tema 13. inicio de tsfr

8/11/2019 Tema 13. Inicio de TSFR

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INICIO DE TSFR

Although the overall objectives of the guidelines and recommendations are to delay progression of both chronic kidneydisease and its complications, a proportion of patients will require renal replacement therapy (either dialysis ortransplantation) to extend their life. Physicians and health care providers must be aware of the need for preparation andthe time that is required to implement these care plans. A kidney transplant from a live donor should be promoted asthe first choice for eligible patients who require renal replacement therapy. At this point, care should be coordinated bya nephrologist.

CMAJ 2008;179:115462.

1. Epidemiologa

El uso de la DP flucta considerablemente de pas a pas ya que la proporcin va desde el 0% a ms del 60% del total dela poblacin en dilisis. En un estudio de 20.702 pacientes, 13.042 (63%) estuvieron en DP continua ambulatoria (DPCAy 7.660 (37%) en DP ambulatoria (DPA).

There are few countries in Latin and Central America that use PD in a majority of the cases. Some examples includeMexic which have PD utilization rates of 66.

Jalisco reporta que han ido creciendo los que reciben hemodilisis (normalmente hecha en clnica con apoyo de personamdico) que en 5 aos pasaron del 34 a ms del 50%, mientras que los de dilisis peritoneal se redujeron del 67 a msdel 49%. La terapia de HD se brinda casi al 50% de los pacientes en modalidad subrogada, lo que genera gastos muyimportantes al instituto.

Mientras en Espaa el 50% de los pacientes inician en condiciones de urgencias 3, en Mxico esteporcentaje se aumenta hasta un 80%, adems ingresan con una funcin glomerular disminuida hasta de 3ml/min en comparacin a lo sugerido por la National Kydney Fundation de 10-15 ml/min.

Nefrologia 2006;26 Suppl 4:1184.Dilisis Y Traspl 2010;31:711.Rev Soc Esp Enferm Nefrol 2011; 14 (4): 236-241Nephrol Dial Transplant. 2013 Oct;28(10):2553-69http://eleconomista.com.mx/columnas/columna-especial-empresas/2014/02/02/urge-registro-insuficiencia-renal-cronica-mexico

2. Cundo iniciar una TSFR

The optimal time to commence dialysis in patients with chronic kidney disease is not clear. This uncertainty has beenrecognized by nephrologists internationally as potentially the most important dialysis-related question to be addressedin the next decade. A number of groups have tried to resolve the issue of when to commence dialysis by use of eithercohort or case-control studies. Within the spectrum of severity of chronic kidney disease, there is a need to identify athreshold before which starting dialysis offers no benefit to the patient but beyond which there may be somemeasurable risk. Identifying this threshold remains a challenge because of the inaccuracy of creatinine-based measuresof kidney function; a body of evidence composed of potentially biased observational data; and reliance on poorlyvalidated nutritional surrogate markers, with an under emphasis on patient-important outcomes such as hospitaadmission and quality of life. Collectively, these factors may account in part for the recent increase in earlier (i.e., at ahigher level of kidney function) initiation of dialysis in Canada and the United States. Considering the enormous burdenimposed by dialysis on patients and health care systems, there is a need for a judicious approach to dialysis initiation.

Gua Ao Criterio Absoluto Criterio Relativo

Sociedad Canadiense de Nefrologaa 2014 6 ml/min/1.73 m2


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European Best Practice Guidelinesc 2011 8-10 ml/min/1.73 m2


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C. In patients with a GFR 100000, in registry-type data sets. These studiesall demonstrated a progressively reduced mortality with starting dialysis at lower levels of eGFR. These studies provideconvincing and reproducible evidence that there is an association between high eGFR when dialysis starts and increasedmortality. They provide some evidence that starting dialysis early could be harmful. As observational studies, they donot prove that starting dialysis with higher eGFR causes the worse outcome, though this is a possible explanation for theresults. There are other possible explanations for the association: Patients with low muscle mass due to inactivity or mal- nutrition will have a lower creatinine generation rate.

Patients with fluid overload will dilute their serum creatinine. Both groups will have higher co-morbidity, yet havelower serum creatinine. Since eGFR is calculated from serum creatinine, eGFR will be overestimated in thesepatients and they are more likely to be included in earlier start groups [17].

