Kidney Failure Treatment, Patient Education, and Course Summary

Kidney Failure Treatment, Patient Education, and Course Summary

1. Kidney Failure Treatment, Patient
Education, and Course Summary
Andrew S Narva, MD, FACP, FASN
Theresa A Kuracina, MS, RD, CDE

2. •Discuss the treatment choices for kidney failure.
•Identify medications that may increase risk for new onset diabetes after kidney
transplant.
•Explain dextrose in peritoneal dialysis fluid as source of carbohydrate.
•Describe the numerous diet restrictions associated with in-center hemodialysis.
Objectives
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3. Key Issues in Managing CKD
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•Ensure the diagnosis is correct
•Implement appropriate therapy
•Monitor progression/Goals
•Screen for CKD complications
•Educate the patient about CKD
•Prepare appropriately for kidney failure

4. Coping with Kidney Disease and Failure is Challenging
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•“I feel fine.”
The signs and symptoms may not be obvious until kidney
disease is advanced.
•“Why me?”
Just like diabetes, acceptance of kidney disease takes time for
most people.
Kidney disease may progress to kidney failure.
•Kidney “failure” or “end stage renal disease” sounds scary.
Grief, fear and depression are not uncommon.

5. Awareness & Knowledge about CKD in
Patients Seen by Nephrologists
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Finkelstein, et al. Kidney International, 2008
Limited Awareness& Objective Knowledge N=401
Unaware of CKD diagnosis 31%
Do not understandCKDimplications, e.g. heart disease 34%
Donot understand kidney functions, e.g. urine production 34%
Do not understand terminology, GFR 32%
Low Self-Rating Perceived KnowledgeN=676
No Knowledge of Hemodialysis / Peritoneal Dialysis 43% / 57%
Littleor No Knowledge Re: Diagnosis 35%
Wright, et al. AJKD 2011

6. Diabetes is the Leading Cause of End-stage Renal
Disease (ESRD)
Reference: USRDS Annual Data Report (NIDDK, 2016)
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7. Almost 90% of People Initiating Renal Replacement
Therapy Start on Hemodialysis
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Trends in ESRD incidence by modality, 1999-2014
USRDS 2016

8. •Discuss treatment choices early with progressive kidney disease.
•“Early” depends on the eGFR and the rate of decline.
•People who are not prepared and need treatment do not have much choice. They may
start hemodialysis using a temporary vascular access (catheter).
•In 2015, more than 80% of people started hemodialysis with a temporary vascular access.
Most People are Not Prepared for Kidney Failure
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9. 1.Kidney transplant
From a living donor
From a deceased donor
2.Dialysis
Peritoneal dialysis (PD)
Continuous cyclic peritoneal dialysis (CCPD)
Continuous ambulatory peritoneal dialysis (CAPD)
Hemodialysis (HD)
In-center (dialysis unit)
Home
3.Supportive care without transplant or dialysis
There are Three Choices for Treating Kidney Failure
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10. Slide 10 of 59
A Kidney Transplant from a Living Donor May Be
Better Than Other Treatments
Number (out of 100) alive at the end of time period by treatment
Preparing for Kidney Treatment You Have a Choice:
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/assets/basic-html/page1.html

11. Types of Dialysis
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PERITONEALDIALYSIS (PD) Continuous
Continuouscycler-assisted (CCPD) Cycler is programmedto perform 3 to 5 exchangesduring
the night.
•Must know how to do manual exchanges
Continuous ambulatory (CAPD) 4 to 6 exchanges per day (manual)
HEMODIALYSIS (HD) Typical schedule
Traditional hemodialysis(in-center) 3-5 hours
3 days per week
Standard homehemodialysis 3-5 hours
3 days perweek (or every other day)
Extendedhours hemodialysis 6-10 hours
3-6 nights per week
Short dailyhemodialysis 2.5-4hours
5-7 days per week

12. •Is healthy enough for surgery that can last up to 4 hours.
•Finds a living donor or gets on the National Kidney
Registry (transplant list) for a deceased donor kidney.
•Is willing to take anti-rejection medications every day
for the rest of their life.
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Kidney Transplant May Be a Choice for
an Individual Who:
Preparing for Kidney Treatment You Have a Choice:
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/assets/basic-html/page1.html

