From the Guidelines
When conventional dialysis is no longer viable for patients with end-stage renal disease (ESRD), the primary last resort option is kidney transplantation, as it offers the best long-term survival and quality of life, providing complete replacement of kidney function through either living or deceased donor organs 1.
Last Resort Options for ESRD
The decision to pursue kidney transplantation should be based on the patient's overall health status, personal preferences, quality of life considerations, and discussions with healthcare providers and family members about realistic outcomes and goals of care.
- Kidney transplantation requires meeting eligibility criteria, including adequate cardiovascular health and absence of active infections or malignancies.
- For patients ineligible for transplantation, palliative dialysis may be considered, which focuses on symptom management rather than extending life, often involving reduced frequency or duration of treatments.
- Conservative management without dialysis is another option, emphasizing symptom control through medications like furosemide for fluid overload, sodium polystyrene sulfonate for hyperkalemia, and phosphate binders for hyperphosphatemia.
Considerations for Last Resort Options
The choice between these options should take into account the patient's prognosis, quality of life, and personal values, as well as the availability of resources and support systems 1.
- Estimating prognosis and discussing life expectancy and quality of life with the patient or legal agent is crucial in making informed decisions about starting or withdrawing dialysis.
- Comprehensive palliative care addressing pain, nausea, pruritus, and psychological support should be included in the management plan, regardless of the chosen option.
Prioritizing Patient-Centered Care
Ultimately, the decision between these last resort options should prioritize the patient's well-being, autonomy, and quality of life, while also considering the clinical evidence and guidelines available 1.
- Healthcare providers should engage in open and honest discussions with patients and their families about the potential benefits and drawbacks of each option.
- Patient-centered care should be the guiding principle in making decisions about last resort options for ESRD, taking into account the individual's unique needs, values, and circumstances.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Last Resort Options for End-Stage Renal Disease (ESRD) Patients
When conventional dialysis is no longer viable for patients with ESRD, several last resort options can be considered. These options include:
- Peritoneal Dialysis (PD): PD is a type of dialysis that uses the patient's peritoneum in their abdomen as a membrane across which fluids and dissolved substances (electrolytes, urea, glucose, albumin, and other small molecules) are exchanged from the blood. Studies have shown that PD can be a viable option for ESRD patients, especially those with hereditary clotting disorders 2.
- Hemodialysis (HD): HD is a type of dialysis that uses a machine to filter the blood outside the body. While HD can be effective, it may not be suitable for all patients, especially those with certain medical conditions or those who have experienced complications with HD 3, 4.
- Short Daily Hemodialysis or Daily Home Nocturnal Hemodialysis: These alternative forms of HD have been shown to improve quality of life and control blood pressure and anemia in ESRD patients 5.
- Hemofiltration Techniques, Sorbents, and the Renal Tubular Assist Device: These emerging technologies may also provide last resort options for ESRD patients, although further research is needed to confirm their effectiveness 5.
Considerations for Last Resort Options
When considering last resort options for ESRD patients, several factors should be taken into account, including:
- Patient motivation and desire: The patient's motivation and desire to undergo a particular type of dialysis can play a significant role in determining the most suitable option 3.
- Geographic distance from a dialysis unit: The distance between the patient's home and a dialysis unit can impact the feasibility of certain types of dialysis, such as HD 3.
- Patient education and support: Educating patients about the different types of dialysis and providing ongoing support can help them adapt to their chosen option and improve their quality of life 6.
- Cost and reimbursement: The cost of dialysis and reimbursement policies can also influence the choice of last resort option for ESRD patients 3, 4.