Treatment of anemia Partial correction of anemia to a target of 11 \200\22313 g/dL is gener ally recommended. Treatment of hypertension Hypertension should be controlled by removal of excess \202 uid . -Blockers should be considered in patients with ischemic heart disease. Antianginal age nts may reduce BP which may necessitate night-time dosing. These risk factors do not explain the progression of left ventricular dysfunction for patie nts who remain on dialysis. As with coronary artery disease, nontraditional risk fac- tors may play a role in the development of cardiac \201 brosis, with in \202 ammation, increa sed oxidative stress, calcium and phosphate abnormalities and a direct effect of uremia all likely to play a role. As in nonuremic patients, the presence of left ventricular dysfunct ion independently predicts early mortality in ESRD. In a cohort of almost 2000 ESRD patient s with diagnosed congestive heart failure mortality at 3 years was 83%. Management of acute coronary syndromes Patients with ESRD and unstable angina or acute myoc ar- dial infarction should be managed with standard therapy. Aspirin, -blockers and nitro glycerin should be used if no contraindications exist. Thrombolysis Although it is unclear if ESRD patients obtain the same benefits from thrombol ytic agents (most studies have excluded patients with signi \201 cant renal dysfunction) t his should be used as per standard criteria. Heparin Heparin should be considered in patients with unstable angina. Unfractionated hepar in is usually preferred for dialysis patients. Although the low molecular weight heparin en oxaparin is considered as effective as unfractionated heparin for the treatment of acute co ronary syndrome there are no clear dosing recommendations for patients with ESRD. A meta-an alysis of patients not on dialysis, with creatinine clearance <30 mL/min, concluded that st andard therapy with enoxaparin results in elevated concentrations of anti-Xa and an increas ed risk of major bleeding. Treatment Strategies to reduce left ventricular mass index and left ventricular dysfunction should include correction of ane- mia and correction of hypertension. Correction of volume overload and limiting interdialytic weight gain are also important. For some patients on H D this may require instituting a more intensive dialysis regime with longer hours, greater frequency of dialysis or a combi- nation of both. For patients on PD, manipulation of the d ialysis prescrip- tion may be required, and consideration given to the use of icodextrin or automated PD. CHAPTER 13.6 Medical management of the dialysis patient 535 First-line pharmacological therapy should be with carvedilol, the only agent that has been shown to be effec- tive at lowering all-cause mortality, cardiovascular mortal- ity and hos pitalization in HD patients with symptomatic left ventricular dysfunction. Consideration sh ould also be given to the use of ACEIs and digoxin as second- and third-line therapies. The K/DOQI guidelines recommend that, at initiation of dialysis, all patients should undergo b aseline echocardiog- raphy and electrocardiography. This should generally be deferred until the hemoglobin and the goal dry weight is achieved. Table 13.6.14 Surgery for ESRD: issues to be addressed Evaluation of hematological and biochemical parameters Fluid balance Nutritional state Card iac state Coagulation Vascular access Anesthetic considerations Antibiotics Analgesia Issues for patients on PD Diabetic ESRD patients The nephrologist will commonly have to deal with ESRD patients with diabetes and manage their multisystem com- plications. The glycated hemoglobin (HbA1C) is t ypically used to monitor glycemic control in ESRD patients. However the target HbA1C to ach ieve optimal outcomes is uncertain in ESRD patients and controversy exists as to whether ti ght control affects survival. Most nephrologists will aim to achieve an HbA1C of 6 \200\223 7%. Hypoglycemic agents Biguanides are generally avoided in ESRD patients due to the risk o f lactic acidosis and drug accumulation. -Glucosidase inhibitors are also avoided due to concerns about their pharmacokinetic pro \201 le. Shorter-acting sulphonylureas, which lac k active metabo- lites, such as glipizide and gliclazide, are usually preferred. The thiazo lidinedones are hepatically metabolized and active metabolites do not appear to accumulate in ESRD, although concerns as to the effects of rosiglitazone on car- diovascular events an d mortality have been raised. The dose of insulin needs to be reduced in ESRD patients due to decreased renal excretion. There is no consensus as to the choice of insulin regimen and type of insulin and treatment should be individualized to the patient. If patients are est ablished on PD then their insulin require- ments will change due to absorption of glucose f rom the