13. Peritoneal Dialysis May Be a Choice
for an Individual Who:
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•Has no contraindicating abdominal pathology.
•Wants to do their own treatments at home.
•Is willing to do treatments every day.
•Has room to store supplies at home.
Preparing for Kidney Treatment You Have a Choice:
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/assets/basic-html/page1.html

14. •Can travel to a dialysis center 3 times a week for scheduled treatments.
•Prefers trained staff to handle their treatments.
•Does not mind needle sticks.
•Is willing to follow a diet that includes numerous restrictions.
In-center Hemodialysis May Be a Choice
for an Individual Who:
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Preparing for Kidney Treatment You Have a Choice:
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/assets/basic-html/page1.html

15. Home Hemodialysis May Be a Choice
for an Individual Who:
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•Wants to do their treatments at home.
•Has someone who is willing to be trained to help them with
treatments at home.
•Is willing to do treatments most days of the week.
•Has room for the machine and to store the supplies.
•Does not mind needle sticks and self-cannulation.
Preparing for Kidney Treatment You Have a Choice:
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/assets/basic-html/page1.html

16. Supportive Care without Dialysis or Transplant May
be the Choice for an Individual Who:
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•Feels treatment will not improve their health.
•Feels they have done what they wanted to do in life.
•Has family and friends who are in support of this decision.
Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

17. Transplanted Kidney is Placed in the Groin
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18. Kidney Transplant: Pros and Cons
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PROS
•Transplanted kidney is a
normal, functioning
kidney
•Fewer diet restrictions
•Successful transplant may
mean a longer life
•Quality of life may be
better
CONS
•Long waiting list for a deceased donor
•Rejection is a possibility
•Anti–rejection medications suppress the
immune system
•Medications and weight gain may make
diabetes harder to control
•New onset diabetes after transplant is a
possibility

19. Anti-rejection Medications Should
be Taken as Directed
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Prednisone Mycophenolate Azathioprine
Weight gain
Hyperglycemia
Hypertension
Hyperlipidemia
Moodchanges
Osteoporosis
Poor wound healing
Decreasedblood counts
Diarrhea
Upset stomach
Stomachupset
Muscle pain
High doses may be
prescribedright after the
transplant occurs; dose may
be reduced over time.
Take on aregular schedule1
hour before or 2 hours after
eating or drinking, about 12
hours apart.
Take once or twicea day
after meals, about the same
time every day.

20. Slide 20 of 59
Tacrolimus Sirolimus Cyclosporine
Hyperglycemia
Hypertension
Tremors, headaches
Diarrhea
Hair loss
Troublesleeping
Hyperkalemia
Hypophosphatemia
Kidney toxicity
Swelling
Hyperlipidemia
Poor wound healing
Proteinuria
Hypertension
Hyperlipidemia
Tremors, headaches
Excess gum growth
Excess hairgrowth
Hyperkalemia
Kidney toxicity
Take on an empty stomach
and regular schedule daily.
Do not eat grapefruit or
drink grapefruit juice.
Takeonce a day, take it the
same way, with or without
food.
Do not take with grapefruit
juice.
Take on a regular schedule
atthe same time each day.
Do not eat grapefruitor
drink grapefruit juice.
Anti-rejection Medications Should
be Taken as Directed

21. •Older age
•Ethnicity
African Americans and Hispanics > Whites
•Family history of diabetes
•Weight
•Positive Hepatitis C
•Immunosuppressant medication
Corticosteroids (prednisone)
Tacrolimus > cyclosporine
The Risk Factors for New Onset Diabetes after a
Kidney Transplant Include:
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Ghisdalet al, Diabetes Care, 2012:35:181-188

22. Peritoneal Dialysis: The Peritoneum is the Substitute
Kidney or “Filter”
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23. What is a PD “Exchange”?
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•Dialysis solution with dextrose flows into the abdominal cavity.
•The solution remains for a prescribed time period, also known as
the dwell time.
•Substances and fluid pass from the capillaries in the peritoneum
into the solution.
•Dextrose enters the blood; and substances and fluid enter the
solution.
•The solution is drained at the end of the dwell.