Patients with symptoms or co-morbidity are more likely to be started on dialysis early. Multivariate adjustment foco-morbidity indeed decreased the benefit of starting with low eGFR, but it did not disappear [1013].

Patients were only included in the study if they actually started dialysis. Patients dying before dialysis started(possibly due to uraemia) were excluded. Only the fittest patients survive long enough to be included in the latestart groups. In the Huang [12] study, deaths within the first 90 days of starting dialysis were excluded, furtherenhancing this survivor bias

On the other hand, these studies are prone to the lead time bias, where the extra period of life gained by delaying

dialysis is not taken into account. This will bias the results in favour of early start.

A Swedish study, based on a complete nationwide inception cohort of chronic kidney disease (CKD) stage 45 patients(as part of a nationwide casecontrol study of risk factors for CKD) followed up for 5 years has recently been completed[19]. This study avoided the lead time and survivor bias by enrolling patients prospectively when their GFR dropped


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Hwang SJ, Yang WC, Lin MYet al. Impact of the clinical conditions at dialysis initiation on mortality in incidenthaemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant 2010; 25: 26162624Stel VS, Dekker FW, Ansell D et al. Residual renal function at the start of dialysis and clinical outcomes. Nephrol DialTransplant 2009; 24: 31753182Lassalle M, Labeeuw M, Frimat L et al. Age and comorbidity may explain the paradoxical association of an early dialysisstart with poor survival. Kidney Int 2010; 77: 700707Clark WF, Na Y, Rosansky SJ et al. Association between estimated glomerular filtration rate at initiation of dialysis andmortality. CMAJ 2011; 183: 4745

Evans M, Tettamanti G, Nyren O et al. No survival benefit from early start of dialysis in an population-based, inceptioncohort study of CKD-patients in Sweden. J Int Med 2011; 269: 275277

Sin cambios en la mortalidad.

The earlier study by Traynor et al. [18] attempted to correct for the lead time bias retrospectively by accounting survivafrom the time when CC (by Cockcroft and Gault method) dropped


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Both NECOSAD and CANUSA were subject to the lead time bias. The NECOSAD study investigators suggested that, if leadtime bias was taken into account, it would remove or reverse this benefit of early start [3]. The NECOSAD study showeda strong association between nutritional indices and GFR in the period before dialysis starts [3]. Two further studies haveshown that renal function measured some months after starting dialysis are powerfully associated with reducedmortality, even if dialysis dose is reduced [21,22]. Higher GFR, some months after starting dialysis could be due to betterpreservation of GFR after starting dialysis (maybe due to less aggressive kidney dis-ease), not necessarily due to startingdialysis with higher GFR. These observational studies may not provide strong evidence to support earlier dialysis startbut do suggest that measured renal function should be taken into account in any future dialysis outcome study. As an

RCT, the IDEAL study was designed to eliminate the various causes of bias which are unavoidable in observationastudies.

Korevaar JC, Jansen MA, Dekker FWet al. When to initiate dialysis: effect of proposed US guidelines on survival. Lancet2001; 358: 10461050Merkus MP, Jager KJ, Dekker FW, De Haan RJ, Boeschoten EW, Krediet RT. Quality of life over time in dialysis: theNetherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD study group. Kidney Int 56(2): 720-728, 1999.

The IDEAL Study

The IDEAL study enrolled patients >18 years old with CC between 10 and 15 mL/min/1.73m 2. Patients were randomizedto two groups, named early and late. The early group were planned to start dialysis when CC was 1014mL/min/1.73m2 and the late group at 57 mL/min/1.73m2. The study protocol allowed patients in either group to startdialysis based on clinical indications, regardless of CC, if that was deemed necessary by the patients nephrologist. CC

was calculated using the Cockcroft and Gault equation, multiplied by 1.73 and divided by surface area calculated usingthe Dubois and Dubois equation. Mean follow-up was 3.64 and 3.57 years in the early and late groups. There were 404and 424 patients in the early and late groups, respectively.

The results of the IDEAL study showed no difference in mortality between the early and late groups. Seventy-six per cenof the patients in the late group started dialysis with CC higher than the intended 7 mL/min/1.73m 2,the majority due touraemic symptoms. The average CC at the time of starting dialysis was 12.0 and 9.8 mL/min/ 1.73m2in the early and lategroups, respectively. Yet, the late group started dialysis on average 6 months later than the early group.

