC# GUID# I!#$ %&R H#'&DIA($I$ AD#)UAC(

GUIDELINE 1. INITIATION OF DIALYSIS

1.1 Preparation for kidney failurePatient! "#o rea$# %&D !ta'e ( )e!ti*ated GF+ , - *L/*in/1.0- * 2!#ould re$ei3e ti*ely edu$ation a4out kidney failure and option! for it!treat*ent5 in$ludin' kidney tran!plantation5 PD5 6D in t#e #o*e or in7$enter5 and $on!er3ati3e treat*ent. Patient!8 fa*ily *e*4er! and$are'i3er! al!o !#ould 4e edu$ated a4out treat*ent $#oi$e! for kidneyfailure. )92

1. E!ti*ation of kidney fun$tionE!ti*ation of GF+ !#ould 'uide de$i!ion *akin' re'ardin' dialy!i! t#erapyinitiation. GF+ !#ould 4e e!ti*ated 4y u!in' a 3alidated e!ti*atin'e:uation ) Ta4le 1 2 or 4y *ea!ure*ent of $reatinine and urea $learan$e!5not !i*ply 4y *ea!ure*ent of !eru* $reatinine and urea nitro'en. Ta4le and Ta4le - !u**ari;e !pe$ial $ir$u*!tan$e! in "#i$# GF+ e!ti*ate!!#ould 4e interpreted "it# parti$ular $are. )92

1.- Ti*in' of t#erapyt!5 ri!k!5 and di!ad3anta'e! of4e'innin' kidney repla$e*ent t#erapy. Parti$ular $lini$al $on!ideration!and $ertain $#ara$teri!ti$ $o*pli$ation! of kidney failure *ay pro*ptinitiation of t#erapy 4efore !ta'e =. )92

*AC+GR&U!D&ptimum timin, o- treatment -or patients it/ C+D pre ents serious and uremiccomplications1 includin, malnutrition1 uid o erload1 3leedin,1 serositis1 depression1co,niti e impairment1 perip/eral neuropat/y1 in-ertility1 and increased suscepti3ilityto in-ection. Ho e er1 all -orms o- 4idney replacement t/erapy entail importanttrade5o s. As G%R decreases1 patients and p/ysicians must ei,/ many ris4s and3ene7ts. Decision ma4in, is more comple8 -or older and more -ra,ile patients.

"o,et/er1 patients and p/ysicians must continually reconsider /et/er t/eanticipated p/ysiolo,ical 3ene7ts o- solute clearance and e8tracellular uid 9#C%:

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olume control no out ei,/ t/e p/ysical ris4s and psyc/osocial toll o- t/erapy. Insome cases1 social and psyc/olo,ical -actors may lead to earlier dialysis t/erapyinitiation1 and in some cases1 to later initiation. "/e initiation o- dialysis t/erapyremains a decision in-ormed 3y clinical art1 as ell as 3y science and t/e constraintso- re,ulation and reim3ursement.

%or some patients1 conser ati e t/erapy1 it/out dialysis or transplantation1 is t/eappropriate option. 2;52< I- t/e patient ma4es t/is c/oice1 t/e /ealt/ care team s/ouldstri e to ma8imi=e )& and len,t/ o- li-e 3y usin, dietary and p/armacolo,icalt/erapy to minimi=e uremic symptoms and maintain olume /omeostasis. "/eseinclude1 3ut are not limited to1 use o- lo 5protein diets1 4etoanalo,s o- essentialamino acids1 loop diuretics1 and sodium polystyrene sul-onate. !ep/rolo,ists alsos/ould 3e -amiliar it/ t/e principles o- palliati e care >0 and s/ould not ne,lect/ospice re-erral -or patients it/ ad anced 4idney -ailure.

+ATIONALEPreparation for Kidney Failure (CPG 1.1)Timely Education in Stage 4 C+D

"imely patient education as C+D ad ances can 3ot/ impro e outcomes and reducecost. >? Plannin, -or dialysis t/erapy allo s -or t/e initiation o- dialysis t/erapy at t/eappropriate time and it/ a permanent access in place at t/e start o- dialysist/erapy. Plannin, -or 4idney -ailure s/ould 3e,in /en patients reac/ C+D sta,e @-or se eral reasons. "/e rate o- pro,ression o- 4idney disease may not 3epredicta3le. "/ere is su3stantial aria3ility in t/e le el o- 4idney -unction at /ic/uremic symptoms or ot/er indications -or dialysis appear. Patients ary in t/eira3ility to assimilate and act on in-ormation a3out 4idney -ailure. ocal /ealt/ caresystems ary in t/e delays associated it/ patient education and sc/edulin, o-consultations1 tests1 and procedures. Results o- access creation procedures ary1and t/e success or -ailure o- a procedure may not 3e certain -or ee4s or mont/s.

