Kidney failure, defined by GFR of less than 15 mL per minute/1.73 m² can be treated with kidney transplant, hemodialysis, peritoneal dialysis or supportive care.
More than 3.5 million people with chronic kidney failure, worldwide receive maintenance dialysis, with 90% receiving hemodialysis.
Replaces about 5-15% of kidney function depending on the intensity and frequency of its use.
Helps to restore fluid and electrolyte balance when kidneys fail.
More than 97% of the approximate 125,000 patients who developed ESRD annually in the US receive dialysis.
Each year as many as 120,000 individuals transition from the advanced non-dialysis dependent chronic kidney disease to maintenance dialysis in the US.
Approximately 520,000 Americans undergo long-term dialysis.
The majority of patients initiating dialysis are men (women:men ratio 4:6).
This male predominance is attributed to men’s biological predisposition to faster rate of chronic kidney disease progression, and gender.
At age 60 years, a healthy person can expect to live for more than 20 years, whereas the life expectancy of a patient aged 60 years who is starting hemodialysis is closer to 4 years.
Initiation of dialysis has been progressively done at higher levels estimated kidney function with the average serum creatinine concentration decreasing from 8.7 mg/dL to 6.3 mg/dL, from 1995-2007.
In 2014 the US average eGFR at initiation was 10.2 mlper minute per 1.73 m².
Initiation of chronic dialysis in 2007 moved up almost 5 months earlier compared those patients who had initiated dialysis in 1997.
Most studies reveal that higher mortality rates exist when dialysis is started earlier in the course of CKD or at a higher estimated GFR:a randomized study of 828 patients to early hemodialysis with a GFR 10 to 14 mL per minute per 1.73 m² versus late hemodialysis with an estimated GFR of 5 to 7 mL per minute/1.73 m² reported no difference in mortality after a median follow up of 3.6 years.
Severe hyperkalemia, and or metabolic acidosis can lead to life-threatening arrhythmias and, if refractory to medical management may necessitate dialysis.
Uremic signs and symptoms and laboratory trajectories can inform dialysis initiation decision making.
There is no specific threshold of estimated GFR or other laboratory values, such as potassium, bicarbonate, phosphorus, at which dialysis should be initiated.
Trends in dialysis show a marked increase in the number of patients older than 75 years who initiate dialysis early, at an estimated GFR of 10 mL/min per 1.73 m2 or higher.
Among elderly patients who initiated dialysis, the proportion who had early initiation increased from 25% in 1996 to 64% in 2009 (US Renal Data System).
Newly started patients have highest mortality within the first few months.
Over treatment of patients whose lives might not be extended by dialysis include the frail, elderly patients and those with multiple coexisting conditions.
Early initiation of dialysis in elderly patients may have little likelihood of long-term survival or improvement in quality of life (Ghavamian M et al).
Dialysis with drawl is among the leading causes of dialysis associated deaths.
At every age, patients with ESRD on dialysis have significantly increased mortality when compared with nondialysis patients and individuals without kidney disease.
No evidence that dialysis improves nutrition, and in fact it may worsen nutritional parameters.
Predialysis low serum albumin is associated with a poor outcome among dialysis patients.
Does not restore kidney endocrine functions so patients may require erythropoeitin and vitamin D.
Hemodialysis most common maintenance dialysis with approximately 90% on this type of program.
Utilizes a semi-permeable membrane as the artificial kidney.
Peritoneal dialysis uses the patient’s own peritoneum or lining of the intestines as the artificial kidney.
7% of patients are on peritoneal dialysis.
Retrospective studies do not show survival benefit with early initiation of dialysis and some studies show delaying the process may improve survival (Traynor JP, Stel VS).
No randomized, controlled trials have shown improved mortality in dialysis patients who were treated with phosphate binders, activated vitamin D, or cinacalcet to manage moderate to severe hyperparathyroidism.
The evidence for the benefits and risks of correcting metabolic acidosis is very limited, with dialysis.
In patients receiving hemodialysis, who are at risk for hyperkalemia after a long interdialytic, interval hyperkalemia is associated with an increased risk of major cardiovascular events and mortality.
The 5-year survival rate for a patient undergoing long-term dialysis in the United States is approximately 35%, and approximately 25% in patients with diabetes.
The most common cause of death overall in the dialysis population is cardiovascular disease; cardiovascular mortality is 10-20 times higher in dialysis patients than in the general population.
The morbidity and mortality of dialysis patients is much higher in the United States than in most other countries.