dialyzate. Patients treated with PD can theoretically be treated with intraperitone al insulin although there are no proven advantages and the practice is now rare. PD patients should continue performing exchanges until the time of surgery and should be dr ained out just prior to surgery. If undergoing an abdominal procedure, which may disrupt th e peritoneal membrane, then placement of a HD cathe- ter under anesthetic is useful. If the patient is diabetic, stopping PD may alter any require- ment for hypoglycemic drugs. Hematological and biochemical parameters A full blood count should be performed and anemia should be corrected to the target range where possible. A base- line set of electrolytes in cluding serum glucose, urea, cre- atinine, potassium, bicarbonate calcium, phosphorus, magn esium and albumin should be evaluated and moni- tored closely in the immediate postoperativ e period. Nutritional state Malnutrition increases the risk of surgical complications and results in a prolonged length of stay due to infection, wound breakdown and multiple organ dysfunction . Where possible elective surgery should be delayed to optimize nutrition. Postoperatively the dose of dialysis should be optimized and may need to be increased as surgery will induc e a cata- bolic state. Drugs which impair appetite should be avoided. Gastro- paresis shoul d be treated aggressively and early, aggressive nutritional supplementation should be consi dered. Fluid balance An assessment of the volume state of the patient should always be performed p reoperatively. HD may be required prior to emergent surgery and should be performed prior t o elective surgery to optimize \202 uid and electrolyte balance. Dialyzate concentrations should be adjusted to normalize serum potassium and calcium concentrations. Perioperative \202 uid requirements should be determined, after discussion with the surgeon and anesthe tist. In patients without kidney disease, solutions such as Plasmalyte and Lactated Ringer \200\231s solution, which contain potassium, are frequently used peri- and intraoperatively . The acid \200\223base and electrolyte state of the ESRD patient will often require other solutions to be used. Close monitoring of \202 uid balance in the immediate post- operati ve period is essential. Multisystem effects Regular screening for other diabetic complications is essential with tr eatment by ophthalmology and podiatry services as required. Peripheral vascular disease is common and will often require input from interventional radiology or vascular surgical serv ices. Peripheral neuropathy is also common as a result of both diabetes and uremia. This ma y respond to increasing the dose of dialysis as well as standard medical treatment. ESRD patients undergoing surgery Patients with ESRD, compared to patients without kidney di sease, are at increased risk of prolonged hospital stay, morbidity and mortality associated with surgery. A number of issues should be addressed in the ESRD patient (Table 13.6.14). J.R. DE ZOYSA 536 Cardiac state Cardiovascular complications are common in ESRD patients. Where possible preo perative cardiac risk assessment will help determine the potential risks of surgery for the patient and may guide perioperative management. Several clinical risk indices, validated i n non-ESRD patients, are available including the Revised Cardiac Risk Index and the Eagle C riteria. Usually patients at low clinical risk do not need further evaluation. Patients at high risk should be considered for coronary angiography prior to elective surgery. In patie nts at intermediate risk, noninvasive testing should be considered. A number of noninvasive tests are available. Exercise toler- ance testing with electrocardiography alone or with t hal- lium imaging is often inadequate or impractical in dialysis patients. [201Tl]Dipyridam ole imaging and dobutamine stress echocardiography tend to be more accurate in identi- fyin g ESRD patients who should proceed to coronary angi- ography. The indications for coronary revascularization of the ESRD patient are unaltered, irrespective of whether the patient is being considered for surgery. If percutaneous intervention is performed then elective surg ery should be delayed until antiplatelet therapy can be safely stopped. -Blockers should not be halted perioperatively, due to the risk of rebound and it is reasonable to consider prescribing -blockers in at-risk patients to minimize the risk of myo- cardial ischemia o r arrhythmias. Anesthetic management Premedications, induction and perioperative agents, will need to be m odi \201 ed in patients with ESRD as metabolism of anesthetic medications is altered in re nal failure. Antibiotics ESRD patients who are undergoing access procedures should receive prophylactic antibiotics. Peri- and postoperative antibiotics, for other surgical pro- cedures, should