Between-group quality-of-life scores did not differ in the IDEAL trial. The rate of hospital admission and total days ofhospital admission did not differ between groups in the IDEAL trial.

After randomization, the median time to start was 1.90 months in the intent-to-start-early group and 7.30 months in theintent-to-defer group (HR 1.96, 95% CI 1.672.30; p < 0.001)].

This was associated with higher dialysis costs (Can$10 777, 95% CI $313$22 801, higher per patient) and transportationcosts ($3610, 95% CI $1111$9959, higher per patient). The costs and number of hospital admissions and outpatientvisits were not significantly different between groups. All economic outcomes suggested cost savings with an intent-to-defer strategy, but the overall quality of evidence for economic outcomes was rated down one level for imprecision

(wide CIs for some estimates). Nevertheless, we concluded that, on average, an intent-to-defer dialysis strategy wouldlikely result in substantial cost savings, especially when applied across a health care system or population.

A new scope

One study let out of the recent guidelines concluded that early dialysis initiation in a hemodialysis cohort may beharmful. This study examined a 19962006 US incident hemodialysis population under age 65, with no reportedcomorbidities (except hypertension). In the subset of this cohort with initial serum albumin of 3.5 gm/dl or higher, the 1year survival showed a corresponding decrease with higher starting eGFR, compared with late starts, who initiateddialysis at eGFR less than 5 ml/min/1.73 m2 (Table 1). The fully adjusted first-year mortality hazard ratio relative to thelate-start group was 1.27, 1.53, and 2.18 for eGFR 59.9, 1014.9, and >15 ml/min/1.73 m2, respectively. Patients with


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high comorbidity and low serum albumin levels (?2.5g/dL) may have had a greater risk of death independent ofhemodialysis. Contrariwise, those in the HG with lower comorbidity and with highereGFRat initiation of hemodialysismight have been more susceptible to potential harm from the hemodialysis procedure.

Although the results of this healthy-cohort observational study do not prove that early hemodialysis initiation isharmful, neither do any of the results from all published studies, including the IDEAL study, and the studies using GFR

measures based on 24-hour urine urea and/or creatinine clearance, show a benefit of early starting.

Am J Kidney Dis. 2011 May;57(5):707-15.CMAJ 2014;186:1127.Nephrol Dial Transplant 2011;26:20826.Kidney Int 2011;80:10057.Adv Chronic Kidney Dis 2007;14:e2734.

4. Cmo valorar al paciente

Variation in Creatinine Generation. It is well established

that creatinine generation may be unusually low inpatients with a number of conditions and may beincreased in individuals of unusually muscular habitus(Table 2). In these situations, GFR estimated by usingcreatinine and urea clearances may be substantiallymore accurate (compared with radionuclide GFR) than

results of creatinine-based estimating equations. In patients

for whom endogenous creatinine generation is likely to be unusually low or high, GFR should be estimated by usingmethods independent of creatinine generation, such as measurement of creatinine and urea clearances. Variation inTubular Creatinine Secretion. Several drugs are known to compete with creatinine for tubular secretion, and advanced

liver disease has been associated with increased tubular creatinine secretion (Table 3). Decreased secretion will result inartifactually low GFR estimates, and increased secretion will result in overestimation of GFR by means of estimatingequations. In patients for whom tubular creatinine secretion is likely to be unusually low or high, the consequent bias toall creatinine-based measures should be considered in interpreting GFR estimates.

The IDEAL study used estimated CCbased on serum creatinine, ascalculated by the Cockcroft and Gaultmethod and corrected for surfacearea. This is closely related to themore commonly used MDRD method


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for estimating eGFR from serum creatinine (though the MDRD method does not require a separate surface areacorrection step). The IDEAL study demonstrated that CC, calculated by Cockcroft and Gault was 35% higher than GFRcalculated by the MDRD method.

Renal function should not be estimated from measurements of blood urea or creatinine alone. Cockcroft and Gaultequation or reciprocal creatinine plots should not be used when the GFR is


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Nefrologia 2006;26 Suppl 4:1184.

