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Part 3: Clinical Experiences |
Central Manchester and Manchester Children's University Hospitals, Manchester, U.K.
Correspondence to: S.A. Heatley, Central Manchester and Manchester Children's University Hospital, Renal Directorate, Oxford Road, Manchester M13 9WL England. Susan.Heatley{at}CMMC.nhs.uk
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ABSTRACT |
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The number of patients receiving renal replacement therapy in the United
Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public
health problem with significant comorbidity and mortality. Several
organizational guidelines have been developed in an attempt to identify when
appropriate referral to nephrology services should occur; however, many of
these guidelines provide conflicting recommendations on referral. Recent
surveys suggest that more than 30% of patients with CKD are referred later
than is ideal. Late referral of patients with CKD is associated with increased
patient morbidity and mortality, increased need for and duration of hospital
admission, and increased initial costs of care following commencement of
dialysis. Additional benefits of early referral include identifying and
treating reversible causes of renal impairment and managing the multiple
coexisting conditions associated with CKD. Referral time also affects the
choice of treatment modality. Patients and their families should receive
sufficient information regarding the nature of their CKD and the options for
treatment so that they can make informed decisions concerning their care.
Literature addressing when to refer to low-clearance or pre-dialysis clinics
is limited. Existing data suggest that such clinics and patient education
programs may facilitate improved medical care for patients, greater patient
involvement in selection of the mode of dialysis, reduction in the need for
"urgent start" dialysis, and improved short-term survival and
quality of life after initiation of dialysis. Audit of our pre-dialysis clinic
has demonstrated improved patient outcomes, and we view the early-referral
service as an essential component of the patient pathway.
KEY WORDS: Chronic kidney disease; late referral; benefits of early referral; pre-dialysis clinics; patient education.
Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. The World Health Organization estimated that, in 2005, approximately 58 million deaths occurred worldwide, with 35 million of those being attributed to chronic diseases, CKD among them. Establishment of renal failure is relatively rare, but treatments with dialysis and transplantation are very expensive. The number of patients receiving renal replacement therapy (RRT) in the United Kingdom is rising steadily and is unlikely to reach steady-state for another 25 years, costing 20% of the National Health Service budget (1). In 2006, the number of adult patients who started RRT in the entire United Kingdom was 6716, equating to an acceptance rate of 111 per million population (pmp)—an increase from 108 pmp in 2005.
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CURRENT REFERRAL GUIDELINES |
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European best practice guidelines advocate that patients whose estimated glomerular filtration rate (eGFR) is below 30 mL/min and declining should be under the care of a nephrologist and should be prepared for the onset of dialysis. The National Service Framework for renal services part 1 guidelines say that patients should be referred to a multidisciplinary team at least 1 year before the anticipated start of RRT (2).
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ADVERSE EFFECTS OF LATE REFERRAL |
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Referral to nephrology services is considered late when management could have been improved by earlier contact. One definition is referral of a patient with progressive kidney failure 1–4 months before the need to commence dialysis treatment. However, definitions of late referral vary, and time limits ranging between an immediate need for dialysis and a need within 6 months have been cited.
The consequences of late referral are many (3). They include
The prevalence of comorbidity and low eGFR are well documented. With an eGFR of less than 60 mL/min, the incidence of conditions such as cardiovascular disease, peripheral vascular disease, stroke, and congestive heart failure become evident.
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FACTORS CONTRIBUTING TO LATE REFERRAL |
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BENEFITS OF EARLY REFERRAL |
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National guidelines for referral to low-clearance clinics (LCCs) or pre-dialysis clinics are limited mainly because of the many differing approaches and models of care across the United Kingdom. Many of the guidelines recommend that people approaching dialysis be given information about all forms of treatment so that an informed choice of modality can be made, but a national survey examining the provision of LCCs across the United Kingdom found that very few units had a full complement of the recommended multidisciplinary renal team (5). A multi-skilled team comprises a dietitian, treatment education provider, anemia coordinator, pharmacist, social worker, access coordinator, counselor, and psychologist. Rather surprisingly, the survey noted that not all centers had a specific dialysis education provider; the authors suggested that this area needs to be improved.
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THE CENTRAL MANCHESTER HOSPITALS EXPERIENCE |
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 TOPABSTRACTCURRENT REFERRAL GUIDELINESADVERSE EFFECTS OF LATE...FACTORS CONTRIBUTING TO LATE...BENEFITS OF EARLY REFERRAL THE CENTRAL MANCHESTER HOSPITALS... HAS OUR DEDICATED PRE-DIALYSIS...REFERENCES |
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Referral pathways have been developed, and patients are referred into our LCC or pre-dialysis service by nephrologists attending our 8 outreach nephrology clinics, our renal and diabetes clinic, and our transplant clinic. Criteria for referral is based on an eGFR of 20 mL/min and declining.
The philosophy of our LCC and pre-dialysis clinic has two parts. First, through correction of complications of CKD, we attempt to stabilize renal function and to slow down the progression of the renal disease. Our second aim is to prepare patients for dialysis therapies through education programs and to ensure a suitable choice for dialysis treatment access renal and palliative care pathways.
Ongoing audit of our service is crucial in measuring the service and patient outcomes. We have seen an increase in the number of referrals into the pre-dialysis service to 282 referrals in 2007 from 194 referrals in 2003. Subsequently, our total pre-dialysis patient population has risen to 505 in 2007 from 243 in 2003, with 45% being CKD stage 4 and 55% being CKD stage 5.
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HAS OUR DEDICATED PRE-DIALYSIS SERVICE DEMONSTRATED POSITIVE PATIENT OUTCOMES? |
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Our structured education program ensures that all patients referred to the pre-dialysis service attend a patient education event. These events are held throughout the year, and the expert patients who attend provide first-hand information about life on dialysis. Our education workshop is based in the clinics so that we can combine education with follow-up pre-dialysis clinic visits. The workshop has life-size mannequins with dialysis accesses inserted, and peritoneal dialysis and hemodialysis machines, providing patients and their caregivers with visual examples of dialysis equipment and dialysis access.
Through a survey of 100 patients, we found that
It is generally accepted, but not proven, that the multidisciplinary approach is the best way to manage the complex needs of patients approaching end-stage renal failure (as recommended by the National Service Framework for renal services). However, evidence for the effectiveness of pre-care in end stage renal failure and for the choice of the care model to use is limited (6). Several studies have highlighted the benefits of early referral to pre-dialysis services and to multidisciplinary teams:
By contrast, however, a study by Harris et al. showed that an intensive multidisciplinary management approach did not appear to offer any significant advantage in terms of progression of renal disease or mortality rate, as compared with standard nephrology care (7). The conflicting results obtained by Harris and colleagues highlight the need for further prospective research to identify the most effective methods of organizing care for CKD patients approaching dialysis.
Currently, several studies in progress in the United States and Canada are aiming to address the foregoing question. However, there is now evidence to suggest that a comprehensive multidisciplinary team approach to the care of patients with advanced declining CKD can positively affect patient outcomes. Our pre-dialysis service places a focus on patients with CKD stages 4 and 5 who are predicted to require dialysis. Early referral into pre-dialysis services where the emphasis is on correction of CKD complications, education, and timely preparation for RRT through input from a multidisciplinary team is vital. Predicting when patients will require RRT can be difficult, but early and timely education and preparation is never a wasted commodity.
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REFERENCES |
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