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.
Highlights
There are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis
There is little information about the ideal blood pressure (BP) in HD patients due to exclusion of this population in clinical trials; for example the trial of intensive versus standard blood pressure control, with a total of 9361 participants, of which 2646 had early chronic kidney disease (CKD) had no subjects who were on HD at the start of the Mallappallil et al BMC Nephrology (2018) 19:147 study [4]
We designed an electronic survey with 39 questions and sent it to a United States database of practicing nephrologists at the National Kidney Foundation (NKF)
Summary
There are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis. Patterns from the Dialysis Outcomes and Practice Study reported the causes for mortality as cardiovascular disease (CVD), followed by withdrawal. There is little information about the ideal blood pressure (BP) in HD patients due to exclusion of this population in clinical trials; for example the trial of intensive versus standard blood pressure control, with a total of 9361 participants, of which 2646 had early chronic kidney disease (CKD) had no subjects who were on HD at the start of the Mallappallil et al BMC Nephrology (2018) 19:147 study [4]. The ideal blood pressure in a HD patients remains unclear and without defined BP targets [5,6,7] [https://www.kidney.org/sites/default/files/KDOQIClinical-Practice-Guideline-Hemodialysis-Update_PublicReview-Draft-FINAL_20150204.pdf] [8]
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