Renal replacement therapy and conservative Mx: NICE 2018 Gui
The National Institute for Health and Care Excellence (NICE) has released a guidance document that covers renal replacement therapy (dialysis and transplantation) and conservative management for people with chronic kidney disease stages 4 and 5. It aims to improve quality of life by making recommendations on planning, starting and switching treatments, and coordinating care.

The recommendations have been made in the following categories:-
• Indications for starting dialysis
• Preparing for renal replacement therapy or conservative management
• Choosing modalities of renal replacement therapy or conservative management
• Planning dialysis access formation
• Indications for switching or stopping renal replacement therapy
• Recognising symptoms
• Diet and fluids
• Information, education and support
• Coordinating care

Some of the key recommendations are:-
• 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

• Before starting dialysis in response to symptoms, be aware that some symptoms may be caused by non-renal conditions

• 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

• Offer a choice of RRT or conservative management to people who are likely to need RRT

• 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)

• 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

• 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

• 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 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

Possible symptoms in people on renal replacement therapy or conservative management:-
1. General
• Breathlessness
• Fatigue
• Insomnia
• Itching
• Lethargy
• Pain
• Poor appetite
• Swelling
• Taste changes
• Thirst
• Weakness
• Weight loss/gain

2. Gastro-intestinal/urological
• Abdominal cramps
• Change in bowel or urinary habits
• Nausea

3. Musculoskeletal
• Muscle cramps
• Restless legs

4. Neurological
• Cognitive impairment
• Dizziness
• Headaches

5. Psychological/behavioural
• Anxiety
• Body image concerns
• Depression
• Mood disturbances/fluctuations
• Sexual dysfunction

About NICE
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE was originally set up in 1999 as the National Institute for Clinical Excellence, a special health authority, to reduce variation in the availability and quality of NHS treatments and care. NICE’s role is to improve outcomes for people using the NHS and other public health and social care services.

Note: This list is a brief compilation of some of the key recommendations included in the guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here:
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