21th Budapest Nephrology School Ágnes Haris, Kálmán Polner

Transcription

1 21th Budapest Nephrology School Ágnes Haris, Kálmán Polner

2 53 years old female, -worked as computer scientist, -lived with her husband and 2 children, -in excellent financial situation. Diagnosed with renal failure Started CAPD in 2 months Due to her poor condition, unable to work, got unemployed.

3 Several hospitalizations: -anemia, high blood pressure accompanied by neurological abnormalitis, infections -having no appetite, weight loss, pleural effusion Had to transfer to HD -needs regular transportation because of weekness -severe protein-energy malnutrition, anorexic Her husband earlier attentive, helpful - decides to divorse, children live separately, No financial income, depressed, poor QoL

4 Length of life and Quality of life However, even advanced dialysis technic fails to impove outcome further nowadays What else can we do for them? 4

5 13th IFKF Annual Meeting August, 2012 BUDAPEST Hungary Presidents: Guillermo Garcia László Rosivall

6 ...employ a holistic approach for the treatment of patients living with chronic kidney disease, recognizing all their bio-psycho-socio-spiritual and somatic needs....focusing on the whole person and individual care to ensure better efficacy in the prevention, treatment and rehabilitation. 6

7 Aim -Reduce progression dialysis can be delayed -Decrease burden of the disease Morbidity and mortality Quality of life Role of the education - Multidisciplinary care Importance of psychosocial care - of patients and their family members/caregivers Dialysis in late life: Geriatric nephrology 7

8 Majority of patients have limited knowledge of their disease By educating them: -reduce their anxiety -better compliance -decrease the number of urgent start of dialysis -decrease the rate of hospitalization -more informed choice of modality selection -higher proportion of dialysed patients remains in employment if educated Education results cost savings!!! 8

9 Questionnaires for 676 patients with CKD 3-5 Nephrological care for 4.8 years (median 2 yrs)

10 The team: nephrologist, nurse educator, social worker, dietician, pharmacist, psychologist Interventional group: multidisciplinary care 1,5h per visit 5 visits/year Control group: standard care: 0,5h per visit, regular nephrological care 10

11 Medical care + education, aimed: -improve compliance -more effective dietary and lifestyle prescriptions -adherence to medications -optimal RRT modality selection 11

12 CURTIS BM ET AL, NDT

13 CURTIS BM ET AL, NDT

14 SURVIVAL AFTER STARTING CHRONIC DIALYSIS THERAPY Curtis B M et al. Nephrol. Dial. Transplant. 2005;20:

15 PREDICTORS OF SURVIVAL: AGE AND TYPE OF EDUCATION Curtis B M et al. Nephrol. Dial. Transplant. 2005;20:

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18 Change of egfr No need for RRT

19 Cumulative survival Composite end points of dialysis and death free survival

20 Thanamayooran et al. NDT patients, multidisciplinary care Choice of modality: 35% PD 8 % Preemptive Tx- 57 % HD

21 Marrón et al. PDI patients starting dialysis is Spain Multidisciplinary v.s. standard nephrological care Dialysis initiation with access: 73 % versus 26 % Choice of peritoneal dialysis: 31 % versus 8 %

22 Manns et al. KI RCT in 70 patients on MDC or statndard care Phase 1 of education: written material +video Phase 2: interactive educational sessions

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24 Significantly affect QoL by - patient s perception of well-being - perception of burden of illness patient s assessment, how the disease interferes with his life in personal, social, familial, and occupational contexts 24

25 Significantly affect QoL by - social support the perception that an individual can receive affection, aid, and obligation - provided by family members, friends, colleagues in the workplace, and medical personnel - socioeconomic issues - jobs, financial difficulties All of these influence the ability of coping with the altered condition compliance QoL survival 25

26 295 HD patients, 26.4±12.8 months follow-up 26

27 Indicators of non-compliance ( 30%) -skipped or shortened HD sessions -missed PD exchanges -serum phosphate level >2.4 mmol/l Psychosocial predictors of non-compliance -lower income -depression -perceived global self-health care -little perceived control over future health -perceived effects of disease on daily life