"imely education ill 9?: allo patients and -amilies time to assimilate t/ein-ormation and ei,/ treatment options1 92: allo e aluation o- recipients anddonors -or preempti e 4idney transplantation1 9>: allo sta time to train patients/o c/oose /ome dialysis1 9@: ensure t/at uremic co,niti e impairment does notcloud t/e decision1 and 9B: ma8imi=e t/e pro3a3ility o- orderly and plannedtreatment initiation usin, t/e permanent access.

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Predialysis education to in-orm t/e patient and support persons a3out t/e relati ealue o- arious renal replacement modalities o ers a -reedom o- c/oice t/at must3e /onored. #ducation and c/oice o- modality also are ital to t/e timely placemento- ascular or peritoneal access1 trainin, -or /ome dialysis1 and actual timin, o- t/einitiation o- t/e selected 7rst modality. A compre/ensi e preempti e discussion o-

t/ese issues ill ena3le patients and t/eir support ,roups to ma4e rational decisionsand ill ser e to in ol e patients as acti e participants in t/eir personal /ealt/ care.Playin, an acti e role in one s o n /ealt/ care1 alt/ou,/ t/ artin, t/e naturalde-ense mec/anism o- denial1 reduces ris4s -rom ne,li,ence and psyc/olo,icaldepression t/at /a e 3een associated it/ poor outcomes a-ter dialysis t/erapy isstarted. >2

Contingency Plans&ptimal timin, o- ascular access creation may depend on plans re,ardin,transplantation and or PD treatment. #arly attempts at nati e ein arterio enous9AV: 7stula creation are particularly important in patients /o are 9?: not transplantcandidates or 92: lac4 potential li in, 4idney donors and also seem unli4ely toper-orm PD. %or patients /opin, to under,o Epreempti eF transplantation1 t/usa oidin, dialysis treatment1 t/e decision a3out /et/er to attempt AV 7stulacreation at C+D sta,e @ 9and1 i- so1 /en in sta,e @: depends on t/e nep/rolo,ist sestimate o- t/e li4eli/ood t/at preempti e transplantation ill 3e accomplis/ed. %orpatients interested in per-ormin, PD1 t/e decision a3out /et/er to attempt AV7stula creation at C+D sta,e @ depends on t/e nep/rolo,ist s estimate o- t/epro3a3ility t/at PD ill 3e success-ul. "/e 3ene7ts o- plannin, -or 4idney -ailuretreatment are re ected in t/e literature comparin, t/e consequences o- early andlate re-erral o- patients it/ C+D to nep/rolo,ists. >>5>6

Education of Health Care Providers and Family Members&ptimally1 education in preparation -or 4idney -ailure ill include not only t/epatient1 3ut also ot/er indi iduals /o are li4ely to in uence /is or /er decisions.

"/ese may include -amily1 close -riends1 and primary care pro iders. "/eirunderstandin, o- suc/ issues as t/e impact o- inter entions desi,ned to slopro,ression1 t/e a3sence o- symptoms despite underlyin, 4idney disease1transplantation eli,i3ility1 t/e c/oice 3et een PD and HD1 and t/e c/oice and timin,o- ascular access may /a e critical consequences -or t/e patient.

Estimation of Kidney Function (CPG 1.2)

Use of GF !Estimating E"uations and Clearances ather Than Serum Creatinine toGuide #ialysis $nitiationVaria3ility in creatinine ,eneration across t/e population ma4es serum creatininele el alone an inaccurate test -or patients it/ 4idney -ailure li4ely to 3ene7t -romdialysis treatment. %or most patients in C+D sta,es @ and B1 estimatin, equations3ased on alues o- serum creatinine and ot/er aria3les appro8imate G%R it/

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adequate accuracy. %or most patients1 measured clearance does not o er a moreaccurate estimate o- G%R t/an prediction equations. >;

%ariation in Creatinine GenerationIt is ell esta3lis/ed t/at creatinine ,eneration may 3e unusually lo in patients

it/ a num3er o- conditions and may 3e increased in indi iduals o- unusuallymuscular /a3itus 9 "a3le 2 :. In t/ese situations1 G%R estimated 3y usin, creatinineand urea clearances may 3e su3stantially more accurate 9compared it/radionuclide G%R: t/an results o- creatinine53ased estimatin, equations. In patients-or /om endo,enous creatinine ,eneration is li4ely to 3e unusually lo or /i,/1G%R s/ould 3e estimated 3y usin, met/ods independent o- creatinine ,eneration1suc/ as measurement o- creatinine and urea clearances.

