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Marc Richards Morning Report November 2nd, 2009 CKD When to refer to a Nephrologist Access When to start dialysis: Symptoms Numbers Pictures of San Diego Zoo animals Estimated 20 million Americans HTN + DM = 70% Others: GN, PCKD, Obstruction, etc… Decreased renal mass Nonspecific clinical presentations 1: GFR > 90 (normal to increased) 2: GFR 60-89 (mildly decreased) 3: GFR 30-59 (moderately decreased) 4: GFR 15-29 (severely decreased) 5: GFR <15 (failure) 6: DIALYSIS (source: National Kidney Foundation, KDOQI) Often occur late (<6 months before eventual start of RRT) ~20-50% first referred <4 months (multiple studies) Due to both patient and physician biases Studies suggest increased all-cause mortality in patients referred late. Suggested for women with SCr > 1.2 and men with SCr > 1.5, or anyone with CKD 3 Why so early? CKD can progress at different rates Reversible causes (vasculitis, etc) Access Management of comorbidities Anemia, Bone-Mineral Metabolism… Living Donor Allograft Dialysis discussions PermaCath (tunneled line) AV Fistula Synthetic Grafts Referral to Vascular Surgeon: FISTULAS: Failed fistula attempt Mature in 2-6 weeks Higher risk of infection, thrombosis LINES: Mature in 1-6 months Expected function: 20 years Very low infectious risk GRAFTS: CKD 4 Expected to require RRT in < 1 year Emergent HD initiation Awaiting maturation of AVF/AVG or out of access Lower Q Highest rate of infection PD CATHETER A E I O U Refractory Hypertension Weight Loss/Malnutrition N/V Persistent Metabolic Disturbances Refractory Anemia “Uremic-Like Symptoms”- depression, decreased conc, RLS Pruritis Currently a topic of contention in the nephrology world Cockraft Gault Equation: Age, weight effects Loose guidelines now suggested by multiple entities: K/DOQI (2006): GFR < 15 (CKD 5) Europe Best Practices (2005): consider when GFR 810, definitely start when GFR < 6 Why the uncertainty? Proposed morbitity benefits: No study to date has effectively proven a survival benefit with earlier initiation of RRT Liberal Nutrition HTN control IDEAL Trial Prospective study underway in Australia/NZ GFR 10 vs 14 when starting RRT Current (2007) UpToDate National Kidney Foundation IDEAL San Diego Zoo