b e administered as normal but will usually require dose adjustment. Analgesia Paracetamol can be used in ESRD patients without dose modi \201 cation. The effe cts of many opioid analgesics are prolonged in ESRD. Sufentanil and fentanyl have a short r edistribution phase, lack active metabolites and appear to have an unchanged free fraction in ESRD, so are the drugs of choice. Oxycodone and methadone may be used cautiously when co nverting to oral opiate analgesia. Primary prevention General healthcare issues should be addressed in ESRD patients. This wil l include immunizations and screening for malignancies. Although dialysis patients have red uced response rates to immunization compared with the general population and controversy ex ists as to cost-effectiveness and overall ben- e \201 ts, most guidelines advocate the fol lowing vaccinations: \200 \200 \200 \200 \200 hepatitis B; pneumococcal; in \202 uenza; tetanus; meningococcal B. Coagulation Adequate dialysis will generally correct uremic coagulopa- thy. If HD is being provided prior to emergency surgery then it is important to avoid prolonging anticoagulatio n. Where possible heparin-free dialysis should be performed. If dialysis cannot be performe d preoperatively then desmo- pressin and/or cryoprecipitate may be required to correct the uremic coagulopathy. For elective procedures, the effects of unfractionated heparin on coag ulation will wear off 4 h after heparin is halted. Patients should be reminded to undergo routine screening for malignancies such as breast, c ervix and bowel as per local guidelines. Palliative care of the dialysis patient Withdrawal from dialysis is common, and is recorded as the cause of death in >20% of dialysis patients. This may be when the patient faces imm inent death from other causes, incurable malignancy, or other reasons including the burden of dialysis outweighing its potential benefit. In the latter scenario, understanding why th e patient feels that therapy is too much of a burden may identify areas where treatment may be modi \201 ed. The survival of patients with signi \201 cant residual renal function m ay be months but in anuric patients is typically <1 week. Many dialysis patients who withdr aw from therapy will die in hospital. However, the option of care at home with com- munity support or hospice care should be considered. Although often described as painless and asso ciated with progressive somnolence, uremic death is often associated with weakness, fatigue , myoclonic jerks, twitching, agitation, dyspnea, pain and nausea. General care should be i nstituted including withdrawal of unnecessary medication, removal of \202 uid and dietary restric- tions and elimination of blood testing. Pain, nausea, constipa- tion and other sy mptoms should be treated with medications at doses adjusted for the level of renal dysfunct ion. Vascular access Vascular access should be discussed with the anesthetist and junior staff. Patients with ESRD may have complex vascular anatomy and this may in \202 uence where the anesthetist elects to place central venous access. Where possible, subclavian veins or cent ral lines on the same side as an arteriovenous \201 stula should be avoided. Patients sho uld be reminded to ask staff to avoid, where possible, blood taking, intravenous cannulas a nd BP meas- urements on areas being used for current or future vascu- lar access. A sign at the patient \200\231s bedside or even temporary marking of the access arm may be required. CHAPTER 13.6 Medical management of the dialysis patient 537 Further reading Chobanian AV, et al. Seventh Report of the Joint National Committee on Prev ention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. J Am Med Assoc 2003; 289: 2560 \200\2232572. National Kidney Federation Dialysis Outcomes Quality Initiative: http://www.kidney.org/professionals/kdoqi/ UK National Kidney Federation: Cice G, et al. Carvedilol increases two-year survival in dialysis patients with dilated car diomyopathy: a prospective, placebo- controlled trial. J Am Coll Cardiol 2003; 41: 1438 \200\2231444. http://www.kidney.org.uk/ Care for Australians with Renal Impairment: http://www.cari.org.au/ European Best Practice Guidelines: K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. K/DOQI Workgroup. Am J Kidney Dis 2005; 45(4 Suppl 3): S1 \200\223153. http://www.ndt-educational.org/guidelines.asp Lim W, et al. Meta-analysis: low molecular weight heparin and bleeding in patients with sev ere renal insuf \201 ciency. Ann Intern Med 2006; 144: 673 \200\223684. See also Endocrine disorders in CKD, p. 398 Hypertension in CKD, p. 406 Cardiovascular risk factors in CKD, p. 412 Hematological disorders in CKD, p. 426 Skeletal disorders in CKD, p . 