%ariation in Tubular Creatinine Secretion$e eral dru,s are 4no n to compete it/ creatinine -or tu3ular secretion1 andad anced li er disease /as 3een associated it/ increased tu3ular creatininesecretion 9 "a3le > :. Decreased secretion ill result in arti-actually lo G%Restimates1 and increased secretion ill result in o erestimation o- G%R 3y means o-estimatin, equations. In patients -or /om tu3ular creatinine secretion is li4ely to3e unusually lo or /i,/1 t/e consequent 3ias to all creatinine53ased measuress/ould 3e considered in interpretin, G%R estimates.

Timing of Therapy (CPG 1. )$nitiation of &idney e'lacement Thera'y

"/is ,uideline is 3ased on t/e assumption t/at o erall 4idney -unction correlatesit/ G%R. *ecause t/e 4idney /as many -unctions1 it is possi3le t/at ? or more-unctions ill decrease out o- proportion to t/e decrease in G%R. "/ere-ore1care,i ers s/ould 3e alert to si,ns o- declinin, /ealt/ t/at mi,/t 3e directly orindirectly attri3uta3le to loss o- 4idney -unction and initiate 4idney replacementt/erapy 9+R": earlier in suc/ patients. Ho e er1 t/ey s/ould consider t/at dialysist/erapy is not innocuous and does not replace all -unctions o- t/e 4idney and t/at

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HD5related /ypotension may accelerate t/e loss o- R+%. "/is may particularly 3etrue o- HD.

Indi idual -actors suc/ as dialysis accessi3ility1 transplantation option1 PDeli,i3ility1 /ome dialysis eli,i3ility1 ascular access1 a,e1 declinin, /ealt/1 uid

3alance1 and compliance it/ diet and medications o-ten in uence t/e decisiona3out t/e timin, o- /en to start dialysis t/erapy. It may 3e optimal to per-orm4idney transplantation or 3e,in /ome dialysis 3e-ore patients reac/ C+D sta,e B.# en /en G%R is ,reater t/an ?B m min ?.;> m 21 patients may /a e a milderersion o- uremia t/at may a ect nutrition1 acid53ase and 3one meta3olism1calcium5p/osp/orus 3alance1 and potassium1 sodium1 and olume /omeostasis.Con ersely1 maintenance dialysis imposes a si,ni7cant 3urden on t/e patient1-amily1 society1 and /ealt/ system. "/is is complicated -urt/er 3y t/e potential ris4so- dialysis t/erapy1 especially t/ose related to dialysis access and dialysate. "/eseconsiderations necessitate conser ati e mana,ement until G%R decreases to lesst/an ?B m min ?.;> m 21 unless t/ere are speci7c indications to initiate dialysist/erapy. "/us1 t/e recommended timin, o- dialysis t/erapy initiation is acompromise desi,ned to ma8imi=e patient )& 3y e8tendin, t/e dialysis5-reeperiod /ile a oidin, complications t/at ill decrease t/e len,t/ and quality o-dialysis5assisted li-e.

"/eoretical considerations support initiation o- dialysis t/erapy at a G%R o-appro8imately ?0 m min ?.;> m 21 and t/is as t/e recommendation o- t/e ?1 mean estimated G%R at t/einitiation o- dialysis t/erapy as m 2 . "/is mean alue re ects lo era era,e alues 9 ; to < m min ?.;> m 2 : -or youn, and middle5a,ed adults and/i,/er a era,e alues 9 ?0 to ?0.B m min ?.;> m 2: -or c/ildren and elderlypatients. A era,e G%R at initiation /as increased in all a,e ,roups since ?


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o- t/e comor3idity plus C+D. *ecause symptoms o- early uremia are -airlynonspeci7c1 one can e8pect t/at patients it/ symptoms associated it/ t/eircomor3idities ould initiate dialysis t/erapy early. Healt/y and /ardy patients it/less comor3idity li4ely ill de elop symptoms at a later sta,e t/an a -railer1 early5startin, comparati e ,roup. %rail patients /o start dialysis t/erapy earlier do not

li e as lon, as /ardy patients /o start dialysis later. Ho e er1 t/is remains merelyan interpretation o- o3ser ational data. A more de7niti e ans er may emer,e -romproperly desi,ned prospecti e trials. &ne suc/ trial e8pects to report in 200 . "/eInitiatin, Dialysis #arly and ate 9ID#A : $tudy -rom !e Mealand and Australia is aprospecti e1 multicenter1 randomi=ed1 controlled trial 9RC": to compare a 3roadran,e o- outcomes in patients startin, dialysis t/erapy it/ a Coc4cro-t5Gault G%Ro- ?0 to ?@ ersus B to ; m min ?.;> m 2 .B?

