Advanced Kidney Care refers to the multi-professional framework required to support high quality care in patients who are at high risk of progressing to kidney failure requiring kidney replacement therapy or supportive care.
The specific criteria for AKC are developing, Renal GIRFT recommends that patients should be seen for AKC by the time that they are within 18 months of a projected requirement for kidney replacement therapy.
This section represents the approach taken by one of the authors (PC), who leads a large AKC service.
Different services use different thresholds for entering AKC. It is our practice to ensure patients should be are offered AKC by a KFRE of 20% at 2-years. KFRE does not censor for death and is not normally distributed therefore this is a level of risk that is consistent with Renal GIRFT recommendations.
There is then increasing consensus that by a KFRE of 40% at 2-years patients should have been supported to make a decision around modality choice, and this should be actioned.
The following principles are useful for AKC
Patient reported and clinical outcomes show kidney transplantation represents the best modality for patients who are fit to receive a kidney transplant.
Kidney transplantation should be discussed with patients such that there is a documented decision around kidney transplantation. Listing at a KFRE of 40% or more is consistent will give a patient an opportunity of a pre-emptive kidney transplant. It is crucial that all patients who may be fit for a kidney transplantation are provided with support.
For patients who are not medically fit for kidney transplantation consider how risk is explained in a way that supports the patient understanding. Many patients who are unfit for kidney transplantation have a good quality of life and good long-term outcomes on dialysis.
Ensure transplant status and modality choice have been actioned by a KFRE of 40%
Patients can be discussed as indicates as active on the kidney transplant waiting list or Deferred In kidney transplant assessment clinic. If patient is not medically fit for a transplant or does not wish to proceed for a transplant, then state this in the modality list.
Home therapies (designated as continuous ambulatory peritoneal dialysis (CAPD) or Home Haemodialysis (HHD)) may be associated with better patient outcomes than in centre haemodialysis. It is uncertain as to whether CAPD or HHD is associated with better clinical outcomes, but at minimum there is clinical equipoise.
At a KFRE 40% or more patients who have chosen CAPD as a preferred modality should have been reviewed in a CAPD surgical assessment clinic or, if KFRE 40%+ and AVF done or patient listed for AVF if not done.
Supportive care pathway patients can be offered follow-up in a supportive care AKC clinic or offered discharge to primary care with a tailored management strategy.
At a KFRE of 20-39% the patient is receiving education from the AKC team to support modality choice. That choice may have been made and the patient may have been seen in the relevant service (e.g. fistula fast/transplant assessment) but suspended on the kidney transplant list.
Key clinical points for patient review
Focus on patient symptoms. For patients requiring AKC the commonest symptoms are fatigue (70%), pain, particularly bone and joint pain (60%), poor sleep, itching, cramps, sexual dysfunction (50%), psychological health symptoms are very common. Malnutrition affects 30-50% of patients.
eGFR is not a good surrogate for patients with advanced CKD. Support patients to understand this and not to over-focus on eGFR but on how they feel.
Don't express eGFR as a percentage (%).
Continue to focus on CVD risk; statin for primary prevention; RASi to continue; SGLT2i to continue; BP target to <140/80 (individualise).
Advise on reduction in salt and processed foods; this supports blood pressure control, heart disease, phosphate management and oedema management. For more information, see 'A healthy diet and lifestyle for your kidneys' (Kidney Care UK).
Manage congestion (oedema); support patients to self-manage, enable them to adjust diuretic dose using daily weights and assessment of oedema. Diuretics are not directly nephrotoxic.
Hb target is 105-125 g/L. There is a SOP for anaemia and the renal anaemia team manage this through the AKC MDT.
Bone chemistry evidence is not strong, avoid activated vitamin D (alfacalcidol or calcitriol) unless severe and progressive SHPT, nutritional vitamin D can be used. Avoid calcium containing binders unless hypocalcaemic. Vitamin D levels should be checked yearly and nutritionally supplemented if deficient. Advise on limiting processed foods and avoid calcium containing binders unless hypocalcaemic or conservative management. Hyperphosphataemia may indicate that RRT is imminent.
Bicarbonate, the evidence is conflicting; BICARB (UK RCT) showed no benefit and increased adverse events; Cochrane review was low certainty evidence; animal evidence suggests delayed progression; have an informed discussion and don't be didactic, remember pill burden.