432 2M amyloidosis in CKD, p. 436 Dermatological disorders in CKD, p. 450 Trespalacios FC, et al. Heart failure as a cause of hospitalization in chronic dialysis pat ients. Am J Kidney Dis 2003; 41; 1267 \200\2231277. Wanner C, et al . Atorvastatin in patie nts with type 2 diabetes mel- litus undergoing hemodialysis. N Eng J Med 2005; 353: 238 \200\223248. Internet resources The Renal Association: http://www.renal.org/ The Renal Registry: http://www.renalreg.org J. HAINSWORTH 538 Psychological aspects of treatment for renal failure Introduction The diagnosis and treatment of renal failure can have a signi \201 cant impac t on patients \200\231 psychosocial functioning and their ability to cope with the inevitab le changes to their lifestyle. For patients approaching ESRD, early referral to renal servi ces is preferred with patients having time to prepare and adjust to their condition and tre atment. Sudden onset may be traumatic and the identification of trauma-related symptoms can go unrecognized. Decision-making Involvement in decision-making and treatment choices has been associated wi th a reduction in anxiety and depression and surveys have indicated that many patients pref er to be involved in their own healthcare. For patients diagnosed with renal failure, treat ment choice (e.g. dialysis, transplantation, or conservative management) may be in \202 ue nced by a number of factors including: \200 \200 physiological factors; involvement of others, e.g. health professionals and fam- ily/carers ; degree of autonomy, control and independence; change in treatment modality; predialysis p atient education; quality of life; capacity to make informed choice, e.g. advanced demen- t ia or severe learning disability. Diagnosis of end-stage renal disease Common reactions Following a diagnosis of ESRD, patien ts may experience a range of emotions similar to the stages of grief typically seen followi ng a signi \201 cant loss or bereavement: Shock: \200 Uncertainty, worry, anxiety: \200 Low mood/depression: \200 Anger: \200 Denial: \200 \200 Relief: \200 Acceptance : \200 \200 \200 \200 \200 \200\230This is not really happening to me. \200\231 \200\230How long will I need these treatments? \200\231 Commencement of dialysis Anxiety and depressive disorders are frequently seen in hemodialys is patients and may affect how they perceive their health status. Furthermore, these affect ive disorders may not be recog- nized or viewed as a normal reaction to the patient \200 \231s ill- ness. A number of factors are important to consider from a psy- chological persp ective in patients who are commencing dialysis: \200 \200\230What did I do to cause this? \200\231 \200\230Why is this happening to me? \200\231 \200\230My kidneys are going to start working again soon. \200\231 \200\230The doctors ha ve made a mistake. \200\231 \200\230Now I know why I was feeling unwell. \200\231 treatment complications, e.g. catheters blocking; access dif \201 culties; infections; cha nge in treatment modality; fear that treatment may not be successful; transportation issues ; \201 nancial concerns; impact on family and other lifestyle factors; anxiety about trea tment procedures; body image concerns. \200\230I feel I can look to the future now. \200\231 \200 \200 \200 \200 \200 \200 Management Allow time for the patient to express how they are feeling and any concerns or w orries they might have. Communicate to the patient that they might expect to feel a variety of emotions in response to their illness. Acknowledge that their reaction is a normal resp onse to diagnosis of a chronic medical condition. Provide an appropriate level of informati on and keep the atient informed in relation to their condition and treat- ment. Refer for p sychological intervention if the patient continues to have dif \201 culty in adjusting. Hospitalization Admission to hospital can be a stressful experience for patients, with chal lenges related both directly and indi- rectly to illness and treatment. Loss of independenc e and uncertainty have been described as the two most stressful challenges faced during hos pitali- zation. Other key issues include: Adjustment Adjustment and ability to cope with the diagnosis and long- term implications of ESRD can be affected by a number of other demographic and psychosocial variables: \200 \200 \200 \200 \200 \200 \200 \200 Loss of control Over body: \200 \200 \200 comorbidity with other chronic health conditions; illness-related factors; medication; impa ct on current lifestyle; age at diagnosis; personality; social and cultural factors; suppor t networks available. loss of privacy and independence; the need to be highly dependent on others; undergoing dis tressing or invasive procedures. Over lifestyle: \200 \200 unable to perform typical activities; unable to ful \201 ll their usual family, social and work roles. Over ability to predict what will happen: \200 \200 \200 not knowing what to expect; confusion and disorientation; unable