Marc Richards Morning Report November 2 nd, 2009

 CKD  When to refer to a Nephrologist  Access  When to start dialysis:  Symptoms  Numbers  Pictures of San Diego Zoo animals

 Estimated 20 million Americans  HTN + DM = 70%  Others: GN, PCKD, Obstruction, etc…  Decreased renal mass  Nonspecific clinical presentations

 1 : GFR > 90 (normal to increased)  2 : GFR (mildly decreased)  3 : GFR (moderately decreased)  4 : GFR (severely decreased)  5 : GFR <15 (failure)  6 : DIALYSIS (source: National Kidney Foundation, KDOQI)

 Often occur late (<6 months before eventual start of RRT)  ~20-50% first referred <4 months (multiple studies)  Due to both patient and physician biases  Studies suggest increased all-cause mortality in patients referred late.

 Suggested for women with SCr > 1.2 and men with SCr > 1.5, or anyone with CKD 3  Why so early?  CKD can progress at different rates  Reversible causes (vasculitis, etc)  Access  Management of comorbidities  Anemia, Bone-Mineral Metabolism…  Living Donor Allograft  Dialysis discussions

 PermaCath (tunneled line)  AV Fistula  Synthetic Grafts

 Referral to Vascular Surgeon:  CKD 4  Expected to require RRT in < 1 year  FISTULAS:  Mature in 1-6 months  Expected function: 20 years  Very low infectious risk  GRAFTS:  Failed fistula attempt  Mature in 2-6 weeks  Higher risk of infection, thrombosis  LINES:  Emergent HD initiation  Awaiting maturation of AVF/AVG or out of access  Lower Q  Highest rate of infection  PD CATHETER

AEIOUAEIOU

 Refractory Hypertension  Weight Loss/Malnutrition  N/V  Persistent Metabolic Disturbances  Refractory Anemia  “Uremic-Like Symptoms”- depression, decreased conc, RLS  Pruritis

 Currently a topic of contention in the nephrology world  Cockraft Gault Equation:  Age, weight effects  Loose guidelines now suggested by multiple entities:  K/DOQI (2006): GFR < 15 (CKD 5)  Europe Best Practices (2005): consider when GFR 8- 10, definitely start when GFR < 6

 Why the uncertainty?  No study to date has effectively proven a survival benefit with earlier initiation of RRT  Proposed morbitity benefits:  Liberal Nutrition  HTN control  IDEAL Trial  Prospective study underway in Australia/NZ  GFR 10 vs 14 when starting RRT

 Current (2007)  UpToDate  National Kidney Foundation  IDEAL  San Diego Zoo