24. What an Exchange Looks Like:
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25. Continuous Ambulatory Peritoneal Dialysis (CAPD)
Requires 3–4 Manual Exchanges/Day
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26. In Continuous Cycling Peritoneal Dialysis (CCPD), a
Machine Performs 3–5 Exchanges During Sleep
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27. PD Dextrose Solutions are a Source of Carbohydrate
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•The dextrose concentrations vary:
1.25%, 2.5%, 4.25%
•The size of the bags vary:
2-liter, 2.5-liter, 3-liter
•More glucose is absorbed in CAPD than CCPD due to longer dwell times.
•Insulin requirements may increase.

28. Slide 28 of 59
•Insulin is absorbed into the portal vein and the liver is exposed to higher insulin levels
than the periphery.
•Insulin may be injected into the bags of PD solution.
•The required dose may double or triple.
•Some insulin adheres to the bag and tubing.
•Lipids may be harder to control.
Intra-peritoneal Insulin May be an Option
Diabetes, Obesity and Metabolism, 2008

29. Slide 29 of 59
PROS
PD preserves residual renal function better
Do it on their own
Choose the time and place
No need to travel to a unit
Toxins are removed daily
Diet is not as restricted as hemodialysis
Peritoneal Dialysis: Pros and Cons
CONS
•Must plan treatments around their activities
•Need to adhere to the prescription for adequate
treatment
•Must follow instructions to keep the risk of infection low
•Must take supplies when traveling
•Generally gain weight
•Diabetes may be harder to control due to the
carbohydrate in the dialysate

30. Slide 30 of 59
•The diet may not be as strict as the diet for hemodialysis.
•The wastes products are removed daily.
•Amino acids lost during the exchanges must be replaced; dietary
protein needs are higher.
•Absorbed dextrose calories may add weight.
•PD patients with diabetes are never really “fasting.”
Peritoneal Dialysis and Diet

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Hemodialysis: Dialyzer is the
Substitute Kidney or Filter
•Removal is based on size.
•Protein-bound substances are not
usually removed.
•Amino acids are small enough to be
dialyzed out of the blood.
•Glucose is removed.
•Water-soluble vitamins are removed to
some degree.

32. Slide 32 of 59
Hemodialysis

33. Slide 33 of 59
•Temporary access is usually a catheter placed in a central
vein.
•Permanent access types include arteriovenous (AV) fistula or
graft.
•Access is usually placed in the non-dominant arm.
•Protect blood vessels in both arms; avoid venipuncture and
IV catheter placement above the wrist.
Hemodialysis Requires Vascular Access

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Temporary Access Use Should be Minimized
•A venous catheter is inserted into a
vein in the neck, chest, or leg near the
groin, for short-term dialysis.
•This is onlyoption when patient is not
prepared and needs immediate
hemodialysis.
•Catheters increase risk of infection,
clotting, and inadequate dialysis.
Catheter for temporary access

35. An AV Fistula is the Preferred Access
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•The artery is connected to a vein.
•Fistula takes 2 to 3 months to mature
before it can be used.
•During maturation, the vein dilates and
thickens.
•Fistula is less likely to become infected or
clot, and provides better blood flow rates.

36. An AV Graft is Another Option
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•Synthetic tube connects artery and vein.
•Takes less time to mature compared to a fistula.
•More likely to become infected or clot.

37. Healthy People 2020 Objectives: Improve Vascular
Access for Adult HD Patients
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•Increase the proportion of patients who use arteriovenous
fistulas as the primary mode of vascular access.
•Reduce the proportion of patients who use catheters as the
only mode of vascular access.
•Increase the proportion of patients who use arteriovenous
fistulas or have a maturing fistula as the primary mode of
vascular access at the start of renal replacement therapy.
Early education by diabetes educators may facilitate
improvement!
http://www.healthypeople.gov/2020/TopicsObjectives2020/objectiveslist.aspx?topicId=6

38. In-center Hemodialysis: Pros and Cons
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PROS
•Social setting
•Facilities are nationwide
•Staff does the work:
Place and remove the needles
Monitor treatment
Maintain the equipment
CONS
•Strict diet
•Must follow a schedule
•Must travel to the unit
•May take more medications
•May feel fatigued
•Some nutrients removed during treatment –
including glucose

