Renal replacement therapy and conservative management: NICE 2018
NICE has released its 2018 guidelines on Renal replacement therapy and conservative management.
Following are the major recommendations:
Indications for starting dialysis
- Consider starting dialysis when indicated by the impact of symptoms of uraemia on daily living, or biochemical measures or uncontrollable fluid overload, or at an estimated glomerular filtration rate (eGFR) of around 5 to 7 ml/min/1.73 m2 if there are no symptoms.
- Ensure the decision to start dialysis is made jointly by the person (or, where appropriate, their family members or carers) and their healthcare team.
- Before starting dialysis in response to symptoms, be aware that some symptoms may be caused by non-renal conditions.
Preparing for renal replacement therapy or conservative management
- Start assessment for renal replacement therapy (RRT) or conservative management at least 1 year before therapy is likely to be needed, including for those with a failing transplant.
- Involve the person and their family members or carers (as appropriate) in shared decision-making over the course of assessment to include: clinical preparation, psychosocial evaluation, preparation and support,the person's individual preferences for type of RRT and when to start, and how decisions are likely to affect daily life.
- Consider further assessment by a clinical psychologist or psychiatrist for: all children and young people being considered for a transplant, and adults being considered for a transplant if risk factors for poor outcomes have been identified; these may include:
- lack of social support
- neurocognitive issues
- non-adherence (medicines, diet, hospital appointments)
- poor understanding of process and complexities of treatment
- poorly controlled mental health conditions or severe mental illness
- substance misuse or dependence.
Choosing modalities of renal replacement therapy or conservative management
- Offer a choice of RRT or conservative management to people who are likely to need RRT.
- Ensure that decisions about RRT modalities or conservative management are made jointly with the person (or with their family members or carers for children or adults lacking capacity) and health care team, taking into account predicted quality of life, predicted life expectancy, the person's preferences and other factors such as co-existing conditions.
- Offer people (and their family members or carers, as appropriate) regular opportunities:to review the decision regarding RRT modalities or conservative management and to discuss any concerns or changes in their preferences.
Transplantation
- Discuss the individual factors that affect the risks and benefits of transplantation with all people who are likely to need RRT, and their family members or carers (as appropriate).
- Include living donor transplantation in the full informed discussion of options for RRT.
- Offer a pre-emptive living donor transplant (when there is a suitable living donor) or pre-emptive listing for deceased donor transplantation to people considered eligible after a full assessment.
- Do not exclude people from receiving a kidney transplant based on BMI alone.
Choice of dialysis modalities
- Offer a choice of dialysis modalities at home or in center ensuring that the decision is informed by clinical considerations and patient preferences.
- Offer all people who choose peritoneal dialysis a choice of continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD) if this is medically appropriate.
- Consider peritoneal dialysis as the first choice for children 2 years or under.
- For people who choose haemodialysis/haemodiafiltration (HD/HDF): Consider HDF rather than HD if in center (hospital or satellite unit), Consider HDF or HD at home, taking into account the suitability of the space and facilities.
Planning dialysis access formation
- Discuss with the person, their family members and carers (as appropriate) the risk and benefits of the different types of dialysis access, for example, fistula, graft, central venous or peritoneal dialysis catheter.
- When peritoneal dialysis is planned via a catheter placed by an open surgical technique, aim to create the access around 2 weeks before the anticipated start of dialysis.
- When HDF or HD is planned via an arteriovenous fistula, aim to create the fistula around 6 months before the anticipated start of dialysis to allow for maturation. When deciding on timing, take into account the possibility of the first fistula failing or needing further interventions before use.
- Offer ultrasound scanning to determine vascular access sites for creating arteriovenous fistulae for HDF or HD.
Indications for switching or stopping renal replacement therapy
- Offer information on all medically appropriate treatment options when discussing switching RRT modality
- Consider switching treatment modality or stopping RRT if medically indicated or if the person (or, where appropriate, their family members or carers) asks.
- Plan switching treatment modality or stopping Renal Replacement Therapy, RRT in advance wherever possible.
- Do not routinely switch people on peritoneal dialysis to a different treatment modality in anticipation of potential future complications such as encapsulating peritoneal sclerosis. However, monitor risk factors, such as loss of ultrafiltration.
- Seek specialist advice on the need for switching treatment modality when women become pregnant or wish to become pregnant.
Recognising symptoms
Recognise that people on RRT or receiving conservative management may have the symptoms in table 1 and that these may affect their day-to-day life.
