Wendy Washington & Anne Graham. Nephrology Nurse Practitioners

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1 Wendy Washington & Anne Graham Nephrology Nurse Practitioners

2 Eight major risk factors for CKD Diabetes High blood pressure Age over 60 years Smoking Obesity Family history of kidney disease Aboriginal or Torres Strait Islander origin Established cardiovascular disease 1 in 3 Australian adults is at increased risk of CKD due to the above risk factors!

3 The new Australian CKD staging schema Albuminuria Stage GFR Stage GFR (ml/min/1.73m 2 ) Normal (urine ACR mg/mmol) Male: < 2.5 Female: < 3.5 Microalbuminuria (urine ACR) Male: Female: Macroalbuminuria (urine ACR mg/mmol) Male: > 25 Female: > Not CKD unless haematuria, structural a b or pathological abnormalities present 5 <15 or on dialysis <GFR + albuminuria = > risk of CKD & CVD more than just one

4 Kidney Disease in Australia Australians aged 25 years CKD staging is according to the CKD-EPI equation 18,000 40,000 Stage 5 not on dx Stage 4 CKD 827,000 Stage 3a and b CKD 856,000 Stage 1 2 CKD 5 MILLION AT RISK Hypertension or Diabetes AusDiab Report, 2001; White et al 2010; Jun 10 ABS data; 2010 ANZDATA report

5 Comparing GFR and Creatinine. Serum creatinine CKD 1&2 CKD 3 CKD 4 CKD 5 Normal blood level Albuminuria GFR ml/min Dialysis

6 Diabetic Kidney Disease (DKD) and end-stage renal disease (ESRD ) in Australia 1 DKD is now the most common cause of patients commencing dialysis in Australia (and QLD) 1 DKD accounts for 35% of new ESRD patients with 90% of these Type 2 (15% non insulin) (ANZDATA - Australia and NZ) 1 Five year survival for diabetics entering dialysis is only 5% compared to 20% for non-diabetics T1DM ESRD patients have 1.77 relative risk of mortality. T2DM ESRD patients have a 1.27 relative risk of mortality compared to non-dm patients 1. ANZDATA 2011

7 Chronic Kidney Disease (CKD) CKD team (North Ward) work to slow progression, to delay or prevent dialysis. NP, dietitian, social worker 693 patients, 132 JPHS, 559 TTH Diabetes on care plan 226 (?%) 340 (61%) Proteinuria on care plan 9 78 (FERRET database)

8 1 st March 13 TSV JPHS albuminuria 78 9 GFR Non DM DKD Non DM DKD > < Total

9 Principal goals of CKD management Self Management of chronic conditions to slow progression Reduction of cardiovascular and kidney risk factors Early detection and management of CKD complications Avoid nephrotoxic medications Ensure all medication doses are appropriate for stage of CKD Manage contributing cause Timely referral to a Nephrologist (GFR<30 or <60 if DKD) Discuss by Stage 4 re dialysis, transplant, conservative care If planning haemodialysis, AVF creation at egfr 15 Home dialysis has best outcomes

10 Diabetes mellitus and ESKD 1 Poor pre-dialysis glycaemic control as a predictor of mortality in type 2 diabetic patients on haemodialysis 1. Adapted from Wu, M. NDT 1997 :12

11 KHA Diabetic Kidney Disease Major Cause of Kidney Failure - March 2010 Research shows 27% of people commencing dialysis did not see a Nephrologist until < three months prior to their kidneys failing. KHA shows only 8.4% of the general population in surveys identifies Diabetes as a cause of kidney disease. People can lose 90% of their kidney function with no symptoms. Combined this with a major community information gap over the link between Type 2 Diabetes and kidney failure. Screening is simple- Quarterly Blood pressure check Annual blood and urine (albuminuria, ACR and creatinine)

12 Diabetic patients on dialysis ANZDATA as at 31/12/09 (209 pts) Townsville Australia T2DM on Insulin 29 (14.6%) 1940 (16.8%) T2DM Non Ins 83 (41.4%) 2440 (21.1%) T1DM I 6 (3.3%) 398 (3.4%) No Diabetes 81 (40.7%) 6802 (58.7%)

13 Renal Replacement Therapy 18,999 (474 per million) people received renal replacement therapy at 31st December Of these, 8,409 (474 per million) had a functioning kidney transplant and 10,590 (459 per million) receiving dialysis and 1208 (2151 per million) were Aboriginal or Torres Strait Islanders