7. DP o HD

Por qu hay tanta diferencia en los porcentajes de tratamiento de la DP y la HD?. La indicacin de una u otra modalidadde dilisis (DP vs HD) tiene una vertiente mdica y otra personal y sociofamiliar. Desde el punto de vista mdico estnrazonablemente definidas las situaciones en las que el tratamiento con DP puede implicar ventajas o desventajas para eenfermo, for example, hemodialysis induces a decline in kidney function within the first 3 months of dialysis, andresidual kidney function has an important effect on survival. Although earlier initiation of dialysis could possibly lead to a

more rapid loss of endogenous clearance and accelerate morbidity and mortality, this risk appears to be less ifperitoneal dialysis (in particular, continuous ambulatory peritoneal dialysis) is used as the initial form of therapy.Automated peritoneal dialysis (APD) may be associated with a more precipitous decline in residual kidney function. In asmall prospective study of 36 patients, endogenous creatinine clearance declined more rapidly in the first year inpatients on APD compared with CAPD.

Sin embargo, en la prctica es habitual la ausencia de factores mdicos que, de manera categrica, indiquen ocontraindiquen la DP. Adems es frecuente la coexistencia, en el mismo paciente, de diversos elementos de decisin quepueden entrar en conflicto a la hora de optar por una u otra modalidad de tratamiento. Tambin, el estilo de vida, laactitud y las posibilidades del paciente constituyen determinantes esenciales para asignar uno u otro tipo de dilisis, si loque se pretende es optimizar la rehabilitacin y la calidad de vida del enfermo. En este sentido la eleccin informada y

razonada por parte del paciente debe ser el elemento fundamental de decisin.

Est plenamente aceptado que el inicio de un programa de dilisis peridica puede hacerse tanto con DP como con HDIncluso, como han sealado Coles y Williams y tambin Gokal, hay ventajas de iniciar el tratamiento sustitutivo de lafuncin renal con DP. Como sealan Montenegro y Olivares, son los factores no mdicos los ms influyentes en laeleccin de la tcnica dialtica: actitudes y recomendaciones del nefrlogo y de la enfermera, la opinin de otrosenfermos, determinados aspectos psicolgicos, costumbres sociales, la derivacin temprana o tarda al nefrlogo, lainformacin y educacin recibida en las consultas de predilisis, y, lgicamente, la preferencia del propio paciente.

Tomar la mejor decisin para la seleccin de la tcnica de dilisis requiere un criterio basado en las evidencias de lainvestigacin, la experiencia clnica del nefrlogo y en las preferencias del paciente18. Con respecto a las evidencias de

la investigacin, vamos a analizar diferentes cuestiones (supervivencia, TR, infeccin por virus de la hepatitis C, calidadde vida, conservacin de la funcin renal residual, pago por dilisis, experiencia del mdico, etc.).

Nefrologia 2006;26 Suppl 4:1184.Adv Chronic Kidney Dis 2007;14:e2734.

a. Cul es la diferencia en supervivencia

En general, no hay diferencias acusadas en la mortalidad entre la DP y la HD. Se ha mencionado que la DP es mejor enlos 2-3 primeros aos de TRS; despus de este perodo, la supervivencia es mejor en HD, sobre todo en pacientesmayores de 60 aos y diabticos (J Am Soc Nephrol 2003; 14: 415424. Kidney Int 2003; 64: 10711079. Kidney Int 200466: 23892401. Ann Intern Med 2005; 143: 174183.). En un estudio de supervivencia de cohortes en 1041 pacientes a 7

aos no se encuentran diferencias de mortalidad en el primer ao entre HD y DP. Posteriormente, la supervivencia espeor en DP, sobre todo a costa de los pacientes con mayor comorbilidad cardiovascular (Kidney Int Suppl 2008; (108):S56-62).

Existen situaciones especficas donde una tcnica puede tener mejores resultados que otra. Entre estas se encuentranaquellos pacientes incidentes que padecen insuficiencia cardaca. En ellos, la supervivencia puede ser mejor en HD queen DP, ya que la sobrecarga de , que puede conllevar la DP incide deletreamente en su riesgo cardiovascular.La DP se asocia con peor supervivencia entre pacientes con enfermedad coronaria. El uso de IECA y ARA en DP podramejorar esta supervivencia.


