kidney care Comprehensive renal care: selection, indications, contraindications

Comprehensive renal care: selection, indications, contraindications






This complete text is the edited and revised transcript of a conference given in the Peritoneal Dialysis Course, organized by the Departments of Nephrology of the universities of Chile and Pontifical Catholic University between December 18 and 20, 2006. Director: Dra. Mireya Ortiz Mejías.

Introduction

Comprehensive renal care is an important and interesting concept; then its indications and contraindications will be discussed.

As a first point, it should be noted that the amount of resources invested in dialysis is very high and that it would be much more advantageous to invest in preventive measures aimed at slowing down progression, so that patients arrive at dialysis later and in better conditions.

Regarding progression, in chronic kidney disease in the pre-dialysis phase, the most important thing is to preserve residual renal function, avoid uraemic complications and provide information and education to patients and their families about what is the therapy renal replacement.

The decision to admit a patient to dialysis must be made in conjunction with the patient, his family and the treating team; if there is no medical contraindication, the decision of the therapy to be used must be made by the patient; if he opts for hemodialysis, a fistula must be scheduled and performed. The latter is very important, because although the main cause of mortality in dialysis patients are cardiovascular problems, in the first 90 days the first cause is infections, mainly in relation to catheters.

The initiation of dialysis therapy should be planned with the purpose of training the patient in therapy, both by hemodialysis and by peritoneodialysis, performing simulations in fixed and fixed schedules, with the aim of achieving adaptation and discipline in patients.

In relation to treatments, the therapy that offers the greatest probability of success is transplantation, although today one of the most important causes of admission to dialysis is chronic rejection in transplant patients.
Dialysis modalities
In the course of their lives, patients can choose between three therapeutic modalities, when necessary: ​​hemodialysis, peritoneodialysis or transplantation, because, more than the type of therapy, the patient cares to live with a good quality of life. If you trust your doctor, you will opt for the therapy indicated by the doctor, so that, unlike cardiologists and hepatologists, nephrologists have the possibility of managing the three therapeutic modalities mentioned. This situation has the advantage that, if the hemodialysis fistula does not work, there is the alternative of using peritoneal dialysis and the same thing happens if the patient who is in peritoneal dialysis has recurrent peritonitis. The goal for nephrologists, in particular for those who work in dialysis, is to complement the three types of treatment.

Hemodialysis and peritoneodialysis are complementary to each other and to the transplant, and during the course of their life the patient will require the three types of therapy. An important aspect is that patients who are in peritoneodialysis do not survive less than those who are on hemodialysis: in a Danish registry in 2001 it was shown that the mortality in hemodialysis is greater than the mortality in peritoneodialysis during the first two years, which does not it means that peritoneodialysis is better, because this relationship is reversed after the first two years (Fig. 1).

Figure 1. Peritoneal dialysis patients have an advantage in the initial survival in relation to hemodialysis patients (1)


In a retrospective study conducted in 2000 in 417 patients, peritoneal dialysis versus hemodialysis was compared. Some patients undergoing hemodialysis were transferred to peritoneal dialysis, others underwent transplantation, and others underwent hemodialysis; The same was done with the patients in peritoneodialysis (Fig. 2). It was observed that in patients who started with peritoneodialysis and then switched to hemodialysis, survival was greater than in patients who had started and continued with hemodialysis (Fig. 3). From the above it can be concluded that the integrated therapy is good. However, this study has a bias and is the fact that the patients did not paired. The conclusion is that using integral therapy, starting with any of the dialysis modalities and then switching to the other at the time it is necessary, is the best alternative that can be offered to patients. This, in terms of dialysis, not transplantation.

Figure 2. Patient flow diagram (2)

Figure 3. Survival analysis. Demonstrates advantages in survival with peritoneal dialysis as initial therapy (2)

Comprehensive renal management
Comprehensive care is a planned approach to improve the lifespan of patients in this therapy; consequently, there is a time devoted to preparation, which includes pre-dialysis education and the preparation of a vascular access. Pre-dialysis education is a very important aspect and not only doctors, but also nurses and the team in general, should participate in the delivery of information to patients and their families on hemodialysis, peritoneal dialysis and end-stage renal disease. By delivering good information and education to the patient's relatives, the anxiety and stress of families decreases.

In a classic Italian study, patients who received pre-dialysis information from their treating physician and patients who did not receive it were compared (Fig. 4) and it was found that a large part of patients who do not have this information start hemodialysis because they do not know that there is another possibility; On the other hand, when they have been informed, more patients choose peritoneodialysis. This is important from the personal point of view of the patients and also from the point of view of the prognosis, since when patients have information, more of them initiate therapy in a planned manner, either with a fistula or with a peritoneal catheter; In contrast, patients who do not receive prior education are those who arrive at the hospital with an indication for emergency dialysis. Unplanned initiation increases not only the costs, but also the morbidity; therefore, the ideal is to start therapy in a planned manner, as this influences the results and outcomes of these patients.

Figure 4. Influence of timely and structured pre-dialysis education in Italy (3)

In another Italian multidisciplinary study, which lasted three years, it was observed that the care of patients during the period 1999-2000 was not done with a planned structure and, from that year, a dialysis education program was started. . Then, the patients were divided into a group that was referred early, before 3 months (36.7% of the patients) and another that was derived late, after 3 months (63.3% of the patients). ; These were subdivided into patients who received pre-dialysis education (40.6%) and patients who had an unstructured management (22.7%). The survival of patients who received education was better than that of patients who were not informed and who did not have a scheduled start; Likewise, it was observed that late-derived patients started hemodialysis more frequently than with peritoneodialysis, which confirms that more patients choose peritoneodialysis, to the extent that they have the appropriate information. On the other hand, late-derived patients initiated hemodialysis in acute form; however, very few of those who had pre-dialysis education started acute treatment and many of them already had a catheter or a fistula at the time of beginning renal replacement therapy. Finally, about half of the patients chose peritoneodialysis.