Table 1 Possible symptoms in people on renal replacement therapy or conservative management
| Category | Symptom |
| General | Breathlessness |
| Fatigue | |
| Insomnia | |
| Itching | |
| Lethargy | |
| Pain | |
| Poor appetite | |
| Swelling | |
| Taste changes | |
| Thirst | |
| Weakness | |
| Weight loss/gain | |
| Gastro-intestinal/urological | Abdominal cramps |
| Change in bowel or urinary habits | |
| Nausea | |
| Musculoskeletal | Muscle cramps |
| Restless legs | |
| Neurological | Cognitive impairment |
| Dizziness | |
| Headaches | |
| Psychological/behavioural | Anxiety |
| Body image concerns | |
| Depression | |
| Mood disturbances/fluctuations | |
| Sexual dysfunction |
- Throughout the course of Renal Replacement Therapy, RRT and conservative management: Ask people about any symptoms they have.,Explore whether symptoms are due to the renal condition, treatment or another cause and explain the likely cause of the symptoms and how well treatment may be expected to control them.
Diet and fluids
- Offer a full dietary assessment by a specialist renal dietitian to people starting dialysis or conservative management. This should include: weight history,fluid intake,sodium,potassium,phosphate,protein,calories,micronutrients (vitamin and minerals).
- After transplantation, offer dietary advice from a healthcare professional with training and skills in this area.
- Re-assess dietary management and fluid allowance when:a person's circumstances change (for example, when switching RRT modality), or biochemical measures or body composition measures (for example, unintentional weight loss) indicate, or the person (or, where appropriate, their family members or carers) asks.
- Provide individualized information, advice and ongoing support on dietary management and fluid allowance to the person and their family members or carers (as appropriate). The information should be in an accessible format and be sensitive to the person's cultural needs and beliefs.
- Follow the recommendations on dietary management and phosphate binders in NICE's guideline on chronic kidney disease (stage 4 or 5): management of hyperphosphatemia.
Information, education and support
- To enable people, and their families and carers (as appropriate), to make informed decisions, offer balanced and accurate information about: all treatments available to them (including RRT modalities and conservative management), and how the treatments may affect their lives. See table 2 for more details.
Information about treatments and how they may affect lifestyle
| Information about treatments* |
| What they involve, for example, availability of assistance, time that treatment takes place, and number of sessions per day/week |
| Potential benefits |
| The benefits of adherence to treatment regimens and the potential consequences of non-adherence |
| Potential adverse effects, their severity and how they may be managed |
| The likely prognosis on dialysis, after transplant or with conservative management |
| The transplant listing process (when appropriate) |
| Switching the modality of RRT and the possible consequences (that is, the impact on the person's life or how this may affect future treatment or outcomes) |
| Reviewing treatment decisions |
| Stopping treatment and planning end of life care |
| Information about how treatments may affect lifestyle |
| The person or carer's ability to carry out and adjust the treatment themselves |
| The possible impact of dietary management and management of fluid allowance |
| How treatment may fit in with daily activities such as work, school, hobbies, family commitments and travel for work or leisure |
| How treatment may affect sexual function, fertility and family planning |
| Opportunities to maintain social interaction |
| How treatment may affect body image |
| How treatment may affect physical activity (for example, whether contact sports should be avoided after transplantation, whether swimming should be avoided with peritoneal dialysis) |
| Whether a person's home will need to be modified to accommodate treatment |
| How much time and travel treatment or training will involve |
| The availability of transport |
| The flexibility of the treatment regimen |
| Whether any additional support or services might be needed |
| * Treatments include RRT, conservative management and dietary intervention. |
- Recognise the psychological impact of a person being offered Renal Replacement Therapy, RRT or conservative management and discuss what psychological support may be available to help with decision-making.
- Discuss with people which treatment options are available to them and explain why any options may be inappropriate or not advised.
- Offer oral and written information and support early enough to allow time for people to fully understand their treatment options and make informed decisions. Information should be in an accessible format
- Direct people to other sources of information and support (for example, online resources, pre-dialysis classes and peer support)
- Remember that some decisions must be made months before RRT is needed (for example, a fistula is created at least 6 months before starting dialysis).
- Be prepared to discuss the information provided both before and after decisions are made, in line with the person's wishes
- Take into account information the person has obtained from other sources (such as family members and carers) and how this information has influenced their decision.
- Ensure that healthcare professionals offering information have specialist knowledge about late stage chronic kidney disease and the skills to support shared decision-making (for example, presenting information in a form suitable for developmental stage).
- Offer people who have presented late, or who started dialysis in an unplanned way, the same information as people who present at an earlier stage.
To read the complete guidelines, click on the following link:
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