Estimated GFR is a calculation based on serum creatinine concentration, and whether derived by the Modification of Diet in Renal Disease equation or the Cockcroft-Gault equation may be inaccurate when kidney function is extremely impaired: a low creatinine may be a reflection of decrease muscle mass or overhydration.
Current recommendations is that renal replacement therapy is initiated based on clinical factors rather than the numerical criteria such as an estimated GFR (Fritsch A).
Peritoneal dialysis significantly less expensive than hemodialysis, but progressively fewer patients are starting on peritoneal dialysis.
Removes solutes and waste products via the process of diffusion, whereby molecules move across a semi-permeable membrane from areas of higher to areas of lower concentration.
By the process of diffusion electrolyte and acid base balance are normalized.
Continuous veno-venous hemofiltration requires blood to circulate out of the body through an artificial kidney and then is returned to the patient, as with hemodialysis, but runs 24 hours a day and is used primarily in an ICU setting with acute kidney injury.
Continuous veno-venous hemofiltration works by convection or solute drag.
In continuous veno-venous filtration fluid is squeezed out of the blood dragging electrolytes and toxins, and fresh fluids with appropriate electrolytes are added to the patient’s blood.
Continuous veno-venous hemofiltration can be added to hemodialysis and is known as continuous veno-venous hemodiafiltration.
Approximately 98% of patients with kidney failure begin dialysis when their GFR is less than 15 mL/min per 1.73 m2.
Presently treatment guidelines recommend that dialysis be initiated when GFR falls below 10.5 mills per minute per be 1.73 m².
In a study of variation to the time of initiation of maintenance dialysis for patients with stage V chronic kidney disease in Australia and New Zealand, the early initiation was not associated with an improvement in survival or clinical outcomes (Cooper BA).
In the above study the median time to the initiation of dialysis was 1.8 months in the early start group and 7.4 months in the delayed start group: no significant difference between the groups in the frequency of cardiovascular events, infections, or complications of dialysis occurred (Initiation Dialysis Early and Late (IDEAL).
The prevalence of long-term dialysis is increasing, partly as a result of the early initiation of dialysis in the natural history of chronic kidney disease.
In the Initiating Dialysis Early and Late (IDEAL) trial adults with stage 5 chronic kidney disease and GFR of 10-15 mils per minute per 1.73 m² were randomly assigned to early start at a GFR of 10-14 mils per minute or a late start at GFR 5-7 mils per minute: there was no difference in survival or in the frequency of adverse events between the two groups ( Cooper BA et al).
The IDEAL study suggests that the initiation of dialysis can be delayed for some patients until the GFR drops below 7 mL/minute or until clinical indicators are present.
The National Kidney Foundation recommends that dialysis be initiated with an estimated GFR of less than 15 mL per minute, and it should be initiated if the GFR is higher than 15 mL per minute, when coexisting symptoms of uremia are present.
The Canadian Society of Nephrology recommends the initiation of dialysis when the estimated GFR is less than 12 mL per minute, and can be deferred, if there is no evidence of malnutrition or uremia.
The US Renal Data indicated that 45% of patients had a GFR greater than 10 mL per minuteat the initiation of dialysis.
The IDEAL trial indicated that delaying dialysis until the appearance of symptoms does no harm to patients.
The IDEAL trial suggested early initiation of dialysis did not improve survival and it did not improve quality of life.
Malnutrition at the time of dialysis initiation is strongly associated with poor survival on dialysis, and protein intake often falls as chronic kidney disease progresses, possibly leading to under nutrition.
Low albumin and prealbumin levels rank among the best predictors of mortality risk in hemodialysis patients.
Malnutrition may not be reversible despite initiation of dialysis.
Cardiovascular disease causes 50% of deaths among patients on dialysis.
The higher morbidity and mortality rate in thevUS compared to Europe, is probably a consequence of selection bias, as US patients receiving dialysis are on the average older and sicker than those in other countries.
Increased cardiovascular disease may be due to high burden of risk factors before and after dialysis, exposure to vascular overload, chronic inflammatory changes, elevated phosphate levels, which may worsen left ventricular structure and function promoting blood vessel disease.
Likelihood of developing de novo CHF in the first year after starting dialysis is about 80%.
Appears that the risk of mortality was elevated in patients with ESRD and congestive heart failure who received peritoneal dialysis compared with those who received hemodialysis.
Median survival time was 20.4 months in patients receiving peritoneal dialysis versus 36.7 months in the hemodialysis group for patients with CHF.
About 35% of elderly patients discontinue dialysis.