39. •Conventional home hemodialysis (most common)
Three times per week
•Daily home hemodialysis
2–3 hours, 5–6 days per week
•Nocturnal hemodialysis
6–8 hours, 3 or more days per week
Home Hemodialysis: Requires Training and Support
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Reference: http://www.homedialysis.org/

40. Home Hemodialysis: Pros and Cons
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PROS
•More frequent treatments mean fewer
diet restrictions
•Choose time schedule
•No need to travel to unit
•Newer machines are small
•Fewer ups and downs occur
CONS
•Must have a partner
•Partner burn-out is possible
•Must have space for treatments: machine, supplies,
access to water and drainage, and electricity
•Must insert needles
•Need time off from work for initial training
•Not offered everywhere

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Supportive Care without Transplant or Dialysis
•The complications can be treated.
•Medications are still continued.
•The goal is to maintain quality of life.
•Encourage the patient to include family in decision making.

42. Slide 42 of 59
Supportive Care without Transplant or Dialysis
•Covers up to 6 sessions
•eGFR < 30
•Medicare Part B
•Requires referral like MNT
•Individual pays 20%, deductible applies
https://www.medicare.gov/Pubs/pdf/11454.pdf

43. Slide 43 of 59
People on Dialysis Still Need
Comprehensive Diabetes Care
•Many times, people on dialysis consider their nephrologist to be their
only doctor. They may not see their primary care provider routinely.
•Keep in mind: They still need to have their eyes, feet, heart, nerves,
gums and teeth checked.
•As you educate them about treatment choices, review the need for
ongoing diabetes care.

44. Slide 44 of 59
Diabetes Educators Can Improve Care
for People on Dialysis
•In 2015, 34% of people with ESRD and diabetes received
comprehensive diabetes monitoring which included an hemoglobin
A1C, lipid test and a dilated eye exam
•86.5% had at least one hemoglobin A1C test
•71.8% had a lipid test
•46.9% had a dilated eye exam
•In 2014-2015 flu season, about 72% had a flu shot
USRDS 2017

45. Slide 45 of 59
A brief summary of key content
COURSE REVIEW

46. Identify Diabetic Kidney Disease (DKD)
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Albuminuria may be the first sign of DKD.
•Confirm abnormal levels.
•Recommend annual urine and blood tests.
Check UACR to assess kidney damage.
•A spot urine sample can be used.
•A normal level is less than 30 milligrams per gram.
Check eGFR to assess kidney function.
•Serum creatinine, age, gender and race are needed.
•An eGFR less than 60 identifies kidney disease.
•An eGFR less than 15 identifies kidney failure.

47. Albuminuria Marks Kidney Damage
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Higher UACR at diagnosis is associated with
increased risk of renal events (loss of half of
eGFR, dialysis or death).
Blood pressure control, use of an ACEi or ARB,
weight loss, sodium reduction, quitting tobacco
and eating adequate not excessive protein may
reduce urine albumin levels.
Other names for UACR include urine albumin,
microalbumin, albumin-to-creatinine ratio or
microalbumin/creatinine ratio.

48. Blood Pressure Control is KEY
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Blood pressure goal is individualized.
•< 140/90 may be appropriate for many.
Multiple medications may be prescribed.
•ACEiand ARBs increase risk for hyperkalemia.
•A loop diuretic may be beneficial for some.
Limit sodium to 2,300 milligrams per day.
•Limit dietary potassium when hyperkalemia is
present.

49. Diabetes Does Not Go Away
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An A1C < 8% may be appropriate for CKD.
•Unexplained improvement in control may be a sign that CKD is progressing.
•People at risk for diabetes prior to transplant may be at higher risk for diabetes after
transplant.
•People with diabetes on dialysis still need comprehensive diabetes care.
Types and doses of medications change.
Treat hypoglycemia the right way.
•Use glucose tablets or lower potassium juice.
•Avoid colas and other beverages with added phosphoric acid.