Table I. In patients treated in centers with pre-dialysis education (PEP) there were fewer cases of unplanned dialysis initiation (4)


Advantages of peritoneodialysis
The importance of choosing peritoneal dialysis is in the preservation of vascular access. The incidence of bacteremia by jugular veins and subclavian catheters is a very large problem, which has been well studied; Another problem is stenosis and hospitalization, especially in the first years, due to infectious complications of the fistula. Patients who start hemodialysis with a central venous catheter are much more exposed to infectious problems and thrombosis; therefore, comprehensive care is a planned approach to get a patient to start dialysis in an appropriate way and to stay a while with this therapy, or receive a transplant, enjoying a good quality of life.

In the transplant-peritoneal dialysis-hemodialysis cycle, the survival results with peritoneal dialysis are at the same level as the results with hemodialysis; likewise, peritoneodialysis is the treatment of choice in children and the problems of peritonitis and infections do not have the same repercussions as they did in the past (Fig. 5).

Figure 5. Comprehensive care in terminal chronic renal failure

Some benefits of peritoneodialysis are: preservation of residual renal function; reduction of anemia time; lower needs for erythropoietin and improvement of vascular access, among others.

The preservation of residual renal function is very important. 1 ml of renal clearance corresponds to 10 liters per week of renal clearance of creatinine, so that 1 ml of clearance means a lot to patients. In a paper by Dr. Pérez Fontán, from La Coruña, Spain (5) regarding renal transplantation, it was found that grafts work more quickly in patients who are in peritoneodialysis than in those who are in hemodialysis and that the function of the graft has a late onset in 50% of patients on hemodialysis who are transplanted. In the same way, the Danish records show that grafts start functioning much more quickly in patients who are in peritoneodialysis versus those who are in hemodialysis.

In several studies carried out in Spain and the Netherlands, it is observed that the quality of life is better in patients undergoing peritoneodialysis, although the patients who chose this therapeutic modality were younger patients. The quality of life is important, which does not mean that the patient does not assume certain restrictions; Thus, for example, if a patient has volume problems it means that he can not drink as much as he wants. Salt is also a problem and one must fight for patients to reduce their intake.

In relation to hepatitis B and C, it is known that the prevalence, in terms of hepatitis B virus antibodies, is much higher in hemodialysis than in peritoneodialysis, a fact that occurs in different regions of the world. Regarding the impact on other comorbidities: in case of anemia less erythropoietin is needed in patients who are in peritoneodialysis than in those who are in hemodialysis; in diabetics, the result is similar with both modalities; and the same is observed in the elderly, those who now have a new modality of dialysis, assisted automatic peritoneal dialysis (AAPD), in which a trained person goes to the patient's home to perform dialysis therapy, so that the person no longer needs to leave his home to perform the treatment. In relation to cardiovascular disease, peritoneal dialysis is associated with better continuous control of volume, reduction of blood pressure, according to the decrease in salt intake, greater hemodynamic stability, stabilization of potassium levels, lower incidence of arrhythmias .
Comprehensive care: timely transfer
If a patient travels constantly, an excellent therapeutic alternative would be assisted automatic peritoneal dialysis, because it allows to lead a more independent life and, consequently, to carry out activities such as traveling. Similarly, if a patient who is on hemodialysis presents cardiovascular and hemodynamic problems, it should be changed to peritoneal dialysis whenever possible. On the other hand, if a patient who is in peritoneodialysis presents recurrent peritonitis or has problems of adequacy to ultrafiltration, he should be transferred to hemodialysis. From the above it follows that it is important to know how to transfer a patient at the right time.


The role of peritoneal dialysis as initial therapy in comprehensive care is that: it preserves renal function; retains vascular accesses; improves the use of resources; allows to control blood pressure and volume; can postpone the onset of amyloidosis; reduces the risk of infections; improves the quality of life and reduces costs.

The pillars of comprehensive renal care are: consider referral to another level of care and preparation and early start, which constitutes a planned start of therapy. Subsequently, the three treatment modalities must be used: first the transplant, then the peritoneum and hemodialysis when necessary, while transferring patients when the case requires it (Fig. 6).

Figure 6. Integral care: timely transfer

There are no medical reasons why patients can not choose between peritoneum or hemodialysis. Peritoneal dialysis is indicated in all patients, except those who do not have a viable peritoneum or those who by their own will do not want to undergo this type of treatment. It is important to note that there are no contraindications for peritoneal dialysis in diabetic patients, the elderly, with chronic hepatic insufficiency (with ascites), obesity, polycystic kidney, anuria or respiratory failure.

Among the absolute contraindications are: the presence of a mechanical defect that can not be corrected and that prevents carrying out an effective peritoneodialysis, for example, a hernia and the documented loss of peritoneal function, which does not include patients who have a scar from abdominal surgery, as many doctors think.

In children, peritoneal dialysis is the therapy of choice against hemodialysis, since it does not require vascular access, it can be used in a wide range of ages, it ensures hemodynamic stability, it allows managing arterial hypertension, it preserves renal function, it requires fewer visits to the hospital and allows for better rehabilitation. A hospital in Mexico has the best experience in the world; there are 300 children monitored in automated peritoneodialysis and 85% of school-age children continue to attend school.

It can be concluded that all patients are ideal for peritoneodialysis and, in any case, if there is doubt, this therapeutic modality can always be tried.