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Dialysis Discussion => Dialysis: Pre-Dialysis => Topic started by: okarol on October 28, 2015, 11:27:49 PM
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Medscape Nephrology > Berns on Nephrology
COMMENTARY
When Initiating Dialysis, Can eGFR Stand Alone?
Jeffrey S. Berns, MD
Disclosures | October 28, 2015
VIDEO: http://www.medscape.com/viewarticle/852971
This is Jeffrey Berns, editor-in-chief of Medscape Nephrology. I recently received an email from a colleague that was sent not only to me, but to a number of other nephrologists around the world, with a copy of the Japanese Society for Dialysis Therapy's clinical guidelines on "hemodialysis initiation for maintenance hemodialysis" (published in Therapeutic Apheresis and Dialysis[1]).
These guidelines generated a fair amount of email discussion over the ensuing several days. A couple of the more salient features in this clinical practice guideline are the following:
Renal function should not be assessed using only serum creatinine levels, but also by using a predictive equation on the basis of serum creatinine values. That has become standard practice.
The time of hemodialysis initiation should be determined by comprehensively assessing the levels of serum creatinine; changes in glomerular filtration rate (GFR) with time; and the physical constitution, age, gender, and nutritional condition of the patient. This is seemingly good advice.
The precise evaluation of renal function at the time of hemodialysis initiation is determined by such measuring methods as inulin clearance test, creatinine clearance (calculated by a 24-hour collected urine specimen), or the sum of clearance values of creatinine and urea divided by 2. The latter is part of my practice very commonly, but estimated GFR (eGFR) doesn't really come into play in these specific recommendations.
Regarding the specifics of timing of hemodialysis initiation—and this is where the controversy really comes in—the guideline states first that the judgment on the time to initiate hemodialysis is allowed when residual renal function shows progressive deterioration and reaction to GFR less than 15 mL/min/1.73 m2 despite sufficient optimal conservative treatment.[1]
The guideline goes on to state that life prognosis after initiation of hemodialysis can be favorable as long as patients can endure, under conservative treatment, until the GFR is less than 8 15 mL/min/1.73 m2. However, from the viewpoint of life prognosis, it is recommended that hemodialysis should be initiated prior to a GFR of 2 15 mL/min/1.73 m2, even when there are no symptoms of renal failure.[1]
This is not a particularly evidence-based guideline, and this point generated a lot of controversy in the email exchange between those who feel that creatinine-based determinations are appropriate for making decisions about initiation of dialysis and those who do not, but who rather feel that other factors should be considered in making dialysis initiation decisions—such as volume status of the patient, potassium, acid/base status, mineral and bone disease issues, symptoms or the lack of symptoms (recognizing that these are very nonspecific), nutritional status (as was mentioned in the Japanese guidelines), changes in some measure or estimate of GFR over time, goals of the patient, and so forth.
There certainly seems to be an increasing inclination to think about non–creatinine-based factors when we are thinking about initiation of dialysis. There is a general consensus that uremia is a vague, ill-defined concept that each of us defines very differently.
One of the comments made during this email exchange was, "I just do not think that the nephrology community should be content with an eGFR creatinine by any equation to assess the level of reduced renal function in very advanced CKD [chronic kidney disease]. It is just too confounded by non-GFR determinants to be a practical value."
Some very important comments were made by Alan Collins, who gave me permission to summarize them. He stated that volume and hypertension are the big areas in the causal path for lactate dehydrogenase, systolic and diastolic function in heart failure, and atherosclerosis. The big mortality in CKD is from cardiovascular disease. The complications of advancing CKD with hyperkalemia limit effective therapies for these, such as angiotensin-converting enzyme inhibitors and other renin-angiotensin system blockers.
He went on to state that the discussion on when to start dialysis must take into account the effectiveness of the nondialysis medical management as well as collaboratively working with patients on their lifestyle choices and the advancing medical realities that unfold with progressive loss of kidney function. He explained why we need to pay more attention to volume status, blood pressure control, and assessment and management of left ventricular hypertrophy, noting that these are more important because they contribute to the morbidity and mortality of our dialysis patients. The creatinine issues—the so-called uremic syndrome—in and of themselves are less important.
This is a very important dialogue. Hopefully it will lead to some refocusing of our attention on a variety of factors that affect our patients as they develop progressive CKD, approaching end-stage renal disease, and drive us away from focusing so much on the eGFR as an isolated laboratory value. The eGFR is just an estimate.
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I don't understand why this topic is so contentious. It just seems like common sense that there is more to the decision to start dialysis than looking at one number, ie serum creatinine.
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Looking at my lab results my neurologist spent better part of a year and a half telling me it was time to start hemo. I kept telling him I was waiting for a sign from God. I never told him that sign was a symptom. I was feeling ok so why start. One day after a particularly fine lunch I spent the afternoon in work ralphing. Now this was the sign I was waiting for and started dialysis the next week. I don't care what the lab numbers said I was not going to upset my life until I felt sick. Now I know some people push it too far but if you wait for the first physical symptom It's easier to give up and start dialysis,. Actually I should have added that when the doctor started pushing for the start I had my fistula installed. Using the lab results to decide to have your fistula created is smart. That way it's ready when you start.
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Could not agree more Micheal. My numbers kept going down, down, and down. My neph never really pressured me to start. He said ...you will know. My numbers seemed to have leveled off although very low. And then the shortness of breath, the constant being tired, the ralphing 3 or 4 times a week, the no appetite got worse and worse. When my breathing got so bad I could not have a conversation I figured time is up.
Having started I wish I had not waited quite so long. Except for the chair time (and previously mentioned fistula issues).... life is not so bad now.
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tl;dr
Could you summarize?
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This is a reassuring conversation. I am poised on the cusp at GFR 15. Guess it's time for the fistula; but since I am not experiencing symptoms and feel pretty good, I want to wait as long as possible to go on dialysis. I find I feel better when I don't obsess about my kidneys (although I watch my died pretty carefully).
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My neph said to wait to a GFR of 8. I felt great until the day I hit that target. I started to lose my balance and new something was wrong and had my levels checked that day and they showed an 8 GFR. A month latter I began PD.
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I think my GFR was about 8 when I started. My neph hadn't outright suggested it yet, but was waiting for me to complain about symptoms. I didn't have any nausea and was still active. One of my transplant evaluation tests showed latent TB and I had to start medication for it. Right after that, I started falling asleep all the time. It wasn't supposed to be a side-effect of the medication and I had to stay on it for 9 months. I decided to start dialysis and then restart the TB medication.
Sibella, if you're considering transplant, you're eligible to start the evaluation process at GFR 15.
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I think my GFR was about 8 when I started. My neph hadn't outright suggested it yet, but was waiting for me to complain about symptoms. I didn't have any nausea and was still active. One of my transplant evaluation tests showed latent TB and I had to start medication for it. Right after that, I started falling asleep all the time. It wasn't supposed to be a side-effect of the medication and I had to stay on it for 9 months. I decided to start dialysis and then restart the TB medication.
Sibella, if you're considering transplant, you're eligible to start the evaluation process at GFR 15.
I am seeing my neph this afternoon and getting results of my most recent labs. Fingers crossed since we are headed out for a month in Gulf Shores, Alabama (the one trip I look forward to every year). I feel fine. I wish I could consider a transplant but I have been told the wait in Michigan is 6-7 years and that people my age are unlikely to find donors. I'll ask about it today. Thanks for the encouragement!