to plan for the future. The impact on family and carers also needs to be consid- ered both from an emotional and pr actical perspective. CHAPTER 13.7 Psychological aspects of treatment for renal failure 539 Lack of information Patients need to understand what is happening to them for a number of r easons: \200 \200 \200 Topics to be included in risk assessment include: \200 \200 \200 \200 \200 \200 level of hopelessness; thoughts of ending life (if so, how persistent); thoughts about a sp eci \201 c, available method of suicide; ever acted on such thoughts in the past; feel abl e to resist them, make them disappear; ability to give reassurance about safety, e.g. until next appointment; circumstances likely to make things worse; willingness to turn for help if crisis occurs; risk to others. to inform their treatment decisions; to make sense of their symptoms and illness; to reduce anxiety (about outcome and procedures). Management It is important for staff to be aware of the types of emo- tional responses and coping strategies used by hospitalized patients. Patients can be helped to cope with psycho logical distress in a number of ways: \200 \200 \200 Treatment/interventions Recognize that depression can be a normal response to diagnosis and hospitalization. Referral for further specialist intervention may be neces- sary (see guid elines at end of chapter). A number of psychological approaches/models have proven effectiv eness in the treatment of depression. Recent guidelines recommend cognitive behavior therap y (CBT) as an effective psychological treatment for mild and moderate depression. A combina tion of antidepressants and individual CBT should be considered for severe depression and t reat- ment-resistant depression. However, more research is needed regarding the effective- ness of CBT with chronically ill patients. Key components of CBT for depression include: \200 keep patients informed of their condition, diagnosis and treatment; help patients use probl em-focused coping; provide patients with appropriate social support. \200 Depression Depression is frequently seen in renal patients both as a reaction to diagnosis and treatment, as well as the losses experienced in terms of health, lifestyle, status, etc . It is commonly seen in the early stages of renal failure and/ or as a response to setback s with treatment or physical health (e.g. transplant failure). The type of depression seen in renal patients is often reac- tive and usually transient in nature. Epidemiology Depression and anxiety are twice as common in medical patients as in the gener al population. In relation to ESRD, it is estimated that up to 30% of hemo- dialysis patien ts have a depressive disorder. However, prev- alence rates vary according to diagnostic cri teria and measures used. Recognition of an anxiety or depressive disorder can be dif \201 cult in a medical setting particularly as typical symp- toms can be confused with those of a physical illness, e.g. uremia, fatigue, loss of appetite, sleep disturbance. Clinical fea tures \200 \200 \200 \200 identifying, monitoring, and altering negative thinking patterns, beliefs and interpretatio ns related to targets symptoms/problems; learning new coping skills: activity scheduling, p roblem- solving, and goal-setting. Anxiety Anxiety may be experienced in relation to: \200 \200 \200 dialysis and treatment; understanding of renal failure; speci \201 c phobias such as needl es and medical/invasive procedures; relationships; quality of life and the future; employme nt and \201 nancial status; impact on overall lifestyle and other family members. persistent sadness or low mood; loss of interest or pleasure; fatigue or low energy; sleep disturbance (either dif \201 culty falling asleep or early morning wakening); appetite dis turbance (either loss or increase in appe- tite); poor concentration or indecisiveness; agi tation or slowing of movement; decreased libido; low self-con \201 dence; suicidal thought s or acts; guilt or self-blame. \200 \200 \200 Epidemiology Anxiety disorders can cause considerable distress, are often chronic in nature , and often unrecognized and untreated in the general population. Anxiety can be manifested in terms of physiological, cogni- tive, and behavioral responses. A medical history is par ticularly important in recognizing physical symptoms that might be due to anxiety as oppose d to physical illness or the side-effects of medication. Clinical features \200 \200 \200 \200 \200 \200 \200 \200 Assessing suicide risk Questions should determine: \200 \200 \200 \200 the presence or absence of suicidal ideas; the persistence of these ideas; the likelihood o f them being acted upon; the risk to others. frequent worrying thoughts; feeling tense; fearing the worst (e.g. that their condition wil l deterio- rate or they might