Modalities of RRT: Renal replacement therapy and conservative management

Excerpt

When people approach or have progressed to later stages CKD they need to decide whether to undergo renal replacement therapy or to choose conservative management. Renal replacement therapy is a term used to encompass life-supporting treatments for severe acute kidney injury or for people who have progressed to later stages of chronic kidney disease. It includes the following modalities: haemodialysis, haemodiafiltration, peritoneal dialysis and renal transplantation. Haemodialysis can be delivered at home, in a satellite unit or in hospital. Peritoneal dialysis can be continuous ambulatory (e.g. four sessions × 40 minutes daily) or automated (e.g. one session × 9 hrs daily). Transplantation may be pre-emptive (before dialysis) or not and may be from a living or deceased donor

Conservative management is the full supportive management (including the control of symptoms and complications and advance care planning) for those in the later stages of CKD who, in conjunction with carers and the clinical team, decide against renal replacement therapy. Conservative management will generally (although not always) be less appropriate for younger, healthier people. Conservative management is rarely an option for children

There is considerable variation in the proportion of people receiving each modality. Data from the UK renal registry show that there were 61,256 adult patients receiving renal replacement therapy (RRT) in the UK on 31st December 2015. Transplantation was the most common treatment modality (53.1%) followed closely by centre-based HD (39.0%) in either hospital centre (17.8%) or satellite unit (21.2%). The proportion on continuous ambulatory peritoneal dialysis (CAPD) and automated PD (APD) was 2.5% and 3.4% respectively. There were 941 children and young people aged 18 years who have progressed to later stages of CKD. 75.3% of paediatric patients aged 16 years and under had a functioning kidney transplant, 13.0% were receiving HD and 11.7% were receiving PD. There is variation across the country with respect to the proportion of people using each modality.

When considering the option of haemodialysis or haemodiafiltration, the optimum frequency needs to be considered. For example, in-centre haemodialysis or haemodiafiltration is typically delivered three times a week but home treatment may be more frequent.

It is also important to consider that certain factors (e.g. age, ethnicity, diabetes) may influence people’s response to renal replacement therapy modalities or conservative management.

The purpose of these questions is to explore the clinical and cost effectiveness of renal replacement therapy, including different frequencies of dialysis and conservative management. Secondly, it will aim to identify the clinical and cost effectiveness of renal replacement therapy or conservative management in specific groups of people.