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Outcomes for unplanned startDr Peter RutherfordMedical Director – Europe, Middle East and Africa, Baxter Healthcare SA, Zurich
Visiting Professor, Glyndwr University, Wales
Outline of talk
Set the scene around the challenges of Unplanned
Start
• Unplanned start to dialysis is still common and a major therapeutic • Unplanned start to dialysis is still common and a major therapeutic
challenge for all renal units
• It is associated with worse outcomes and most patients will remain on
a hospital based therapy and not receive a choice of dialysis
• The use of central venous catheters (CVCs) is a major driver of this
poor prognosis
• Peritoneal dialysis can be a viable alternative to allow patient choice
and improve patient outcomes with unplanned start
Referral – early vs late = patient referred more than 3 months before need for dialysis. Would allow education, access formation/maturation and some biochemical
All talking about the same thing
access formation/maturation and some biochemical control.
Known – known vs unknown = is patient known to have CKD and be referred to nephrologist vs not
Timing – urgent vs emergency = patient needs dialysis within hours for high K, fluid overload or needed within days to 2-3 weeksdays to 2-3 weeks
…is a known or unknown patient starting dialysis in an urgent/emergency way with a temporaryvascular access.
An Unplanned Start patient
vascular access.
� Known patient = known to the nephrology unit 3-6 months prior to dialysisstart
� Unknown patient = unknown to the nephrology unit
� Urgent start: has to start dialysis within the next days- weeks
� Emergency start: has to start dialysis now.
Unplanned still frequent
60
%
Overall n=5.805
Unplanned start to dialysis is still common
24
49
3646 46 44 45
3730
20
30
40
50
Overall n=5.805
2430
0
10
Metcalfe 00 Gorriz 02 Caskey 03 Loos 03 Marron 05 Castellano 06 Buck 07 Couchoud 07 Mendelsshon 09
Mendelsshon; BMC Nephrol 2009
Systematic Review – Navaneethan BMC Nephrology 2008; 9: 3
What are common features of late referred patients?
• Increased mortality and morbidity
• Increased hospitalisation, use of resources and
Consequences of unplanned start
• Increased hospitalisation, use of resources and
cost
• Impact on RRT treatment modality selection
• Increased use of central venous catheters
(CVC)
1. Kazmi et al1
Late Referral (LR) is associated with a 44% higher risk of 1- year mortality compared with Early Referral (ER)
Unplanned start - Clinical outcomes
1- year mortality compared with Early Referral (ER)
2. Metcalfe et al2
Unplanned start patients were 3.6 times more likely to die within 90 days compared to planned start patients.
1.Kazmi W et al, NDT(2004) 19 :1808-1814
2.Metcalfe et al, Kid Int, Vol 57 (2000), 2539-2545
The known patient – unplanned start
Buck et al, NDT 2007
Characteristics and outcome of unplanned patients
4.7
3
4
5
HR for mortality
30
35
40
45
Planned
Unplanned
2.2
4.7
1.1
3.6
0
1
2
Medium risk High risk Unplanned Albumin
42.7
27.8 29.524.8
41.9
33.3
0
5
10
15
20
25
30
Low risk Medium risk High risk
Metcalfe. Kidney Int 2000; 57: 2539
%
Unplanned start – impact on modality and access
Marron B et al: Nephrol Dial Transplant (2006) 21 [Suppl 2]: ii51–ii55
Unplanned start is a main risk factor for CVC at
initiation of RRT
3HR
1.01
1.691.41 1.46 1.31
2.7
0.5
1
1.5
2
2.5
3
0
Age Female Late
referral
Type 2 DM Vascular
disease
Lung
disease
Polkinghorne; J Am Soc Nephrol 2004; 15: 477
A high proportion of ESKD patients still start
RRT with a CVC as a dialysis access
Ethier et al; Nephrol, Dial & Transplant 2008; 23: 2319
Patient survival, HD starters, by access type
80%
100%
Survival probablity
Starting dialysis with a CVC carries significant risk
0%
20%
40%
60%
0 50 100 150 200 250 300 350 400Days
Survival probablity
AVF+AVG
Temp line + Tunnel line
UK Renal Registry, Vascular Access Survey
Unplanned start and CVC impact independently on
survival
Lorenzo et al. Am J Kidney Dis 2004; 43: 999
How to prevent infections in unplanned?
� Be dynamic for education and modality election
Methods to reduce infection risk in unplanned start
• If HD is the choice, get functioning permanent internal access
as soon as possible
• Appropriate use of CVC
• Early and accurate diagnosis of infection
• Timely and effective treatment of infections, including systemic
antimicrobials, antibiotic locks and catheter removalantimicrobials, antibiotic locks and catheter removal
• Consider PD!
Infection-related hospitalizationUSRDS
2525
Hemo
Pediatric Adults
Infection related hospitilisation (USRDS)
23.221.3
10
15
20
Hemo
PD
10
15
20 PD
11.6
6.3
0
5
12 months 36 months
0
5
12 months 36 months
All differences p<0,005Chavers et al. J Am Soc Nephrol 2007; 18: 952
Unplanned start patient pathway
1.HD within 24-48h
Temporary catheter
2.Need for dialysis within
2-4 weeks, no permanent access.
Unplanned - Emergency Unplanned - Urgent
Referral to identified
educator(s)
Key Step
1
DecisionKey Step
2
Access PlacementKey Step
3
PD HD 18
Unplanned Start Programme
1.Placement of temporary HD
Access (ICU or HD Unit)
Tell patient that this access
is temporary
4. Choose therapy
5.Final access placement
HHD
is temporary
2. HD sessions in HD Unit
HD nurses become key
influencers
3. Education by nurse educator
PD
PD nurse(s)
3. Education by nurse educator
(CKD, PD, other)
•Patient stabilised
(3 days-2 weeks)
•3 meetings min
•Patient and significant other
•Need to make decision
Nephrologist(s)
Nurse Educator
HD nurse(s)
IC HD
Surgeon Nephrologist(s)
Unplanned Start Programme:
Tools
• Choice map: Provided to each
patient including a DVD, a patient including a DVD, a
Treatment Options Booklet and
Patient photo stories
• Treatment Options Flipchart:
to use with the patient. Includes
tips and question for the
educator.
• Guide on patient education
education and decision making.education and decision making.
• Decision aids: to help the
patient making a treatment
option decision.
Outcomes in Unplanned Start
A problem – but some solutions exist
• Unplanned start is still a major problem
• Infection is a major problem and many patients receive no choice of
therapy
• There are alternative approaches to reduce risk and deliver choice
Survival and late referral
Chow et al, PDI, 2008
Curtis et al, NDT, 2005, 147-154
Outcomes better with multidisciplinary education
Recommended