die); palpitations; sweating; hyperventilating; \200 \200 The National Institute for Mental Health in England (NIMHE) provides useful advice and guid ance including assessing the severity of depression and suicide risk. J. HAINSWORTH 540 \200 \200 \200 \200 Patients may view dialysis access as a form of \200\230mutilation \200\231 or feel dis \201 gured: Hemodialysis \200 \200 inability to be at ease or relax; restlessness; sudden feelings of panic; feeling dizzy or faint; indigestion or diarrhea. appearance of \201 stula, e.g. scarring, size; appearance of vascular access catheter. Treatment/interventions A range of effective interventions is available including medicatio n, psychological therapies, and self-help. Furthermore, it has been demonstrated that anxie ty disor- ders with marked symptomatic anxiety are likely to bene \201 t from CBT. CBT for anxiety includes: \200 Peritoneal dialysis \200 \200 appearance of abdomen; PD catheter and associated fears including concerns about sexual int imacy. Treatment/interventions Be aware of the potential impact of treatment procedures on appeara nce. Acknowledge that patients might have a very different view of their \201 stula or ca theter, i.e. perceive in terms of appearance as opposed to functional status. Refer for fur ther psychological intervention if body image disturbance is having a signi \201 cant impa ct on treatment and overall psychosocial functioning. identifying and altering negative thinking patterns and associated behaviors; learning new cognitive skills, e.g. distraction (useful for immediate symptom management), positive self -talk; affective education (provide information about anxiety), monitoring and management; relaxation and breathing techniques; exposure-based therapy to manage avoidance of feared s ituation. \200 Sexual dif \201 culties Sexual dif \201 culties can arise at an early stage of renal fail ure, although may not be experienced by all patients. Distorted body image and sexual dif \201 culties can also be a psychological response to dialysis treatment. Sexual difficultie s may be influenced by vascular or hormonal changes arising from renal failure; side-effect s of medication and/or as a psychological response. Psychological factors include: \200 \200 \200 \200 Needle phobia A phobia is a persistent and excessive fear of an object or situation that is not dangerous and is characterized by avoidance behavior. Epidemiology Fear of needles and medical/invasive procedures is fre- quently seen in renal patients, with estimated prevalence rates of 10% in the general population. However, more s evere cases are probably not identi \201 ed due to avoidance of medical settings. Clinical features A typical phobic response includes: \200 adjustment to condition and treatment; anxiety and depression; change in body image; relati onship dif \201 culties. Loss of physical health and vitality is also a factor, as is body image. The most common se xual dif \201 culties in renal patients are: Men: \200 \200 \200 vasovagal syncope or fainting in response to fall in blood pressure; fear and avoidance in absence of vasovagal response. Key features can include: \200 \200 \200 \200 erectile dysfunction; loss of libido; ejaculatory dif \201 culties. anxiety; avoidance; fear of pain; loss of control. Women: \200 \200 \200 dyspareunia (pain during sexual intercourse); change in libido; fears related to fertility and pregnancy. Treatment/interventions Behavioral therapy in the form of in vivo exposure (i.e. graded and prolonged exposure to feared stimuli) is the treatment of choice for speci \201 c, uncomp licated phobias. Applied tension can be taught to counter vasovagal response. Cognitive beh avioral techniques taught alongside gradual exposure to feared situation include: \200 \200 \200 Treatment/interventions Psychosexual counseling (individual or couple). Provision of inform ation about common sexual dif \201 culties experienced. Involvement of partner is preferab le. relaxation; breathing retraining; cognitive restructuring and distraction. Nonconcordance Epidemiology Reported medication nonconcordance rates in patients with ESRD are high. Nonconcordance rates of 50% or higher have been reported for different aspects of the HD patient \200\231s treatment regime. Psychosocial factors underlying nonconcordance in PD patients are less well understood. Main areas of nonconcordance: \200 \200 Body image Changes in appearance as a result of certain procedures and dialysis treatment c an have an impact on a patient \200\231s psycho- social functioning and relationships with other people. Body image can in \202 uence psychosocial recovery, adaptation to illness an d quality of life as well as the degree of psycho- logical morbidity in a range of chronic illnesses. \202 uid restriction; medication; CHAPTER 13.7 Psychological aspects of treatment for renal