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Vonesh y Moran20, estudiando datos del USRDS referidos a pacientes prevalentes e incidentes, refieren que noencuentran diferencias significativas en la mortalidad entre DP y HD.

La supervivencia por modalidad de dilisis en diabticos puede variar con la edad; algunas series han mostrado mayorsupervivencia en diabticos ms jvenes en DPCA21, mientras que otros22-23han encontrado menor supervivencia endiabticos mayores. Estas aparentes contradicciones pueden explicarse en parte por sesgos de seleccin: cuando secomparan los tratados con HD, los diabticos ms jvenes generalmente tenan menor comorbilidad mientras que losdiabticos ms viejos tenan ms enfermedad vascular perifrica.

En resumen, se necesitan ms estudios para determinar si la DP tiene ventajas o desventajas en la supervivencia frente ala HD. En conjunto parece que los diferentes resultados son debidos a diferencias entre pacientes incidentes y el tipo demtodo analtico utilizado. El mtodo ideal para solucionar esta cuestin sera un estudio prospectivo querandomizadamente asignara los pacientes a DP o a HD, y aplicara el conocimiento actual sobre dilisis adecuada a todoslos pacientes del estudio.

NDT Plus 2010;3:22533.Nefrologia 2006;26 Suppl 4:1184.Libro montenegro

b.

Cul es la diferencia en calidad de vida

Las tcnicas domiciliarias demuestran habitualmente una mejor calidad de vida, pero slo en algunos estudios lasdiferencias son significativas. La satisfaccin con el tipo de tratamiento es habitualmente mayor en los pacientes en DPque en HD en Centro. Tambin la actividad laboral es superior en la DP, particularmente en la DPA. La conclusin deestos estudios es que la calidad de vida no se ve perjudicada en DP con respecto a la HD, incluso puede ser mejor. Apesar de lo expuesto, el grupo del estudio NECOSAD, en un estudio prospectivo de cohortes, concluy que la calidad devida (QL) fsica a lo largo del tiempo era mejor en pacientes en HD que en pacientes en DP. Los valores mentales de QLpermanecieron similares en ambos tratamientos. El estudio IDEAL no encontr diferencia entre ambos grupos.

N Engl J Med 2010;363:60919.

Kidney Int 56(2): 720-728, 1999.Nefrologia 2006;26 Suppl 4:1184.

c. Cmo se afecta la funcin renal residual

Otro aspecto a considerar es la funcin renal residual. En DP desciende la funcin renal residual pero se sabe que seconserva mejor que en HD. Incluso, hemodialysis induces a decline in kidney function within the first 3 months ofdialysis.

La funcin renal residual contribuye al aclaramiento total de solutos y est ligada a menor mortalidad y mejor estadonutricional, incluso con valores bajos. Tambin se conoce bien la relacin que existe entre control de la tensin arterial y

funcin renal residual. No olvidar tampoco la asociacin negativa entre funcin renal residual e hipertrofia de ventrculoizquierdo. Sin embargo conviene indicar que la hipertrofia de ventrculo izquierdo es mayor en pacientes en tratamientoa largo plazo con DPCA que en pacientes en HD y que este hallazgo se asocia a una mayor expansin de volumenhipertensin arterial e hipoalbuminemia en los enfermos en DPCA, en relacin con los enfermos en HD.

Se ha discutido si el mantenimiento de la funcin renal residual es slo un indicacodr de filtrado glomerular renalremanten o si tambin es un reflejo de funciones en endrcrinas tales como produccin de eritropoyetina, homeostasisdel calcio, fsforo y vitamina D, control de volumen y aclaramiento de protenas de bajo peso molecular.

Adv Chronic Kidney Dis 2007;14:e2734.Nefrologia 2006;26 Suppl 4:1184.


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Libro de Montenegro

d. Cul es el mtodo ms adecuado

Otro aspecto de gran inters, a la hora de elegir tcnica de dilisis, sera saber cul podra ser la mejor de cara a unfuturo TR. Los pacientes en DP pueden tener una incidencia menor de retraso de la funcin renal del injerto y/o derequerimientos de dilisis tras el TR. Prez Fontn y cols mostraron que la incidencia del retraso en la funcin del injertofue significativamente menor en pacientes en DP que en pacientes en HD. sta menor incidencia de retraso en la funcindel injerto, un conocido factor de riesgo para el desarrollo ms tardo de rechazo crnico del injerto puede ser una razn

para la tendencia hacia una mayor supervivencia del injerto a largo plazo en pacientes en DP.

