1602
PRE-DIALYSIS CARE AND RATE OF PROGRESSION OF RENAL DISEASE:
EXPERIENCE OF AN OUTREACH RENAL PRE DIALYSIS CLINIC
Osanlou, O², Morgan, H¹, Archer, T¹,Osanlou, R², Greer, A B¹, Khalil A¹, Ahmed, S¹
¹Renal Unit, Royal Liverpool University Hospital, ²Warrington Hospital
INTRODUCTION: 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). The National Service
Framework for renal services recommends that patients with chronic progressive renal disease
be referred to a multidisciplinary pre-dialysis team so as to ensure a smooth transition to
appropriate treatment pathways (2). 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 optimise 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 with a creatinine
clearance of <15– 20 ml/min. At our renal unit, patients are referred for pre-dialysis care with
an eGFR < 20ml/min for optimisation of treatment and patient education to facilitate informed
decision making process.
METHOD: 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.
RESULT: 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) values
Median
At 0 months (current)
At 12 month
At 24 month
Serum Cr( umol/)
322
285
255
eGFR
14
16
20
A 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).
CONCLUSION: 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.
References: 1. Ansell D, Feehally J st al. U.K. Renal Registry Report. Bristol: U.K. Renal Registry; 2007
2. National Service Framework for Renal Services. London: DH; 2005: 1–50.