In 20001 t/e !+% +D&)I CPG on !utrition in C+D ad ocated t/at in patients it/C+D and estimated G%R less t/an ?B m min ?.;> m 2 /o are not under,oin,maintenance dialysis i- 9?: protein5ener,y malnutrition de elops or persistsdespite i,orous attempts to optimi=e protein5ener,y inta4e1 and 92: t/ere is noapparent cause -or it ot/er t/an lo nutrient inta4e1 initiation o- +R" s/ould 3erecommended. B2 %urt/ermore1 t/ose ,uidelines set -ort/ measures -or monitorin,nutritional status and identi-yin, its deterioration. "/ose ,uidelines are consistentit/ t/e present recommendations.

LI?ITATIONSIndi iduals ary tremendously in t/e p/ysiolo,ical response to uremia and dialysistreatment. Patients e8pected to e8perience uremic complications o-ten sur i emuc/ lon,er t/an t/e p/ysician anticipates1 it/out apparent ad erseconsequences. Patients also ary in t/eir illin,ness and a3ility to ad/ere to amedical re,imen intended to -orestall t/e need -or dialysis treatment. Healt/ caresystems and pro iders ary ,reatly in t/eir capa3ility to monitor patients it/ad anced 4idney -ailure sa-ely it/out dialysis treatment. At 3est1 t/e decision toinitiate dialysis treatment or per-orm preempti e transplantation represents a Nointdecision 3y patient and p/ysician1 re ectin, t/eir mutual understandin, o- t/ecompromises and uncertainties. It requires clinical Nud,ment 3ased on clinicale8perience.

O 2006 !ational +idney %oundation1 Inc.

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!i,er 'ed. 20?0 Apr5 unJ?56.

%lini$al pro>le of #ae*odialy!i! patient! "it# dia4eti$ nep#ropat#yleadin' to end !ta'e renal di!ea!e.

Ga==a= M 1 "as/4andi A 1 D/a-ar +& 1 %arooq 'U .

Sour$e

Al5!oor $pecialist Hospital1 'a44a/1 $audi Ara3ia. /rdQalnoor ya/oo.com

A4!tra$t

9A%&G+OUND

"/e incidence o- patients it/ end5sta,e renal -ailure and type 2 dia3etes mellitusas a comor3id condition /as increased pro,ressi ely in t/e past decades. Causes o-renal disease mi,/t ary -rom one population to anot/er. "/e aim o- t/is study asto 4no t/e c/aracteristics o- t/e dia3etic patients on re,ular dialysis at Al5noor$pecialist Hospital1 'a44a/1 $audi Ara3ia.

http://www.ncbi.nlm.nih.gov/pubmed/20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Gazzaz%20ZJ%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Tashkandi%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Dhafar%20KO%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Farooq%20MU%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed/20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Gazzaz%20ZJ%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Tashkandi%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Dhafar%20KO%5BAuthor%5D&cauthor=true&cauthor_uid=20642079http://www.ncbi.nlm.nih.gov/pubmed?term=Farooq%20MU%5BAuthor%5D&cauthor=true&cauthor_uid=20642079


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?ET6ODOLOGY

"/e data /ad 3een collected retrospecti ely in t/e mont/ o- $/a al ?@2Bcorrespondin, to ?>5??5200@5555?25?25200@ -rom t/e dia3etic patients directly t/atere on dialysis due to end sta,e renal disease 9#$RD: and -rom t/eir 7les.

+ESULTS

"/e mean a,e o- Dia3etics as 9BB.2 years: s/o in, male predominance >?960. S:. All ere $audies. "/e mean duration o- Dia3etes mellitus T dialysis ere9?6. years: and 922 mont/s:1 respecti ely. "/e mean a,e o- start o- Dia3etesmellitus T dialysis as 9>;.@ years: T 9B>.B years:. "/e mean duration o- onset o-dia3etes to dialysis as 9?6.? years:. &ut o- t/e total1 2< 9B6. 9@BS:-ollo ed 3y ?B 92

linical practice guidelines and clinical practice recommendations

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