Snyder y cols. compararon los resultados en 252402 pacientes, procedentes de los Centros de Medicare y Medicaid65. ETR fue ms frecuente en DP que en HD. El TR en pacientes en DP se asoci ms frecuentemente con fallo del injertoprecoz pero no tardo. La funcin retrasada del injerto fue menos comn en DP.

Otro estudio mas por Yang Q y cols no demostrdiferencia en la supervivencia del injerto al ao y a los 5aos, ms si demostr una menor tasa de infeccin porvirus de hepatitis B en pacientes bajo DP.

Nefrologia 2006;26 Suppl 4:1184.Adv Perit Dial. 1996;12:101-4.Clin Nephrol. 2009 Jul;72(1):62-8.Kidney Int 62(4): 1423-1430, 2002.

e. Cul es el coste

Sennfalt y cols.69 apuntan a que el ratio coste-utilidad esms favorable a la DP, como mtodo primario detratamiento para pacientes que pueden ser tratados conDP o con HD.

In general, PD tends to be very affordable in countries which have local manufacturing facilities for CAPD bags (such asMexico). From a macroeconomic standpoint, we can see that increasing PD utilization rates in developed countries(where PD is significantly less expensive than HD) can help reduce the overall healthcare expenditure. Anotheradvantage connected to PD is that it is not as dependent on infrastructure and geography as HD is. Countries

which are disadvantaged by either a lack ofinfrastructure or cannot provide HD to somepatients because of unfavourablegeographical dispersion could possiblyconsider PD as an alternative.

Nephrol Dial Transplant. 2013Oct;28(10):2553-69Nefrologia 2006;26 Suppl 4:1184.

f. Indicaciones y contraindicaciones de dilisis peritoneal

Las indicaciones y contraindicaciones de la DP estn ampliamente expuestas en diversas publicaciones; en estecaptulo incluimos la de Olivares y cols. por su sentido claro y amplio.

Puede demostrarse que son factores no mdicos los ms influyentes en la decisin como actitudes y opiniones de lospropios equipos sanitarios, de otros pacientes, de las normas de recepcin de pacientes nuevos, de la existencia de


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consultas de predilisis, de la relacin con medicina familiar, etc. Junto a estos, pueden encontrarse razones personalesque actan como conflictos de decisin, frecuentemente provocados por el desconocimiento o falta de informacinadecuada.

Hay razones sociofamiliares, como tipo de trabajo, caractersticas domsticas, miedo a lo desconocido, etc., que tambintienen una base de informacin insuficiente. La superacin de esta situacin pasa por seguir aportando razones quepotencien o faciliten la entrada en una tcnica u otra. Iniciar esta opcin significa separarse del contenido habitual yanalizar otras razones que diferencien efectos de DP o HD.

The following conditions should not be considered as contraindications to PD: Physical or mental inability to perform PDOlder age, Poor adherence/non-compliance to therapy, Obesity, Congestive heart failure, Polycystic kidney disease,Diverticulosis, Abdominal hernias, Portal hypertension, Liver transplantation.

Performing PD requires a minimum of physical skills and mental capacity. It is clear that some physical problems, such asvisual impairment and tremor or deformities of the hands, may interfere with PD handling. In the opinion of the ERBPExpert Group, these problems do not a priori preclude the application of PD as an RRT. Moreover, several centres in theworld have gained experience in the socalled assisted PD. In this setting, it is not the patient him/herself but a nurse o

another assisting person that performs the PD treatment. Assisted PD must be considered as an alternative to in-centreHD for non-autonomous patients. Even with the additional cost of the assistance, assisted PD in developed countries hasbeen reported to be cheaper than in-centre HD.

