CKD transition to Hemodialysis (Cheung, 9/11/2024)

 Many thanks to Dr. Eric Cheung, nephrologist, for a great talk on transitioning patients with CKD to Hemodialysis. 

A recording of his presentation is available HERE. 

My notes:

Dr. Cheung began with the global trends of 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. 

 

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

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 (HD>> PD, PD>> HD)
• Failed transplant -> dialysis
• Dialysis -> transplant

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

 

Categorizing patient risk for progression from CKD to HD:

• High Risk Patients: any patient with diabetes (especially those with proteinuria), uncontrolled HTN, CHF, cirrhosis, >60 years old, and Polycystic kidney disease.
• Lower Risk Patients: AKI with recovery (i.e. Sepsis, cardiac arrest, dehydration, obstructive uropathy), ironically Polycystic kidney disease (really based on family history—if hx of PKD on HD high risk for HD, if PKD but no progression, unlikely to progress)

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— there is a 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/pleuritis

·         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

And last but not least. . .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