The Prelude to Hemodialysis (Cheung 12/1/2021)

Thanks so much to Dr. Eric Cheung, nephrologist, who delivered a FABULOUS Grand Rounds originally titled the Transition from Chronic Kidney Disease to Dialysis, now rebranded as "The Prelude to Hemodialysis" Dr. Cheung’s presentation was tremendously informative and extremely practical. . .and he even had some good jokes. 

A link to a recording of his presentation is available HERE.

 Dr. Cheung first shared with us the global trends regarding dialysis. While center-based hemodialysis (HD) is much more common in the US (~90% of US pts), home peritoneal dialysis (PD) is much more common in developing countries (it’s cheaper and requires less infrastructure). Interestingly PD rates are also quite high in Hong Kong (80%) where ALL patients are mandated to start dialysis on PD. In general the highest rates of dialysis are in the wealthiest countries. Both the US and Japan have a slightly lower incidence of new dialysis over the past decade which is reassuring.

 

In the US, there are 468,000 patients on dialysis, and 193,000 with a “functional transplant”.

Fortunately there are several minority groups who have a decreasing trend in the need for dialysis over the last decade: 15% lower in Blacks, 24% lower in American Indian/Alaska Native, 17% lower in Hispanic, and 11% lower in females. (We hope this is because of improved prevention and education!)

 

One area we need to improve in is telling our patients they have CKD.  

• Of patients who have CKD 1-3 (who are thus asymptomatic), less than 10% know they have CKD
• For patients who are CKD stage 4, only 45% know they have CKD. Yikes!

 

There are several types of transition from advanced CKD:

• Advanced CKD -> dialysiS
• Advanced CKD -> pre-emptive transplantation
• Changing dialysis modalities (HDà PD, PDà HD)
• Failed transplant -> dialysis
• Dialysis -> transplant
• Withdraw of care from dialysis (which leads to death in about 7-10 days)

And don’t forget that no initiation of dialysis is an option- just conservative management

 

Categorizing patient risk for progression from CKD to dialysis:

• High Risk Patients: any patient with Diabetes (but especially those with proteinuria), uncontrolled HTN, CHF, cirrhosis, >60 years old, and Polycystic CKD.
• Lower Risk Patients: AKI with recovery (i.e. Sepsis, cardiac arrest, dehydration, obstructive uropathy), ironically Polycystic CKD (really based on family history—if

There is an online calculator to help! https://kidneyfailurerisk.com/

 

Does it help to start dialysis early (GFR 10-14) vs late (GFR 5-7)?

• The IDEAL study for ASYMPTOMATIC patients with CKD shows us that there is NO difference in mortality. So…
• if the eGFR is >15 or is 5-15 without symptoms -> monitor (of course with the help of your friendly neighborhood nephrologist
• if the eGFR is 5-15 with symptoms or <5 -> start dialysis

 

Initiation of dialysis is risky!  Especially the first several months—7-10x increase in death (even over all dialysis patients who already have a high mortality)!

Cardiovascular and infectious causes are major causes of increased mortality. Indications to initiate dialysis include:

·         Absolute indications: uremic encephalopathy, uremic pericarditis/pleuritic

·         Common indications: declining  nutrition/appetite, fatigue/malaise, mild cognitive impairment

Ideally, initiation starts gradually with advanced planning including setting expectations and getting long-term access coordinated (see below).

However, some patients need to start HD in the hospital – if no other option, poorly controlled HTN or hypotension, active angina, hx of seizures, or lack of social support.

 

Hemodialysis Access:

·         AV fistula is preferred and often lasts the longest and is basically a direct connection of the artery and vein in the forearm. Greatest risk of clot in the first month but thereafter clots are uncommon. Can last decades.

·         AV graft needed sometimes in vasculopaths and connect the artery and vein, but tends to clot when no longer in use.

·         Central venous catheter/tunneled cath: definitely least preferred but often used in transition. It is inserted into the internal jugular (NEVER the subclavian due to risk of stenosis), double lumen 14-16 french.

TIPS from your friendly nephrologist for primary care providers:

 Medications to avoid/adjust:

o   DM: ask CKD progresses, pts generally need less insulin needed because it hangs around longer; ALWAYS stop metformin when GFR <30 to avoid lactic acidosis; and d/c thiazolidinediones

o   HTN: as CKD progresses, stop ACE/ARBs (but after they start on HD they are great HTN meds)

o   Seizure/Pain meds: avoid gabapentin and baclofen which have toxic metabolites in CKD/ESRD

o   Antibiotics: Bactrim/Septra – don’t use in CKD patients since the SMX component can cause hyperkalemia; Cefepime can accumulate (care with this!)

 Preserve the Veins in your CKD patients long BEFORE they may need dialysis!

• Avoid subclavian lines
• Avoid PICC lines and midlines as much as possible
• For phlebotomy, use dorsal veins of the dominant hand instead of AC fossa

 A word on race based GFR.  Dr. Kohatsu shared a recent NEJM editorial from a few weeks ago really challenging our notions of race-based GFR estimations, which can lead to underdiagnosis and later transplant evaluation for black patients. For more, check out this article as well. Thanks, Dr. Kohatsu for your local advocacy work to change the way GFR is reported in our community. 

And last but not least. . .What is Dr. Cheung’s personally preferred form of dialysis? (and hopefully he never needs it!)….HD at HOME!  (yes, this is actually an option). Rare but has lower mortality and complications than HD at centers