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Although transplantation is shown to have the best outcomes, this may not be possible for many patients due to co-morbidity, lack of a donor or, sometimes, patient choice. When pre-emptive transplantation is not possible, timely referral for placement of either a peritoneal dialysis catheter or formation of definitive vascular access is essential (Table 1).

There are no adequate randomized controlled trials comparing outcomes of peritoneal dialysis (PD) versus haemodialysis (HD) or of home versus centre based therapies but there is considerable observational data which suggests


approach to renal replacement therapy"'

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'• All medically suitable patients should be informed about the advantages of pre­ emptive living kidney transplantation and efforts made to identify potential donor to allow pre-emptive transplantation before the need for renal replacement therapy'


information about available treatment options, were more

likely to choose a self-care based therapy as first modality - peritoneal dialysis in particular, but alsohome haemodialysis and minimal care haemodialysis. Patients malting a "good decision" about treatment options are more likely to adhere to treatment regimes and tolerate complications better than those not fully involved in the decision making processesl9,20. Incomplete presentation of treatment options may be a major reason for the under-utilization of home dialysis therapies and contribute to delayed access to transplantation . Pre-dialysis education may also influence employment status. People who had undergone pre-dialysis education were more likely to continue in workl 7. Finally, pre-dialysis education may also have a beneficial effect on both short-term23 and long-term survival. The risk of death in patients who did not receive pre-dialysis education has been estimated as double that in those who had received this education, and similar to that inlatereferrals .

In 2010, the IDEAL (Initiation of Dialysis Early and Late) study reported its findings from 828 incident adult patients commencing dialysis in 32 centres in Australia and New Zealand. Patients were randomised to receive dialysis early (eGFR 10-12 ml/min/1.73m2 based on the Cockcroft and Gault formula) or late (eGFR 5-7 ml/min/1.73m2). Although many of the late starters commenced RRT at an eGFR greater than 7 owing to the onset of symptoms, the study showed no benefit for starting dialysis early, before the onset of symptomsl7. Therefore, there seems to be no evidence to support the commencement of RRT prior to onset of symptoms. This emphasises the need to include patients in the discussion over timing ofinitiation of RRT.


Late Presentation CKD requiring immediate


dailysis

Late Presentation CKD requiring immediate


dailysis


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Tunnelled line Acnte PD

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Transolant assessment


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Not Fit for Tx


Discussion re: Dialysis No immediate live

donors

Fit for Tx


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Live dovors


Hospital -based therapy


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Home based Rx


HD


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Refer for AVF

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Indeuendent PD Assisted PD


Workup donors and proceed with Trasulant

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patient aged 65-69 years

for an aged matched person in general population 13.Two recent studies have developed risk scores to predict 6 month mortalityl4,15. These may be useful in informing discussions with patients but predicting individual prognosis is clearly imprecise. (With increasing age and dependency, progression of underlying medical conditions, or the emergence of new medical problems, life on dialysis may become difficult to bear. In such situations, it is important to recognise that end oflife may be approaching, signalling the need to re-focus the emphasis of care, from prolongation of life to relief of symptoms, maintenance of comfort and attention to psychological, social and spiritual concerns).

There is evidence that nephrology health care professionals


  1. Sanerl E, Nitsch D, Descoeudres C, et al. Outcome of home haemodialysis patients: a case-cohort study. Nephrol Dial Transplant 2005;20:604-610

  2. Nitsch D, Steenkamp R, Tomson C, et al. Outcomes in patients on home haemodialysis in England and Wales,1997-2005: a comparative cohort analysis. Nephrol Dial Transplant 2011; 26:1670-1677

  3. Ghossein C, Serrano A, Rammohan M, et al. The role of comprehensive renal clinic in chronic kidney disease stabilization and management: The Northwestern experience. Semin Nephrol2002;22:526-532

  4. Levin A, Lewis M, Mortiboy P, et al. Multidisciplinary

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