14 A clear vision of Starting dialysis

15 Townsville Patient Treatment Options Transplant PAH only after extensive workup Hospital Haemodialysis at TTH Satellite Haemodialysis at: Home Hill Mt Isa Palm Island North Ward Community Campus Home: Haemodialysis, CAPD, APD Visiting every 3/4 months; contact monthly

16 Transplantation Transplant is a treatment, not a cure. Organ failure and rejection can happen at any time. Medication Forever Only Qld transplant unit is PAH, Brisbane With Diabetes, aim for combined Pancreas and Kidney only Sydney or Melbourne Problems are damage to other organs and vessels from diabetes may prevent this option

17 Goals of Dialysis Remove waste products (urea, creatinine) Remove some toxins Balance electrolytes Replenish bicarbonate (acid base balance) Remove excess water

18 Haemodialysis regimens Intermittent haemodialysis (3x/wk): Incenter, Satellite, home. (usually 5 hours) Daily dialysis done at home. Nocturnal slow dialysis is the best (at home). Haemofiltration, replacement of all the electrolyte fluid with new

19 Haemodialysis Semipermeable membrane. Cellulose or biocompatible synthetic Hollow fibre Blood in the hollow tubes and electrolyte fluid surrounding it

20 Cannulation of Arterio-Venous Fistula for Dialysis

21 What is actually seen Computer/ alarm system Both blood and fluid alarm systems Dialyser Air Detectors Blood Pump (300ml/min) Heparin Bicarbonate and Electrolyte concentrate

22 PERITONEAL DIALYSIS Continuous Ambulatory Peritoneal dialysis (C.A.P.D) Automated Peritoneal Dialysis (A.P.D) where machine does it overnight so you have days free

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24 DIANEAL Dianeal uses Glucose to produce an osmotic gradient which moves extracellular fluid into the peritoneal cavity, to remove excess fluid no longer excreted by Kidneys. The higher the strength of glucose, the greater the fluid loss 0.55%; 1.5%; 2.5%; 4.25% The least Glucose load = 3 bags 1.5% dextrose And 1.5% glucose is 83mmol of Glucose = Increased insulin requirement (may be overnight)

25 HEMODIALYSIS V S PERITONEAL DIALYSIS (all free on Medicare) HEMODIALYSIS Need access to good blood supply Needles access blood Good water and electricity supply essential Need a dialysis partner Need a machine P. D Need access to the peritoneum Must have clean area Need to learn sterile no touch technique Dialysis is performed all day everyday

26 Townsville - Renal Service About 500,000 sq. km. Bigger than Victoria, not quite as big as NSW Mostly coastal towns but inland communities eg.mt Isa several indigenous communities High CKD and dialysis in remote areas Up to 1 in 70 dialysis dependent in some areas.

27 Townsville reality Townsville has approx 230 Dialysis Clients attached to its service > 50% have Diabetic Kidney Disease 78 are on home dialysis, so back in their own homes and communities (spending between 2 weeks to 2 years stuck in Townsville) Current QH policy aims for minimum 40% clients on Home dialysis with a 50% target.

28 Those Not at Home We have 3 rural or remote Satellite dialysis units but all clients start in Townsville and all return here if problems 16 in Mt Isa Unit 3 in Joyce Palmer Palm Island Unit 12 in Home Hill Unit The other 125 dialyse at TTH or North Ward.

29 The 125 in Townsville 53% are ATSI 34% come from rural and remote areas That number has been about 1/3 for several years Mt Isa and surrounds, 31 clients so ¾ of those inc Mornington Island, Doomadgee, Burketown.. Flinders Highway -Charters Towers to Richmond Palm Island, Magnetic Island Bruce Highway Cardwell to Burdekin or Bowen.

30 Added impact of CKD Having CKD does not mean other things go away. Still worry about feet, eyes, heart.. Pill burden is higher than non CKD as addition of medications for CKD if it worsens; may change after every blood test. Changing insulin or oral agents required

31 Psychosocial Impact Coping with chronic illness anxiety, depression Haemodialysis is at least 5 hours every second day. Isolated in TSV when you need most support Usually unable to attend important events; births, birthdays, weddings, sorry business. Distance home, expensive and few flights

32 Take home message CKD prevention or slowing progression is possible from preventable causes. BGL and BP control Referral to CKD team and Nephrologists earlier Combined Pancreas- Kidney transplant if suitable. If dialysis inevitable - home dialysis best outcomes (long slow nocturnal Hd = same as transplant) PD first maintains residual renal function longer, then home nocturnal Haemodialysis

33 Further Resources CKD Management in General Practice 2012 Guidelines booklet New Edition! now available at