Resumen de Improving care for end-stage chronic renal disease and kidney transplant patients
It is known that mistakes are of human nature from long time ago, and also that mistakes usually help us to improve every day. By looking backwards we have been able to evolve both as individuals and at work. And by reviewing the history of Nephrology, it has been possible to find our weak areas and focus our efforts on improvements. Population with end stage kidney failure is nowadays a growing health concern due to the great prevalence and morbimortality associated, and hence deserves our thorough attention as noble health care professionals.
Despite of great advances in technology and pharm industry, providing a free of illness condition today is rather difficult and sometimes unreachable. Consequently, the quality of life of our patients has become a mandatory objective in our clinical practice today. The aim of this PhD is to contribute with little improvements to increase the care received by our patients with ESRD from a quality of life point of view.
Four articles explain these improvements in the care of patients with kidney failure receiving dialysis and living with kidney transplant.
The first article is focused on information about the End-of-Life Care and Advance Directives (AD) provided to patients in dialysis in Spain. The aim has been to investigate patient familiarity on Advance Care Planning to improve patient awareness of their condition and end of life concerns. By helping to prevent future misguided decisions, we can improve patients` quality of life. But unfortunately, the results of the study have revealed that this branch of the health care continues to be deficient in the country and the implementation of AD is very scarce. This should impulse further investigations and resources development in this area of care.
An early referral to the Nephrologist is advocated by most of the renal guidelines to allow patient and families receive education, assimilate information and weight treatment options. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend planning for kidney failure once CKD stage 4 is reached. In many occasions, options for renal replacement therapies are limited by patient disorders. However, it is our responsibility to aim patient preferences rather than any other interest. By addressing barriers of a technique, we can wide options to renal patients and improve their care. Hernias in peritoneal dialysis are a common mechanical complication, but the effect of hernia occurrence and treatment on residual renal function (RRF), which is known to confer significant prognostic benefit, remains unknown. In this large retrospective cohort study is shown that a timely management of abdominal hernias has no negative impact on PD technique survival, RRF, or patient survival. Subsequently, according to these results, renal physicians should not limit PD option to ESRD patients with hernias or previous abdominal surgeries related to hernia.
Two articles are dedicated to aim improvements on renal transplant patients. From the very begging of receiving a foreign organ into the body, immunosuppression drugs are mandatory in most cases. Then, quality of life of a transplanted patient will not only be affected by the amount of pills that patients should take every day, but also by the variable intensity of its side effects. Improvements related to laboratory results are common in transplant patients and subsequent contributions to their health care, increasing their well-being, have been possible in the last decades. However, it is known that the quality of life of these patients has still not reach the sky and it would be greatly improved by minimizing or eluding side effects of immunosuppressive drugs without increasing exposure to risks. The aim of the studies has been to examine the short-medium effect of switching immunosuppressive medication on graft survival and patient welfare in Cruces Hospital, Spain.
MMF/MPA is an antiproliferative agent essential in the initial maintenance medication and has proven efficacy in preventing acute rejection. However, uncomfortable side effects that may affect patient’s quality of life, mainly diarrhoea, have been attributed to its use. Alternative combination of Tacrolimus and Everolimus has been studied in our centre in kidney transplant patients who revealed intolerance to MMF/MPA. And the promising results obtained could impulse larger studies to continue improving transplant patients’ quality of life without affecting graft survival.
Cyclosporine and Tacrolimus are calcineurin inhibitors (CNI) drugs very effective in preventing acute rejection and they are advocated in initial and long-term maintenance regimens of kidney transplantation. Nevertheless, chronic allograft nephropathy and nephrotoxicity has been thought to be related with these agents. This means that lifespan of the implanted kidney can be compromised and renal replacement therapies might be sooner required. Efficacy and safety of conversion to Everolimus has been studied in our centre with the aim of looking for a graft survival lengthening and a subsequent improvement of quality of life. Results have found that Everolimus can be a safe alternative to widen therapeutic options in renal transplanted patients with CNI toxicity, even in those patients with significant decreased renal function at the time of switch.
Definitively, caring for patients with end-stage renal disease and kidney transplantation is rather challenging. Not only is important to take care of their interventions, but also to consider their opinions, their quality of life, their future planning and the profound review of their daily medication, aiming to elude side effects without compromising patient and graft survival. Every little step in the care of ESRD population is encouraging to our community and we should endeavour to provide our patients the most similar life to those who live without renal disability.
