Prepare for Renal Replacement Therapy (RRT)

Prepare for Renal Replacement Therapy Early

Patients who develop kidney failure, defined as eGFR below 15 mL/min/1.73 m², may benefit from early education about RRT. Early education gives the patient time to process the information and prepare both psychologically and physically. Treatment options include conservative management (no dialysis), hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation. Even with information about treatment options, many patients may have difficulty making active choices about treatment modality, vascular access, and initiation of dialysis. However, an informed patient may be better prepared to face kidney failure.

Lack of appropriate care, synonymous in much of the literature with “late referral,” is associated with more rapid progression of CKD, worse health status at the time of initiation, higher mortality after starting dialysis, and decreased access to transplant. The result is often emergent initiation of HD using a catheter.

Health care providers should avoid vena puncture or intravenous catheter placement proximal to the wrist to protect the blood vessels for permanent vascular access.

Preparing your patient for RRT may include referral for vascular access placement for HD, a peritoneal catheter for PD, and/or transplantation evaluation. An arteriovenous (AV) fistula, the preferred vascular access, requires a minimum of 3 to 4 months of maturation prior to use. An AV graft takes less time for maturation (2 to 3 weeks), but is more likely to clot, become infected, and require replacement than an AV fistula. The temporary venous catheter is the most problematic and inefficient access for HD. A PD catheter may be ready for use after 2 to 3 weeks. The home treatment options require extensive education by dialysis unit staff, typically 1 week for PD or 3 to 5 weeks for home HD. A transplant evaluation may take months to complete. The waiting list for a deceased donor kidney varies but, in many regions, exceeds 5 years.

Other topics for early education may include information about comorbidity management, delaying the need for dialysis, and preventing uremic complications. Medicare now reimburses for education when the eGFR is 30 mL/min/1.73 m² or less. A basic curriculum, developed by NKDEP, can help you organize a 6-lesson kidney disease education program that meets the CMS requirements for reimbursement.

Ongoing Medical Management

A number of organizations have developed guidelines for the care of patients with CKD prior to initiation of RRT. There is consensus that patients should receive multidisciplinary, comprehensive clinical management by kidney disease professionals for at least 6 months prior to requiring RRT. Consensus guidelines also emphasize placement of permanent dialysis access, which is functional at the time of initiation, as well as assessment and referral for preemptive kidney transplant, if possible.

Consensus Guidelines on Treatment of CKD/Preparation for Dialysis:

• Clinic follow-up, including modality education, dietary instruction, and comprehensive clinical management for at least 6 months prior to initiation
• CVD risk reduction: physical activity, smoking, lipids
• Blood pressure
• Mineral and bone disorders: control of calcium, phosphorus, PTH
• Anemia management
• Hepatitis B immunization
• Renoprotection: angiotensin II antagonists (ACE inhibitor, ARB)
• Assessment for transplant and referral prior to initiation
• Access: functioning fistula or PD catheter at initiation of dialysis