A comparative investigation of the indications for renal replacement therapy and the optimal timing for commencing the therapy

Abstract

End stage renal disease (ESRD) is a major health problem resulting in conside rably increased morbidity and mortality, in decreased qual ity of life and in high costs from renal replacement therapy (RRT) . There are almost a million people that owe their lives to dialys is and currently there is a 5 yea r survival rate of chronic renal failure (CRF) patients . Today optimization of dialys is must guarantee the full time restitution t o . society of a totally rehab ilitated individual. This study a ims at investigating the indications for commencing RRT and the optima l timing for commencing the therapy , derived from comparative investigations , and incorporat ing factors affecting renal failure patients. It includes the benefits of screening high risk individua ls for renal d isease, and the benefits of managing factors affecting renal function to pro long the pretreatment phase . It also looks at the effectiveness and opt imal timing for commencing a pre-end stage renal disease (PESRD) program, and considers whether there is patient imp rovement in patients managed before development of renal failure . Finally the study aims at investigating a way to reduce the financial aspect related to treatment. The research was twofold. First ly it involved a screening of 100 indiv iduals at tht: risk of chronic kidney disease (CKD), whereby a serum creat in ine va lue was taken and the glomerular filtration rate (OFR) calculated . Secondly it incorporated a biochemical and clinical assessment of 95 CRF patients , a month prior to RRT, at commencement of RRT, at I month and 3 months after RRT. The screening revealed a mean creatin ine for males 128.45 flmollL and for females 108 .99 flmollL. Twen ty-four percent (24%) of patien ts had a OFR of between 30 - 59 , 6% of patients had a OFR of between 15 29, and 3% of pat ients had a OFR of < 15 ml / minlI.73m2. T his strongly ind icates the need to screen individua ls at risk for renal failure . The second part of the study revealed that at commencement the mean OFR was 6.7 ml/ minlI .73m2, uremia , malnutrition, anemia, hyperparathyroid ism, hyperphosphatemia, and other electro lyte imbalances were present , all predisposing a patient to a poor clinical outcome , an inc rease in morbidity and mortal ity, and a dec rease in the qual ity of life. From the investigation of patients commencing dialysis it was determined that the optimal timing for commenc ing RRT was at the first clin ical evidence of deterioration in the presence of uremia and / o r malnutrit ion despite medical in tervention . It was found that RRT should not be postponed until creatinine falls within mandated range , as postponement adversely affects the patient, and the survival of dialysis patients depends on their condition at the time dialysis is first initiated. Postponing treatment was found to have adverse effects on patients commencing RRT, with an increase in the number of acute hemodialysis (AHD) sessions and increase in the number of access. Patients managed prior to commencement of RRT and patients commencing dialys is at a higher GFR experienced fewer complications, when compared to patients who commenced dialysis later. There is an improvement in patient outcome in patients managed prior to the commencement of RRT and it is beneficial to manage factors affecting renal function in order to prolong the pre-treatment phase . The PESRD educational program is an effective component in the management of kidney disease and initiating a PESRD program early in the course of kidney disease is advantageous to the patient. The financial costs related to renal replacement are extremely high, and can be reduced allowing more patients to be treated for the same amount of money. From the results obtained from the study it is clear that effective PESRD management and early commencement of RRT in dialysis patients leads to an improved qual ity of life, and a decline in complications experienced.