What is the treatment for patients requiring dialysis?

Treatment Options for Patients Requiring Dialysis

The optimal treatment for patients requiring dialysis should be individualized based on a shared decision-making approach, with home-based dialysis (peritoneal dialysis or home hemodialysis) considered as the first-line option whenever feasible due to better quality of life and potential early survival benefits. 1

Types of Dialysis Modalities

Hemodialysis (HD)

• In-center hemodialysis (ICH): Typically performed three times weekly for 3-5 hours per session 2
• Home hemodialysis (HHD): Can be performed more frequently (5+ sessions/week) or for longer durations (≥5.5 hours/session) 2
• Frequent hemodialysis options:
  • Short frequent HD: 5+ sessions/week, <3 hours/session 2
  • Long HD: ≥5.5 hours/session, 3-4 times/week 2
  • Long-frequent HD: ≥5.5 hours/session, 5+ sessions/week 2

Peritoneal Dialysis (PD)

• Continuous Ambulatory Peritoneal Dialysis (CAPD)
• Automated Peritoneal Dialysis (APD) with cyclers for overnight exchanges 1

Dialysis Prescription Guidelines

Hemodialysis Adequacy

• Target single pool Kt/V (spKt/V): 1.4 per session for thrice-weekly HD, with minimum delivered spKt/V of 1.2 2
• For non-thrice weekly schedules: Target standard Kt/V of 2.3 volumes per week (minimum 2.1) 2
• For patients with significant residual kidney function: Dialysis dose may be reduced if residual function is measured periodically 2

Peritoneal Dialysis Adequacy

• Initial prescription: Based on patient's weight, residual kidney function, and lifestyle constraints 2
• Adjustment: Total solute clearance will be monitored and prescription adjusted as residual kidney function or peritoneal transport changes 2
• Volume considerations: Most patients will need to increase instilled volume over time, and approximately 85% of APD patients will need one or more daytime dwells 2

Patient Selection and Modality Choice

Factors to Consider in Modality Selection

1. Patient preference and lifestyle considerations 2
2. Medical conditions and comorbidities 2
3. Residual kidney function (PD better preserves residual function) 3
4. Geographic distance from HD center 1
5. Home support system 1
6. Vascular access options 2

Specific Patient Considerations

• Patients awaiting transplantation: PD may be preferable as it better preserves residual kidney function 3
• Patients with significant residual function: May benefit from PD initially 3
• Patients with cardiovascular instability: Home or longer/more frequent HD may reduce intradialytic hypotension 2
• Pregnant women: Long frequent hemodialysis recommended 2

Initiation of Dialysis

When to Start Dialysis

• Decision should be based primarily on:
  • Signs/symptoms of uremia
  • Evidence of protein-energy wasting
  • Inability to safely manage metabolic abnormalities or volume overload with medical therapy
  • Not solely on a specific level of kidney function 2

Preparation for Dialysis

1. Patient education: All patients with CKD stage 4 should receive education about kidney failure treatment options 2, 4
2. Access placement: Plan for vascular access (HD) or PD catheter placement ideally 10-14 days before starting PD 2
3. Baseline assessment: Obtain 24-hour urine collection for urea and creatinine clearance to assess residual kidney function 2

Monitoring and Adjusting Treatment

Monitoring Parameters

• Hemodialysis: Regular assessment of Kt/V, ultrafiltration rate, and blood pressure control 2
• Peritoneal Dialysis: Monitor total solute clearance, peritoneal transport characteristics, and ultrafiltration 2
• Both modalities: Regular assessment of:
  • Anemia (consider epoetin alfa when hemoglobin <10 g/dL) 5
  • Mineral metabolism (phosphorus, calcium, PTH) 4
  • Nutritional status 2
  • Residual kidney function 2

Anemia Management

• Evaluate iron status in all patients before and during treatment 5
• Target hemoglobin: Avoid levels >11 g/dL due to increased cardiovascular risks 5
• Starting dose for adults with CKD on dialysis: 50-100 Units/kg three times weekly 5
• Monitoring: Check hemoglobin weekly until stable, then monthly 5

Special Considerations

Time-Limited Trials

• Consider offering a time-limited trial of dialysis for patients with uncertain prognosis or when consensus about providing dialysis cannot be reached 2
• Reassess goals of care after the trial period 2

Transitioning Between Modalities

• PD to HD transition: Consider when signs of under-dialysis develop after a few years of PD as residual kidney function declines 3
• Modality changes: Should be anticipated and planned for as part of the overall treatment strategy 2

Withdrawal Considerations

Appropriate Circumstances for Withdrawal

• Patient with decision-making capacity who refuses dialysis 2
• Patient without decision-making capacity who previously indicated refusal in advance directive 2
• Patient with irreversible, profound neurologic impairment 2
• Patient with terminal illness from non-renal cause 2

Palliative Care

• All patients who forego dialysis should receive continued palliative care 2
• Consider hospice involvement for managing medical, psychosocial, and spiritual aspects of end-of-life care 2

Common Pitfalls to Avoid

1. Inadequate pre-dialysis education: Many patients are not educated about all modality options, particularly PD, before beginning dialysis 6
2. Over-reliance on central venous catheters: Associated with increased infection risk and mortality 6
3. Delayed referral for transplantation evaluation: Should be considered early when appropriate 4
4. Failure to adjust dialysis prescription: As residual kidney function declines, dialysis prescription needs adjustment 2, 3
5. Neglecting quality of life considerations: Home-based therapies often provide better quality of life 1

By following these guidelines and considering the individual patient's circumstances, clinicians can optimize the treatment approach for patients requiring dialysis, with the goal of improving survival, reducing complications, and enhancing quality of life.