Presumed or real non-adherence to the prescribed PD regimen can be a challenge to the PD team. It is important for thecaregiver, particularly if there is a sudden change in adherence of the patient, to try and find out why this happened. It is

especially important to find out whether the non-compliance is related to the PD therapy itself or whether it is a generaattitude of the patient. In some cases, the cause of non- compliance is a condition that requires attention from thecaregiver, such as denial of disease, depression, social problems (like divorce or death of a beloved person), intercur-rent illness and cognitive deterioration. Some of these conditions are only temporary and/or can be treated ade-quately. Some of the adherence problems may be solved by the implementation of assisted PD.

There is currently not enough evidence to contraindicate PD to obese individuals. However, several comments on thisissue are necessary. Obese patients, especially if diabetic, were shown to have increased risk of death after starting onPD compared to HD; however, such evidence is scarce. Furthermore, most studies in PD patients have found similar (ifnot better) survival in those who are obese versus those with normal body mass index. Obese patients may need largerdialysate volumes, usually provided by APD, to achieve adequate Kt/V, although the increase in body mass is not


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associated with a proportional increase in body water volume. However, PD may not be the preferred dialysis modalityor is relatively contraindicated in patients with morbid obesity, in which there may be difficulties in peritoneal catheterplacement and tunnel healing process, increased risk of pericatheter leak and infection, possible further weight gain dueto increased caloric absorption from the dialysate, as well as a risk for abdominal pain or discomfort, and aggravation ofdyspnoea, gastro-oesophageal reflux, abdominal hernias or vertebral disease, because of increased intra-abdomina

volume and pressure.

Congestive heart failure (CHF) is increasingly common in patients with ESRD. It is often associated with low bloodpressure, in spite of fluid overload, and it is one of the frequent causes of haemodynamic instability during ultrafiltrationto dry weight in HD patients. As such, PD, with its more subtle and gentle capacity for ultrafiltration, might be a betterand more comfortable alternative. Based on the existing information, it is difficult to either support or discard PD as amethod of choice in CHF patients. One particular subgroup, however, could be that of anuric PD patients with CHF, inwhich maintaining adequate dry weight is quite difficult.

NDT Plus 2010;3:22533.Libro de Montenegro

8. Tratamiento Conservador

The care of patients with chronic kidney disease necessarily includes proactive comprehensive management for thosewho choose not to receive renal replacement therapy and for those who come to the end of their life after a period oftime on a therapy. We describe the components and needs for comprehensive conservative management and end-of-life care for patients with chronic kidney disease (Box 9). We recognize that not all patients will have been referred to anephrology team at the time that they declined renal replacement therapy, therefore, we have tried to be appropriatelybroad in these recommendations. Comprehensive conservative management requires the involvement of aninterdisciplinary team, including nephrologists, chronic kidney disease nurses, dietitian, social workers, psychologists,


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spiritual care workers, palliative care physicians and nurses, and appropriately trained and supervised volunteers. Thepatients primary care physician is an integral part of this team.

In conjunction with the patient and family, the interdisciplinary team should develop a care plan that addresses thephysical, psychological and spiritual needs of the patient and his or her family and caregivers. Shared decision-making isan integral component of this process, and revisions to the care plan should be based on the changing needs andpreferences of the patient and family.

CMAJ 2008;179:115462.

9. Conclusin

Together, patients and physicians must continually reconsider whether the anticipated physiological benefits of soluteclearance and extracellular fluid (ECF) volume control now outweigh the physical risks and psychosocial toll of therapy.In some cases, social and psychological factors may lead to earlier dialysis therapy initiation, and in some cases, to laterinitiation.lo The initiation of dialysis therapy remains a decision informed by clinical art, as well as by science and theconstraints of regulation and reimbursement.

The observational studies have shown that dialysis is started at a wide range of eGFR, therefore, nephrologists are usingother criteria to decide when to start dialysis. These other criteria have not been well defined in the literature.We needobservation studies on the criteria used to start dialysis and the association between these criteria and subsequentoutcome. We currently lack any validated and objective measurement of the uraemic state which could be used to guidethe decision on when to start dialysis. Even accurately measured GFR has not been tested for this purpose in an RCT. Itmay be that a composite uraemia score would be required. Any future RCT on dialysis outcome should include

measurements of renal function, rather than estimation from serum creatinine.

Am J Kidney Dis 2006;48 Suppl 1.Nephrol Dial Transplant 2011;26:20826.

tema 13. inicio de tsfr

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