Optimalen začetek zdravljenja s peritonealno dializo. Doc.dr. Jernej Pajek, dr.med KO za nefrologijo UKC Ljubljana
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1 Optimalen začetek zdravljenja s peritonealno dializo Doc.dr. Jernej Pajek, dr.med KO za nefrologijo UKC Ljubljana
2 Kazalo Pred začetkom dialize Pravočasna napotitev, preddializna edukacija, izbor nadomestnega zdravljenja, ocena primernosti za PD Kdaj vstaviti kateter in kdaj začeti z dializo? Ali je možen takojšnji začetek PD? Vzpostavljanje stabilnega dializnega zdravljenja
3 Gent Amsterdam Manchester Colmar Leicester Berlin Madrid Thessalonkiki Caen Brugge Brescia Brussels Vicenza Gent Amsterdam Manchester Colmar Leicester Berlin Madrid Thessalonkiki Caen Brugge Brescia Brussels Vicenza Prepozna napotitev manj PD Zgodaj Prepozno 100% 100% 80% 80% 60% 40% HD PD 60% 40% 20% 20% 0% 0% Napoteni vsaj 1 mesec pred dializo Nujni začetek dialize Lameire N, et al, NDT 1999;14(suppl 6):16-23
4 Vpliv edukacije Marron B et al;pdi :S bolnikov Ustrezna edukacija Brez preddializne edukacije, FU<3 mesece PD 31% HD69% PD8% HD92%
5 Kaj lahko storimo Prehod iz pediatrične skrbi v odraslo populacijo preveriti izgubljene Preiskati sezname v nefroloških ambulantah identifikacija izgubljenih bolnikov Vzdrževanje dobrega sodelovanja z zdravniki osnovne ravni Smernice za napotitev k nefrologu Stalno izobraževanje Izobraževanje javnosti o KLB, ki poteka tiho
6 The Multidisciplinary Team PD Nursing Team Ward Nursing Team Nephrologist (access, tx) Administration of fluid deliveries PATIENT Dietitian Social Worker Counsellor Pharmacist
7 Izbor metode (Glede na pričakovano preživetje) Starost, pridružene bolezni, prehranjenost, rgfr Kvaliteta življenja Medicinski dejavniki Osebni, socialni vidiki in lastna volja
8 Creatinine Clearance (ml/min) Integrirano nadomestno zdravljenje Peritonealna dializa prva opcija če: medicinsko ustrezno, izbor bolnika, konsenz, odločitev je trdna PD TX Hemodializa 5 0 Time on Dialysis Gokal R, Perit Dial Int,1999; 19(Suppl. 3):S35-S42
9 Creatinine Clearance (ml/min) Integrirano nadomestno zdravljenje TX 10 Hemodializa PD 5 0 Time on Dialysis
10 Zakaj je tako? Kako dobro izvajamo preddializno edukacijo? Kje izvajamo preddializno edukacijo in kaj lahko pokažemo bolniku? Kateri trajni pristop za dializo zagotavljamo nefrologi sami? Ali pomeni več PD: več/manj AV fistul? Kako zelo se bojimo EPS? Ali je možno imeti PD program brez EPS? Zakaj nam je vseeno koliko našega dela zahteva določena metoda? Izvajanje metode Zapleti metode
11 KDAJ ZAČETI Z DIALIZO: ERBP 2002 Dializa ko GFR<15 in simptomi ali upad v nutriciji V vsakem primeru je potrebno začeti ko pade GFR<6 ml/min/1.73m2 Za večino to pomeni začetek pri GFR 8-10 ml/min, da bi se izognili padcu pod 6 ml/min
12 Raziskave, ki pravijo, da je zgodnji začetek z dializo škodljiv Wright S, et al.. Timing of dialysis initiation and survival in ESRD. Clin J Am Soc Nephrol 2010;5: Kazmi WH, et al.. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis 2005;46: Hwang SJ, et al.. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant 2010;25: Stel VS, et al. Residual renal function at the start of dialysis and clinical outcomes. Nephrol Dial Transplant 2009;24: Lassalle M,et al.. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int 2010;77: Clark WF, et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ 2011;183: Fink JC, et al. Significance of serum creatinine values in new end-stage renal disease patients. Am J Kidney Dis 1999;34: Kaj v resnici pomeni zgodnji
13 Problemi in biasi Osnovna predpostavka MDRD formule v KLB 5 ne drži*,** Bias simptomov in komorbidnosti Preživetveni bias Lead time bias *Beddhu et al. JASN 2003;14: ** mgfr is not related to egfr (NECOSAD), egfr is related to muscle mass, mgfr is not, egfr is related to survival mgfr is not: (Grootendorst DC et al. The MDRD formula does not reflect GFR in ESRD patients. Nephrol Dial Transplant 2011; 26: 1932.)