More frequent dialysis episodes than 3/week increases risk of vascular access problems.
Mortality rates for dialysis patients sustaining an myocardial infarction are 59% and 90% at one and 5 years, respectively.
Dialysis-5 year survival for hemodialysis and peritoneal dialysis from 1995-1999 was under 35%.
Mortality then tends to improve over the next 6 months, before increasing gradually over the next 4 years.
The 5-year survival rate for a patient undergoing long-term dialysis in the United States is approximately 35%, and approximately 25% in patients with diabetes.
Median life expectancy of hemodialysis and peritoneal dialysis was 38.4 and 36.6 months, respectively (US Renal Data System).
Patients who received renal transplants have a 68% lower mortality rate in patients eligible for transplant who continue to receive hemodialysis.
Obesity as measured by body mass index in patients with chronic kidney disease and those undergoing dialysis provides a survival benefit.
The prevalence of atrial fibrillation among dialysis patients is as high as 11.6%.
At the time of initiation of dialysis 78% of patients have hypertension, 23% have coronary artery disease, 15% have congestive heart failure and 8% have arrhythmias.
Approximately 75% of patients receiving dialysis had left ventricular hypertrophy as documented by ultrasound (Foley RN).
High serum creatinine levels is a surrogate measurement of muscle mass, and not of residual renal function in dialysis patients, but it is related to better survival.
Annual mortality of dialysis patients is the U.S. is about 22%.
It is suspected that protein-energy wasting is a cause of the extreme high mortality in dialysis patients.
On average patients are hospitalized two times per year.
One year mortality rate for patients on hemodialysis ranges from 20-25%.
2-year mortality about 16% for children aged 0 to 4 years, about 6% for 5 to 9 year-olds, greater than 7% for 10-14 year-olds, and 5.75% for 15 to 19 year-olds.
There is an increase in 5-year mortality in patients who receive less than 6 months of predialysis nephrologic care (41%) versus those who received more than 72 months of predialysis care by a nephrologist (23%).
Higher cholesterol levels associated with lowered mortality in dialysis patients.
Lower cholesterol in patients on dialysis is secondary to systemic inflammation and malnutrition.
It is routine to administer HBV vaccine to all dialysis patients.
Initiated when the symptoms, particularly anorexia and lethargy, are prominent and at the time when treatment is expected to relieve such symptoms.
Initiation of dialysis usually when the GFR is about 7% of normal, and conventional dialysis only slightly provides better removal of many solutes but is inferior in its removal of some.
In a study of 3702 nursing home patients that started dialysis at three months, 39% maintain their functional status, and by 12 months 58% of patients died and three dialysis functional status was maintained in only 13% of patients (Tamura).
In 1999 nursing home residents accounted for 4% of all new patients with end-stage renal disease and 11% of new patients were older than 70 years of age ( Collins , A J).
Mortality in the first year after initiation of dialysis is greater than 34% in patients older than 70, and is more than 50% among patients older than 80 years of age ( Collins AJ).
Patients frequently have “residual syndrome” (Depner) with partially treated uremia manifested by
illness from extracellular fluid volume fluctuations, exposure to bioincompatible materials , inorganic ion abnormalities, acidosis, hyperphosphatemia with complications of systemic diseases and advanced age responsible for the loss of renal function.
Eptifibatide, a platelet glycoprotein IIb/IIIa inhibitor, is renally cleared and its use is contraindicated with dialysis because of increased bleeding risk.
Enoxaparin, a low molecular weight heparin that is renally cleared, is not recommended for use in dialysis patients because of increased risk of bleeding complications.
Nonrenally cleared drugs abciximab and unfractionated heparin are available antithrombotic agents to be used with dialysis.
Blacks are overrepresented in the end-stage renal disease population.
More than 500,000 people with end-stage real disease in the US, approximately 1/3 are black, and the relative incidence of end-stage renal disease is 3.6 times higher among black than white individuals.
Blacks with chronic kidney disease are less likely to be under the care of a nephrologist, have a referral for peritoneal dialysis or kidney transplantation.
Black patients are less likely to receive adequate dialysis dosing, to have a fistula placed, to achieve target hemoglobin levels.
Black patients survive longer than white patients on dialysis, with a 13-45% lower mortality.
The overall survival advantage for black patients on dialysis applies only to older adults, while those younger than 50 years have a higher risk of death (Kucirka LM et al).
Among patients on dialysis at for-profit facilities compared with nonprofit facilities, there is a lower likelihood of accessing kidney transplant (Gander JC).