ESRD

Question 1

end-stage renal disease (ESRD) - defined

Answer 1

*TREATED stage V CKD (GFR < 15)
*once they are on renal replacement therapy (RRT): includes patients on dialysis (HD and PD) and patients with a kidney transplant

Question 2

inherited risk for ESRD

Answer 2

*APOL1 gene (kidney failure progression gene)
*more common in those with recent African ancestry

Question 3

transition from CKD stage V to ESRD

Answer 3

*usually start renal replacement therapy once:
1. GFR less than 15 mL/min (stage V CKD)
AND
2. another compelling factor:
-uremia
-metabolic derangements (hyperkalemia, metabolic acidosis, hyperphosphatemia)
-volume overload that cannot be managed with diuretics

Question 4

risks and benefits of starting renal replacement therapy (RRT)

Answer 4

*comorbid conditions - dialysis does not cure disease
*functional status - frailty, dementia; these pts do worse on dialysis
*consider surgical and immunosuppression risks in potential transplant patients
*is conservative care without RRT more appropriate?

Question 5

renal replacement therapy (RRT) - 3 options

Answer 5

1. peritoneal dialysis (PD)
2. hemodialysis (HD)
3. kidney transplant

Question 6

goal of dialysis (HD and PD)

Answer 6

*replace as many native kidney functions as possible: filter blood (remove solutes), balance electrolytes, regulate volume and fluid

*dialysis is pretty good at:
-clearance of small molecules (urea)
-remove excess fluid (ultrafiltration)
-correct metabolic acidosis
-maintain electrolyte concentrations

*fairly good at: middle molecule clearance
*cannot replace endocrine functions of kidney (like endogenous EPO production)

Question 7

the physics of hemodialysis

Answer 7

*bring blood and diasylate into close contact with a semipermeable membrane
*urea, creatinine, and potassium filter OUT OF BLOOD
*calcium and glucose filter INTO the blood
*based on a CONCENTRATION gradient (removal of small molecules) and a PRESSURE gradient (removal of fluid)
*blood is returned into the patient

Question 8

hemodialysis (HD)

Answer 8

*semipermeable membrane = the dialysis filter
*need ability to get high blood flow rates through the access to the dialyzer
*options for access site:
1. arterialized venous flow:
-natural AV fistula (AVF) - preferred
-AV graft
2. central dialysis catheters (permacaths and vas-caths)

Question 9

peritoneal dialysis (PD)

Answer 9

*semipermeable membrane = the patient’s peritoneal membrane
*diffusion down concentration gradient, across peritoneal membrane, into dialysate
*oncotic gradient from glucose provides ultrafiltration (fluid removal) and convective clearance
*sterile PD fluids are repeatedly instilled, then after a dwell are drained from peritoneal cavity

Question 10

exclusions for kidney transplant

Answer 10

*severe CVD
*malignancy within past 2 years
*active infection
*morbid obesity
*poor functional status
*uncontrolled psychiatric disease
*active substance abuse

Question 11

modality of choice for RRT

Answer 11

*for patients who meet eligibility criteria, renal transplant is the modality of choice for treatment of patients with ESRD
*transplant recipients have significantly lowered risk of mortality compared to dialysis

Question 12

conservative care for ESRD

Answer 12

*interventions to slow rate of native kidney function decline
*dietary counseling to minimize hyperkalemia
*diuretics to manage volume overload
*correct anemia to manage fatigue
*phosphate binders to minimize symptoms of hyperphosphatemia
*referral to hospice if indicated
*symptom management to maximize comfort