failure 541 \200 dietary advice; continuing/withdrawing from treatment. Psychological interventions which speci \201 cally focus on the management of reported sle ep dif \201 culties are therefore important to consider. Key issues Self-ef \201 cacy, i.e. patients \200\231 understanding of the treatment plan a nd ability to carry it out. Patients \200\231 health-related beliefs and expectations regar ding outcome. Patient choice and involvement in decision-making. Psychological factors, e.g . depression; impact of past or current psychological trauma; anxiety. Concerns over long-t erm effects and dependence on med- ication. Unpleasant side-effects of medication or other aspects of treatment. Nonintentional, e.g. practical dif \201 culties in daily living; for get- ting aspects of treatment regime or information provided. Eating disorders Eating disorders have not been widely reported among patients with ESRD, b ut may be more common than previ- ously thought. It is recommended that patients who presen t with low body weight and vomiting in a renal setting should be care- fully assessed to ex clude an underlying or coexisting eating disorder, such as anorexia or bulimia. Referral to more specialist services Referral to a clinical psychologist May be necessary w hen the patient: \200 responds to illness/hospitalization in a way that is unu- sual or unexpected; refuses to ad here to treatment or health advice; has a phobic response to illness/treatment; has dif \201 culty coping with the demands of the illness/ treatment; holds unusually negative beli efs about illness/treatment; has a level of distress that exceeds capacity of support avail able through the team and threatens to interfere with treatment or would have a negative im pact on health status. \200 \200 Management Agree on treatment goals. Ensure that the patient has an adequate understanding of their condition and treatment regime. Identify any potential barriers to concordance. En sure good communication and patient involvement. Refer for further specialist help if under lying psychological factors have been identi \201 ed and are contributing to non- concorda nt behaviors. \200 Referral to liaison psychiatry May be necessary: \200 Trauma/post-traumatic stress disorder (PTSD) Traumatic experiences (e.g. severe life-threat ening compli- cations, emergency treatments) may give rise to symptoms of PTSD. Past psycho logical trauma may be recalled and impact on a patient \200\231s ability to cope with treat ment. Typical reactions to trauma include: Re-experiencing the traumatic event: \200 \200 \200 if the patient is psychotic, severely depressed, is at a sig- ni \201 cant risk of self-ha rm, or has suicidal ideation; if level of distress is suf \201 cient to require medication (e.g. antidepressants or anxiolytics \200\223 see Royal College of Psychiatrists guidelin es). Further reading Stein A, Wild J. Kidney failure explained. London: Class Publishing; 2007. \202 ashbacks; intrusive memories; distressing dreams and nightmares. White CA. Cognitive behavior therapy for chronic medical problems: a guide to assessment an d treatment in practice. Chichester: Wiley; 2001. Arousal reactions: \200 \200 \200 \200 \200 \200 Internet resources British Association for Behavioral and Cognitive Psychotherapies (BABCP) : sleep disturbance; irritability and/or anger; impaired concentration and memory; hyperalert ness; exaggerated startle response; physiological response such as anxiety and panic attack s. Avoidance (e.g. of situations connected with trauma) and emotional numbing. http://www.babcp.org.uk National Institute for Health and Clinical Excellence (NICE): http://www.nice.org.uk National Institute of Mental Health: http://www.nimh.nih.gov National Phobics Society: Treatment/interventions It is recommended that the following treatments should be provided to people who have been diagnosed with PTSD: \200 \200 http://www.phobics-society.org.uk Royal College of Psychiatrists: trauma-focused CBT; eye movement desensitization and reprocessing (EMDR) therapy. http://www.rcpsych.ac.uk/mentalhealthinforma- tion.aspx Sleep disorders Research has demonstrated that many hemodialysis patients experience a slee p disorder, including delayed sleep onset and/or night-time waking. Restless leg symptoms h ave also been described in patients experiencing insomnia. See also Neuropyschiatric disorders in CKD, p. 454 Sexual disorders in CKD, p. 402 Dialysis strategies, p. 480 This page intentionally left blank 543 Chapter 14 Renal transplantation Chapter contents Selection and preparation of the recipient 544 Assessment of live renal donors 548 Transpla nt surgery and surgical complications 552 Early management of transplant recipients 556 Imm unosuppression for renal transplantation 560 Long-term medical complications of renal trans plantation 566 Recurrent and