Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists

Abstract

BackgroundThere are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis. We conducted this study to determine if there are uniform patterns in how nephrologists transition patients to dialysis.MethodsWe designed an electronic survey with 39 questions and sent it to a database of practicing nephrologists at the National Kidney Foundation. Factors that were important for transitioning a patient to hemodialysis were evaluated, including medication changes on dialysis initiation, dry weight and dialysis prescription.Results160 US Nephrologists replied to the survey; 18% (29/160) of the responses were completed via social media sites. Prior to dialysis, 74% (118/160), prescribed furosemide and 67% (107/160) used furosemide with metolazone. Once dialysis started, only 46% (74/160) of the responders continued patients on diuretics daily. Hypertension medications prescribed in dialysis were calcium channel blockers 69% (112/160), beta blockers 36% (58/160), angiotensin converting enzyme inhibitor 32% (53/160), angiotensin receptor blocker 29% (46/160) and diuretics 25% (42/160). Once dialysis started, 68% (109/160) routinely changed medications. Most, 67% (107/160) ordered patients to avoid anti-hypertensive medications on dialysis days to allow for ultrafiltration. Dry weight was determined in the first week by 29% (46/160) and in the first month by 53% (85/160). Most, 59% (94/160) felt that multiple causes lead to hypertension. Most nephrologists would prescribe small dialyzers and a shorter period of time for the first dialysis session.ConclusionThe transition period to chronic hemodialysis has variations in practice patterns and may benefit from further studies to optimize clinical practice.Electronic supplementary materialThe online version of this article (10.1186/s12882-018-0943-0) contains supplementary material, which is available to authorized users.

Fluid overload is associated with use of a higher number of antihypertensive drugs in hemodialysis patients

“…Despite the use of antihypertensives, pre‐dialysis SBP (150 ± 24 mmHg) was higher than recommended, a result usually consistent with other studies . These results could be influenced by the fact that patients did not use all the antihypertensive drugs prescribed prior to the HD session (either on their own or by medical advice) to reduce the risk of intradialytic hypotension and to facilitate ultrafiltration . Also, noncompliance with medications is likely a contributor to uncontrolled hypertension in HD patients …”

“…However, no current guideline addresses the management of hypertension in HD . A recent survey that included 160 U.S. practicing nephrologists found that the highest percentage of respondents prescribe CCAs (68%) because they consider it to be more effective in treating hypertension in dialysis patients, followed by BB (35%), ACE (32%), BRA (29%), and diuretics (25%) . Studies suggest that lower systolic and diastolic blood pressure with the use of antihypertensive drugs results in a 30% lower risk of cardiovascular events and mortality, but adequately controlled hypertension is observed in only 65% of hypertensive patients …”

The Pre-Dialysis Care Trajectory of Chronic Kidney Disease Patients and the Start of Dialysis in Emergency: A Mixed Method Study Protocol

“…The ways patients view and manage their disease(s), the actions taken (or not taken) and the underlying motivations, but also to a larger extent, their life experiences, are as essential in the definition of the care trajectory and must be investigated in a complementary manner. Moreover, the care trajectory is heavily influenced by the individual practices of the involved health professionals, and in our case, by the coordinated work of GPs and nephrologists [24]. One example might be difficulties to obtain a consultation with (or be referred to) a nephrologist in a reasonable interval of time.…”

Correlation and Diagnostic Value of Serum RBP4 and sRAGE and the Condition of Patients with Chronic Kidney Disease

“…Chronic kidney disease (CKD) is a chronic kidney injury caused by various causes of primary glomerulonephritis, secondary glomerulonephritis, diabetes, and hypertension. The main feature is the progressive deterioration or irreversible damage to the structure and function of the kidney [ 1 ]. In the early stages of CKD, patients may have no symptoms or only mild fatigue, low back pain, and nocturia.…”