14 Raziskava IDEAL Cooper BA, N Engl J Med Aug 12;363(7):
15
16 Osvežitev 2011: kako ravnati Preden postane KLB 5 simptomatska pripravi načrt za dializni pristop GFR < 15 začni z dializo ko so uremični simptomi, v/p preobremenitev, slabšanje prehranjenosti GFR 6-9 večina bolnikov bo dobila simptome (rezultati raziskave IDEAL!) Če je slab nadzor in/ali hitra izguba GFR začni z dializo že v asimptomatski fazi KLB 5 Asimptomatska faza KLB 5 lahko čakamo, da pristop za dializo dozori Kreatinin, CG CC, MDRD egfr - ne uporabljaj za oceno ledvičnega delovanja in/ali potrebe po dializi pri bolnikih v KLB 5
17 Kdaj vstaviti PD kateter 6 tednov pred ocenjeno potrebo po rednem dializnem zdravljenju Vsaj 2 tedna Ali pa še to ne
18 AKUTNI ZAČETEK PD Ustrezno izobražen bolnik, ki je izbral PD vendar je prišlo do nepričakovanega poslabšanja Pozno napoteni bolniki, ki rabijo zdravljenje in se jim zdi PD sprejemljiva po pogovoru z zdravnikom
19 Kontraindikacije za akutno PD Huda hiperkaliemija Hipervolemija z dihalno stisko Uremična encefalopatija
20 Protokol Days 1-3 Days4-6 Days7-9 Dwell volume 1.2* l Dwell time 60 minutes 90 minutes 120 minutes Type of fluid Physioneal Dianeal 1.36% Dianeal 1.36% *Povlsen, NDT 2006: using this standard prescription, the youngest doctor on duty could prescribe the treatment, and the youngest renal nurse on duty could carry it out
21 J.V. Povlsen and P.Ivarsen;NDT (2006)21 Suppl 21:ii56-ii59 Rezultati Acute start Planned start P-value N 52 (%) N 88 (%) Infectious, total 10 (19.2) 11 (21.2) NS Peritonitis Exit site infections Mechanical, total Pleural leakage Leakage along catheter PD catheter dysfunction Surgical replacement Pd technique survival 8 (15.4) 15 (28.9) 8 (15.4) PD je izvedljiva in varna alternativa HD tudi pri akutnih 2 (3.9) 3 (5.8) NS začetkih dialize 4 (7.7) 3 (5.8) 1 (1.9) 4 (7.7) 0 (0) 8 (15.4) 3 (5.8) 10 (19.2) 2 (3.9) 39 (86.7) 45 (90.0) NS <0.01 NS NS NS <0.02 NS
22 Izhod starostnikov nad 65 let z akutnim začetkom PD Povlsen et al. PDI 2008; 28:461.
23 Spremljanje po začetku Diuretik? ACEi/Sartan Spironolakton? Hipokaliemija tveganje za peritonitis
24 Vizija 2018 Zavarovalnica odobri ustrezno vrednotenje preddializne edukacije, ki bo potekala redno v nefroloških ambulantah Bolnika lahko napotimo k dietetiku na obravnavo Nefrologi sami skrbimo za vse vrste nezapletenih dializnih pristopov >50% bolnikov, ki nimajo kontraindikacij, bo na listi za presaditev pred začetkom dialize 20% bolnikov bo začelo z dializo preko peritonealnega katetra Za izbrane bolnike v visoki starosti bomo imeli na voljo institucionalizirane načine za konzervativno oskrbo (dieta, ambulantni obiski, obiski na domu) Dializa na domu (HD, PD, asistirana PD) bo pomemben način izvajanja kronične dialize (30% bolnikov)
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