The importance of avoiding "crashing" into dialysis due to kidney failure & best practices for preparing chronic kidney disease patients to better manage their disease
More than 26 million Americans have chronic kidney disease,1 a progressive, usually irreversible condition, in which their kidneys lose the ability to remove wastes and excess fluid from the blood. Each year, more than 100,000 people in the United States begin dialysis2 after their CKD leads to complete kidney failure, or end-stage renal disease.
Unfortunately, far too many of those kidney disease patients are unprepared to start dialysis. As a result, tens of thousands of people "crash" into dialysis with kidney failure, requiring emergency hospitalization, placement of temporary vascular accesses and costly medications to treat life-threatening complications. Emergency dialysis crash starts result in longer hospital stays, more frequent readmissions and higher patient mortality rates. Enormous extra costs are incurred by patients and their families, hospitals and insurers.
Missed opportunities
According to the latest U.S. Renal Data System Annual Report, 42 percent of all new dialysis patients begin treatment without having been previously followed by a nephrologist (medical kidney disease specialist).3
As a nephrologist who has devoted more than three decades to treating kidney disease, I am concerned that by waiting to begin counseling and treatment until people are at or near the point of complete kidney failure, we are missing opportunities to slow the progress of their disease, and possibly delay or avoid the need for dialysis. We are also increasing costs for the entire U.S. healthcare system, and potentially reducing patients' future quality of life and life expectancy.
The good news is that many of these costs, consequences and negative patient outcomes can be greatly reduced if the medical community works together to identify and educate at-risk individuals and refer them to renal specialists for evaluation, treatment and in-depth education about the disease and available treatment options.
There is no question that CKD can be challenging to identify, especially since kidney function typically declines gradually, over a period of months or years, and many patients exhibit no symptoms during its early stages. However, the leading causes of kidney disease — diabetes and high-blood pressure — are well known and easily diagnosed. We also know that older patients, African Americans and certain other ethnic groups are far more prone than the rest of the population to develop CKD. It makes sense to focus on those populations first as we increase our efforts to identify and refer earlier-stage CKD patients for treatment and education.
Besides saving lives and improving patients' quality of life, this proactive, integrated approach to a currently fragmented sector of the healthcare industry has the potential to set a new standard for effective chronic disease management.
Earlier diagnosis needed
CKD has many causes. When it is discovered early, it may be possible to slow the progress of the disease with exercise, diet changes or medication. However, those remedies work best in the early stages of the disease. Early diagnosis is also important for those with more advanced kidney failure, who have less time to learn about their various treatment options. For example, home dialysis options may improve their lifestyle and health outcomes. Yet since those options require training and advance preparation, they typically aren't offered when patients arrive at the emergency room in urgent need of dialysis.
Advance planning is also needed for surgeons to create a fistula or other permanent "vascular access" in a patient's arm to make it easier to connect to the bloodstream for hemodialysis treatment. It takes several weeks or months for an access to mature sufficiently for regular dialysis use. So when patients crash into dialysis, they usually have to undergo surgery to place a temporary central venous catheter access in the blood vessels of their neck or groin.
Patients with CVCs are far more likely than those with fistulas to develop blood stream infections. Yet because of the deficiency in advanced planning for end-stage renal disease care, nearly 80 percent of new U.S. dialysis patients continue to start dialysis with a CVC.4 In contrast, only 41 percent of patients who see a nephrologist for at least a year before beginning dialysis start out with a CVC access.
Better starts on dialysis
The prevalence of crash starts varies by region in the U.S. We are seeing improvement in some areas where dialysis providers have begun working cooperatively with primary care physicians to identify CKD patients and help prepare them for the onset of dialysis. Some primary care providers and nephrology practices are having success using nurse practitioners as renal care coordinators to provide integrated education and support services for at-risk patients.
Another successful approach is the free classes that Fresenius Medical Care North Americaoffers to CKD patients and their families on how to prepare for life after kidney failure. Since 2002, nearly 100,000 patients have attended these "Treatment Options Program" classes at locations across the country. Patients who complete this program before starting dialysis are more likely to choose home dialysis or start hemodialysis with a fistula than those who have not attended the classes.
More remains to be done to reduce the incidence of dialysis crash starts, but the key elements of the solution — earlier diagnosis, referral and better patient education — are known and proven to be effective. With effort they are achievable. The results, including lower healthcare costs and improved patient health and longevity, will benefit us all.
Dr. Hymes is senior vice president and associate Chief Medical Officer for Fresenius Medical Care North America, a leading provider of renal products and services.
1 National Kidney Foundation (2014, Jan.). Chronic Kidney Disease – A Growing Problem. Retrieved from https://www.kidney.org/news/newsroom/factsheets/CKD-A-Growing-Problem.cfm
2 U.S. Renal Data System (2013). USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. http://www.usrds.org/2013/pdf/v2_ch1_13.pdf Volume 2, p. 216.
3 Ibid. p. 226.
4 Ibid. p. 226.