50. Monitor and Treat CVD Risk Factors
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51. CBC and Iron Studies May Be Ordered
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52. Diet and Medications May Impact Potassium Levels
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Insulin moves potassium into
cells.
•Insulin deficiency may
lead to hyperkalemia.
Treating metabolic acidosis
may lower serum potassium.
Limit dietary potassium when
serum level is high.
•Avoid salt substitutes containing
potassium chloride.
•Use glucose tablets or low
potassium juice to treat lows.
ACEior ARBs decrease
urinary potassium excretion.
•A loop diuretic may be
prescribed to increase
urinary potassium excretion.

53. A Serum Bicarbonate < 22 mEq/L May Indicate
Chronic Metabolic Acidosis
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Damaged kidneys are unable
to produce enough
bicarbonate and cannot
excrete excess acid.
•Accelerates muscle
degradation.
•Reduces albumin synthesis.
•Exacerbates bone disease.
•May impair glucose tolerance.
Animal protein is a source of
metabolic acid. Eating less
protein may increase serum
bicarbonate.
Supplemental base such as
sodium bicarbonate may be
prescribed. Monitor blood
pressure closely when used.

54. Vitamin D, Calcium, Phosphorus and iPTHLevels
May be Monitored
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Damaged kidneys are unable to
activate sufficient vitamin D.
•Abnormal levels of vitamin D,
calcium, parathyroid hormone,
phosphorus, and fibroblastic
growth factor–23 may develop.
Different types of renal bone
disease may develop.
•Vascular calcification is a
cardiovascular risk factor.
Limit dietary phosphoruas needed.
•Added phosphorus may be
absorbed more efficiently than
natural phosphorus.
•Avoid foods and beverages with
added “phos”.
Supplemental vitamin D and
phosphate binding medication may
be prescribed.
•Active vitamin D may increase both
serum calcium and phosphorus
levels.
•Take binders with meals.

55. Prevention: Healthy Eating and CKD
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LIMIT:
•Sodium
•Less than 2,300 milligrams/day
•Saturated fats
•Less than 10% total calories
•Trans fats
•Added sugar
•Less than 10% total calories
2015 Dietary Guidelines

56. •Dietary carbohydrate (CHO) and protein are the nutrients used for microbiota growth &
maintenance
•The ratio of dietary fiber (indigestible complex CHO) to protein affects type of bacteria and
resultant metabolites.
•Without dietary fiber, proteolytic bacteria dominate, and higher levels of potentially toxic end-products are
produced.
•Fiber plus protein means more saccharolytic bacteria (healthier type) and more short chain fatty acids.
•Fiber is prebiotic = nondigestible food ingredients that benefit certain microbiota.
What We Feed the Gut Matters
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References: Sabatinoet al. CurrDiab Rep 2017; 17:16; Conlon et al. Nutrients2015;7:17-44

57. Healthy Eating Patterns and Kidney Disease
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•ARIC study: High intakes of red and processed meat may increase risk of developing CKD
(excluded DM). Haring et al. JRN2017; 27:233-242
•NIH-AARP Diet and Health Study: Less sodium and higher potassium were associated with
reduced risk of mortality or self-reported dialysis initiation. Smyth et al. JRN2016; 26:288-298
•Healthy eating patterns with adequate vegetable and fruits and limited alcohol may delay CKD
progression and improve survival. Wai et al. JRN2017;27175-182
•Meta-analysis found higher fruit & vegetable, fish, legume, whole grain and fiber intake and
reduced red meat, sodium and refined sugar intake were associated with lower mortality in CKD.
Kelly et al, Clin J Am Soc Nephrol 2017;12:273-279

58. Key Concepts to Discuss
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Talk to patients about their kidneys,
CKD, and their risk.
•Most people don’t feel any
different until CKD is advanced.
•Self-care behaviors may be
beneficial in managing CKD.
Communicate the importance of
testing and how CKD is
diagnosed.
•eGFR
•UACR
Explain the progressive nature of
CKD and basics of treatment.
•Educate on safe use of
medication to avoid acute
kidney injury.
Begin to speak about dialysis and
transplantation.
•Avoid venipuncture above the
wrist.

59. Congratulations!
You have completed module 4
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