Epidemiology - renal outcomes

Abstract

Introduction and Aims: The number of patients with Chronic Kidney Disease (CKD) is rising and is associated with significant morbidity and mortality. The annual acceptance rate for renal replacement therapy in the United Kingdom is also rising steadily (1). Patients with advanced CKD have an increased cardiovascular risk that needs to be addressed in the earlier stages. In addition, a multidisciplinary, integrated approach to pre-dialysis care can optimize dialysis and transplantation outcomes and reduce morbidity and mortality. In the Kidney Disease Outcomes Quality Initiative (KDOQI) classification system of CKD, preparation for renal replacement therapy has been recommended in CKD stage 4 with the estimated glomerular filtration rate (eGFR) to <30 ml/min. The term 'pre-dialysis' has not been officially defined in guidelines. However, most renal physicians will initiate pre-dialysis care in patients (Table presented) with a eGFR <15- 20 ml/min. At our renal unit, patients are referred for pre-dialysis care with an eGFR < 20ml/min for optimization of treatment and patient education. Methods: All patients who were referred to the pre-dialysis team with an eGFR < 20ml/ min from 2010-2012 at a satellite outreach renal clinic were included. Data was collected retrospectively. The rate of renal disease progression and other important biochemical parameters over a 24 month period were recorded. The prevalence of diabetes and hypertension in this cohort were also reported. Results: A total of 81 patients were included in data analysis who remained in pre-dialysis care . eGFR at time of analysis was 13.9 (mean) and 14 (median). At 12 months previously eGFR was 16.2 (mean) and 16 (median);at 24 months eGFR was 22.6 (mean) and 20 (median). Therefore, rate of renal disease progression was 4.4ml/ year (mean) and 3ml/year (median). The monthly rate of renal disease progression being 0.36 ml/month (median) and 0.25ml/month (median). Table: Renal progression: eGFR and serum creatinine ( Cr) valuesA total of 30 patient went to dialysis during this period (24 haemodialysis and 6 peritoneal dialysis) and 10 patients died while on pre-dialysis care without reaching end stage renal disease (not included in this analysis). Conclusions: Management of severe CKD requires a well organised and patient-focused multidisciplinary approach. Optimal pre-dialysis care can maintain the residual renal function for longer and delay progression and the need for renal replacement therapy. Therefore, specialised pre-dialysis care leads to improved quality of life for these patients and also have economic benefits.