True Statements About End-Stage Kidney Disease (ESKD)

Diabetes is the leading cause of ESKD requiring renal replacement therapy worldwide. 1

Etiology of ESKD

Diabetes has become the leading cause of CKD and is responsible for approximately half of all cases of ESKD worldwide 1
In the United States, diabetes accounts for 47% of patients who began ESKD treatment, followed by hypertension at 29% 2
The prevalence of diabetes in ESKD patients ranges from 66% to 86% depending on age and race/ethnicity 1
Diabetes is more prevalent in ESKD than in earlier CKD stages because it may co-occur with other causes of CKD or develop after ESKD, particularly in kidney transplant recipients 1

Cardiovascular disease is the most common cause of morbidity and mortality in ESKD patients, not infections 3, 4
Treatment of ESKD by hemodialysis is associated with poor long-term survival, with an adjusted survival after 3 and 5 years of hemodialysis initiation of only 55% and 40%, respectively 1
Patients with diabetes have the worst adjusted-survival rates among the ESKD population 1
Hypertension is extremely common in advanced CKD, with prevalence approaching 80% in those with stage 4 CKD 1

Peritonitis is indeed a major complication of peritoneal dialysis 1
Peritoneal dialysis solutions containing glucose can interfere with glucose monitoring devices, particularly those using glucose dehydrogenase-based–pyrroloquinoline-quinone/glucose oxidase–based glucose meters 1
Hypoglycemia is a common acute complication of hemodialysis, not acute myocardial infarction (AMI) 1

Patients with diabetes on hemodialysis commonly experience hypoglycemic episodes that require adjustment or discontinuation of insulin and oral antihyperglycemic agents 1
Several mechanisms contribute to hypoglycemia during hemodialysis: 1
1. Decreased gluconeogenesis and impaired insulin clearance by the kidney
2. Reduced insulin degradation due to uremia
3. Increased erythrocyte glucose uptake during hemodialysis
4. Impaired counterregulatory hormone responses
5. Nutritional deprivation
6. Variability of exposure to antihyperglycemic agents

Kidney transplantation typically yields the best patient outcomes compared to dialysis, with data showing 70% reduced mortality among patients with ESKD who underwent transplantation compared to non-transplanted counterparts 1, 3
Insulin is the preferred treatment for patients with ESKD and diabetes mellitus requiring medication 3
Patients should be monitored for signs of protein-energy wasting and malnutrition 3
Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through 26 years of age), and Streptococcus pneumoniae is advised for ESKD patients 3

The decision to initiate dialysis should be made through shared decision-making, considering life expectancy, risks and benefits of each dialysis modality, quality of life, and patient preferences 3, 5
A palliative approach to ESKD is a reasonable alternative to dialysis, particularly for individuals with limited life expectancy, severe comorbid conditions, or those who wish to avoid medical interventions 3
Frailty is more common in elderly patients with CKD than without and is associated with poor outcomes 5