Renal replacement therapy and conservative management

Context

People with chronic kidney disease (CKD) have an irreversible and progressive deterioration in kidney function. Renal replacement therapy (RRT) is a treatment option in people with CKD whose condition progresses to kidney failure. RRT essentially comprises either transplantation or dialysis (artificially removing waste products and excess water from the blood). Transplantation can be from living or deceased donors, and for some people it may involve the transplantation of more than one organ simultaneously (for example, combined pancreas and kidney transplantation for people with type I diabetes mellitus). In some cases, transplantation may be pre-emptive, occurring before dialysis would be needed. There are 2 main types of dialysis: haemodialysis (where the blood is filtered outside of the body using a dialysis machine) and peritoneal dialysis (where the person's abdominal lining is used to filter the blood). Some people choose not to receive RRT but continue to receive other supportive and symptomatic treatment for kidney failure – for example, treatment for their anaemia or dietary modification. This is usually called conservative management. People may also receive end of life care, and this may include both supportive and palliative care.

According to the 19th annual report by the UK Renal Registry (2016), on 31 December 2015 there were 61,256 adults in the UK receiving RRT. Of these, 53.1% had received a transplant, 41.0% were receiving haemodialysis (21.2% in satellite units, 17.8% in hospitals, 2.0% at home), 2.5% were receiving continuous ambulatory peritoneal dialysis and 3.4% were receiving automated peritoneal dialysis. In addition, 769 children and young people under the age of 16 years were receiving RRT. Most had received a transplant (41% live, 34% deceased), with 13% on haemodialysis and 12% on peritoneal dialysis. The median age of all people newly requiring RRT was 59.0 years; 22.7% of people were from minority ethnic groups. The reported 1-year risk of death for people on RRT aged 35 to 39 years was approximately 22.0 times higher than age- and sex-matched controls not on RRT. Survival rates for people with diabetes on maintenance haemodialysis are lower than those of people without diabetes. The number of people receiving conservative management varies between renal units and has been difficult to establish, but up to 40% of people over 70 choose this option. Most of these still receive their care and treatment through renal services.

Approximately 5,500 adults and children are currently on the national renal transplant (waiting) list (NHS Blood and Transplant), with about 3,000 renal transplants performed each year. The median time to transplantation for those on the list is around 1,000 days for adults and 300 days for children. There is considerable inequality across ethnic groups, with relatively fewer people from black, Asian and minority ethnic groups on the organ donor list. These groups have a higher incidence and prevalence of CKD needing RRT and tend to reach this stage at a younger age.

RRT is an expensive treatment. The total cost of CKD in England in 2009–10 was estimated at £1.45 billion; more than half of this sum was spent on RRT.

This guideline aims to improve the care of people with CKD who need RRT or conservative management. The guideline covers the choice, timing, preparation for and switching of RRT 'modalities' for children and adults, as well as symptom recognition, information, education and support, and coordination of care.