The DOPPS Study To what extent does vascular access account for mortality on dialysis?
Late Referral in Bradford 13/35 new chronic HD patients referred late in 2001 Nephrologists are not blameless as only 8/35 commenced HD with a fistula Late referrals are more likely to be older, Asian and to have diabetes In all studies patients perceived as higher risk are referred late
Earlier referral should improve subsequent mortality/morbidity of patients with ESRF due to diabetes
Demographics Current take on rate in Bradford is approx 100 pmp Diabetes/hypertension/ESRF all more prevalent in South Asians Pending epidemic of type 2 diabetes DM 2x odds of death on dialysis cf non-diabetes Bradford dialysis cohort likely to double by 2010
Are we going to be able to dialyse our way out of trouble?
Is diabetic nephropathy preventable? Tight control Blood pressure Proteinuria ACE inhibitors Lipids Smoking cessation
Blood pressure and proteinuria Reducing blood pressure slows the rate of disease progression Superiority of ACE Inhibitors –Lewis et al NEJM 1993, Captopril Proteinuria is not just a disease marker but is pathogenetic Reduction in proteinuria slows progression –Reviewed in lancet editorial 1999, DeJong et al
Blood pressure and proteinuria Hovind Kidney International 2001 Normal progression of DN 10-12ml/min/year 7 year study of 300 type 1 patients 31% remission 22% regression (GFR decline 1ml/min/year) Even in this clinic many patients do not achieve BP targets
Glycaemic control Prevention of microalbuminuria (PDS, DCCT) Little evidence for beneficial effect on progression of established DN although did predict regression in the Hovind study Limits other complications Patients who cannot achieve tight control still benefit from BP treatment
Smoking and Lipids Meta-analysis suggests that lipid lowering can preserve GFR Renal function declines twice as fast in smokers –This is under appreciated by patients and doctors Progression, remission, regression of chronic renal disease Ruggenenti, lancet 2001: 357
Blood Pressure Initiate therapy if BP > 140/80 Aim for 130/80 or lower Follow PACE hypertension guidelines
Anti-hypertensives in Diabetes Most patients will need several agents ACE inhibitors first line if ACR >2.5 Some contra-indications may be relative in diabetes Do not omit non-pharmacological measures
Blood pressure treatment in normotensives? Schrier et al, Kidney International 2002 128/75 vs 137/81 Type 2 DM Reduced progression from normal to microalb to DN Reduced progression of retinopathy Reduced stroke
ACE Inhibitor guidelines Check creatinine prior to prescribing Check creatinine approx 10 days after 1st dose Re-check after any dose increase Omit in the presence of intercurrent illness especially if dehydration/hypotension Higher degree of vigilance if PVD or other reason to suspect renovascular disease