28 Less likely to receive Tx -women -patients with low income -patients belonging to ethnic minorities Psychosocial factors influencing patients decisions about getting wait-listed -social background -education -lack of information, cultural beliefs -depression -lack of trustful pt-physician relationship

29 HD patients in Budapest, n=459, <70 year old -sociodemographic factors -perceptions regarding dialysis versus Tx -information on Tx -attitudes to Tx

30 71 % of the patients wanted to be transplanted (regardless of eligibility), more likely -younger patients -men (56%) -employed -have higher education -have prior Tx 35 % believed Tx causes more problems than benefits 46 % had significant fears about Tx surgery and 45 % about immunosuppressive meds

31 25 % of patients reported that have not heard about Tx from their doctors 56% reported that received insufficient information Strongest predictor of positive attitude to Tx: Perception of transplantation is the best modality of RRT

32 Suggestions based on the results Vámos EP et al, NDT 2009

33 Patients: assessed for living donor kindey Tx (n=61) Controls: wait-listed patients for cadaveric Tx Willingness to accept living kidney donation was associated with knowledge of the facts, that -recipient would live longer -donor s perioperative complication is low -greater perceived appropriateness of asking a family member to donate

34 Majority of patients perceived a greater need for information (in spite of availability of internet, teaching materials, etc.) Improvement of educational strategy is necessary for both the patients and their family members.

35 ..ESRD has become a geriatric illness..., and..nephrologists will be forced to practice mainly geriatric medicine as amateur geriatricians.. Success of their care depends not only on nephrological treatment, but early multidisciplinary medical care, adequte social support, good nutrition, appropriate physical activity, and rehabilitation promoting their ability for self-care

36 In most countries elderly patients are less likely to start PD compared to younger patients PD is underutilized E.g. in UK, Denmark, Belgium, Netherlands PD is the RRT modality yrs old patients 20-41% % > %

37 PD is likely less disruptive for their lifestyle - no need for transportation - family is around - personal independence - comfort and dignity Avoid difficulty to adjust HD due to impaired physical and cognitive functions Avoid rapid changes in hemodynamic and fluid status, associated with HD No need for central catheter insertion, avoid catheter infections

38 Mortality and hospitalization rate of elderly patients treated with PD or HD North Thames Dialysis Study Harris et al. PDI

39 Brown et al. NDT patient on PD and 70 on HD Mean age 73.1±5.5 and 73.4 ± 5.1 yrs 58% of PD patients were on APD, 42% on CAPD

40 p=0.032

41 Major aim in the future: To enable higher proportion of elderly patients to receive the dialysis modality of their choice Thorough predialysis education is necessary Possibly with multidisciplinary team support

42 Specialized dialysis modality for a special subgroup of ESRD patients Nursing service provides the APD or CAPD exchanges Utilized in several countries (e.g. France Canada, Switzerland Belgium, Germany, Denmark, Spain, UK) Most frequent comorbid conditions: stroke, palliative care, dementia, bedridden patients

43 Castrale C et al. NDT patients - older than 75 yrs - started PD between Mean age 81,9±4,5 yrs CAPD 89%, APD 11%, Assisted PD 82%: family member 5,4%, nurse 76% Survival (median): - patient: 27 months - technic: 21 months - peritonitis free survival: 32 months

44 Probability of survival of patients on peritoneal dialysis Castrale, C. et al. NDT :

45 Li M et al. AJKD Special rehabilitation program for elderly patients with ESRD intoronto Rehabilitation Institute Major aims: - to impove functional condition - to support the patients ability for self-care -enable patients to provide self-care at home instead being in nursing home - to decrease their needs for assistance by home care or institutional care

46 Li M et al. AJKD patients rehabilitated in 3 years - mean age: 74,5±7,8 years - Charlson comorbidity score 7,9±2,4-98% had severe limitations in mobility - 84% needed help for transfer between bed and chair Daily 2x30-60 minutes training sessions with psysical and cognitive exercises Short daily dialysis sessions (6x2 hrs/week) in the Satellite Dialysis Unit of the Institute

47 Median treatment time: 48,5 days Significant improvement in the functional condition - FIM scale score at admission: 76,4 at discharge : 101,5 83% successful rehabilitation - 69% of the patients was able to go home

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