de novo disease post renal transplantation 572 Outcome of rena l transplantation 576 C. NEWSTEAD 544 Selection and preparation of the recipient Introduction Overall renal transplantation both increases survival and greatly improves the quality of life of recipients. Most ben- e \201 t is seen when the patient is transplante d either just before or shortly after initiating dialysis. Because of the imbalance between the numbers of those who could bene \201 t from renal transplantation and the supply of o rgans it is sensible to exclude potential recipi- ents who can be predicted to have a poor outcome. Recommendations in this chapter are based on guidelines published by the American Society of Transplantation and the American Society of Transplant Surgeons as well as the E uropean Best Practice Guidelines for Renal Transplantation published on behalf of the Europ ean Renal Association \200\223 European Dialysis and Transplant Association. Cancer How long to delay transplantation in a potential recipient who has been previously t reated for cancer and potentially cured is a common clinical issue. The key consideration i s to minimize the risk of relapse of occult metastatic disease which may be accelerated by immunosuppression. Transplant registries have demonstrated that in general recurrence rates of cancer are less the longer the waiting time, with: \200 \200 \200 53% recurring within 2 years; 34% between 2 and 5 years; remaining 13% recurring after 5 ye ars. Because of the survival advantage of transplantation compared to dialysis, a reasonable com promise is to wait 2 years after successful treatment for most cancers prior to transplant listing. Current guidelines are summarized in Table 14.1.1. Cardiovascular disease Cardiovascular disease is the major contributor to prema- ture death in renal transplant recipients. An algorithm for the workup of cardiovascular disease in p otential recipi- ents is shown in Fig. 14.1.1. Breast cancer It is dif \201 cult to know how best to manage patients with treated cancer of the breast as the majority of relapses occur after 3 years. Many cancers are heterogeneo us conditions, with the prognosis depending on staging. Therefore, it is important to adopt an individualized approach to this problem with close consultation with the oncology team. Breast cancer is twice as common in renal transplant recip- ients compared to the general population. Ischemic heart disease Criteria to select asymptomatic patients for further investigation m ay include: \200 \200 \200 \200 age >50 years; diabetes; smoked cigarettes in the past 5 years; resting ECG shows a rhythm disturbance or ST segment abnormalities. Screening for cancer The issue of screening for occult de novo cancer in poten- tial renal transplant recipients is contentious. It is reasona- ble to adopt an individualized approac h with cancer screening based on symptoms, signs or in the presence of conditions known to particularly predispose to cancer. Exercise tests have the most discriminating power but may not be practical due to poor exer cise tolerance. Pharmacologically driven cardiac stress testing is com- monly used as an al ternative. If there is signi \201 cant reversible ischemia, coronary angiog- raphy should be undertaken. If left ventricular function is adequate and symptoms are controlled then tr ansplant listing can be recommended. Gastrointestinal disease The rate of colonic perforation post renal transplantation is 1% and most commonly associated with diverticular disease. Screening of asymptomatic patients is not justi \201 ed, as one study found that none of the patients with signi \201 cant d iver- ticular disease had symptomatic disease post transplanta- tion. Patients with symptom atic disease should undergo imaging and consideration given to resection of extensive disea se. Screening of asymptomatic individuals for peptic ulcer disease is not recommended becau se of the low morbidity rate even in patients with past peptic ulcer disease. How best to m anage incidentally noted cholelithiasis is not straightforward, although a detailed decisio n analysis recommended expectant management as the preferred strategy for kidney transplant recipients with asympto- matic cholelithiasis. Cerebrovascular disease Screening asymptomatic potential renal transplant recipi- ents for cerebrovascular disease is not recommended. Patients with a completed stroke or a transient ischemic attack within the past 6 months should be referred for neu- rological assessment. Transplantation should be reconsid- ered after medical and surgical management has been op timized and the patient free of recurrent transient ischemic attacks for 6 months. Carotid ultrasound screening after the discovery of an asymptomatic bruit is routine but the result s of this and further investigations rarely alter the clinical decision.