Chronic Kidney Disease Programs (Diagnosis and Intervention)
Patients with disease within the kidney itself, in particular with blood (hematuria) and protein (albuminuria or proteinuria) in the urine, require a careful work-up as many of such diseases are chronic. Proper treatment may abolish the disease completely or reduce the disease activity, thus slowing down the progression of Chronic Kidney Disease (CKD). Special blood tests are sometimes needed, and a kidney biopsy is often required to make the diagnosis.
Renal nutrition programme
We are what we eat! Proper nutrition is the key essential step for managing CKD and End-Stage Kidney Disease (ESKD). A good diet is essential to reduce the burden of other diseases associated with kidney disease, such as hypertension, diabetes, and early atherosclerotic disease (heart attacks and strokes).
Patients with CKD and patients opting for conservative management may attempt the Very-Low Protein Diet with essential keto-amino acid supplementation programme, coupled with regular follow-ups with the dietitian.
In pre-dialysis ESKD patients and patients who are already on dialysis, good nutrition is needed to prevent complications, in particular infections, and muscle wasting. Regular assessment using tools such as bioimpedance spectroscopy, blood test for nutrition markers (albumin and pre-albumin), and body measurements will help clinicians in prescribing the most appropriate diet and supplements.
There are many causes of hypertension (high blood pressure), which is a disease multiplier. Hypertension increases the risk of rapid progression of kidney disease, strokes, and heart attacks. Patients with poorly controlled hypertension will undergo a careful evaluation of the likely cause of their resistant hypertension. Strict residual risk is abolished by tracking goals using a variety of monitoring methods, including 24-hour ambulatory blood pressure monitoring, home blood pressure monitoring, and bioimpedance spectroscopy (for blood volume assessment).
Patients suspected of a specific treatable cause of hypertension may be referred for specific therapy, such as surgery, renal denervation, renal artery angioplasty, amongst others.
Patients with ESKD who are no longer able to undergo dialysis or are developing symptoms while on a conservative treatment programme will be enrolled into a palliative care programme, where the goals of management are to reduce symptoms and discomfort. These patients and their next-of-kin will be referred to specialist doctors and nurses in palliative care.
Palliative care may be performed at home whereby healthcare professionals will make regular home visits, or where appropriate, patients are admitted to a hospice.
End-Stage Kidney Disease Programs (CKD G5)
Chronic maintenance haemodialysis
Patients who are unsuitable for, or can no longer undergo peritoneal dialysis, are placed on haemodialysis. Patients undergo a minor surgery to connect a vein to an artery and create an arterio-venous fistula (AVF). Once the AVF is mature, the needles can be inserted for dialysis to take place. Blood is removed and passed through a machine for processing (removing waste and excess water), and finally returned to the patient. There are several formats of undergoing haemodialysis. Where suitable, patients can perform home haemodialysis (short daily dialysis or nocturnal dialysis). More often, patients travel to an outpatient dialysis centre three times a week, and undergo dialysis for about five hours each time.
Peritoneal dialysis
The initial kidney dialysis therapy for ESKD is Peritoneal Dialysis (PD), unless there are medical reasons not to do so. In the life-cycle of ESKD, PD is started to take advantage of the remaining very low kidney function (residual kidney function). This allows a patient to start with low doses of PD, and to increase the intensity of treatment as the CKD G5 progresses in severity.
Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD) are offered. Patients and their caregivers are trained to perform PD at home or at convenient places. The PD programme is run by a team of nephrologists, renal dietitians, and specialist nurses. Regular follow-up, surveillance testing, and dietary counselling provide holistic care to PD patients to minimise avoidable complications of ESKD.
Kidney Transplantation
Kidney transplantation is the initial preferred option for ESKD, and can be performed for suitable patients even without embarking on dialysis (pre-emptive transplantation). Kidney transplantation offers the best clinical outcomes for ESKD. Patients are evaluated for their suitability for transplantation, and potential donors are assessed for suitability to donate. Singapore citizens may be placed on the National Deceased Donor kidney transplantation programme. Because of the long wait-time for deceased donor kidneys, where suitable and available, all ESKD patients are encouraged to undergo living (related or unrelated) kidney transplantation. A team of nephrologists, kidney transplant surgeons, transplant coordinators, and nurses provide long-term integrated care, and coordinates the pre- and post-transplant care of transplant patients and donors.
Diagnostic and Interventional Nephrology
Kidney biopsy
Kidney ultrasound
Peritoneal dialysis catheter insertion
Haemodialysis catheter (tunnelled and non-tunnelled) insertion
Vascular access ultrasonography
Vascular access endovascular intervention
