What is the treatment for kidney failure?

Treatment of Kidney Failure

Kidney replacement therapy (KRT) is the definitive treatment for kidney failure, with options including kidney transplantation, hemodialysis (in-center or home), peritoneal dialysis, or conservative management without dialysis. 1

Patient Education and Preparation

• Timely education must begin at CKD stage 4 (eGFR < 30 mL/min/1.73 m²) about all treatment options including transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative treatment 1
• Family members and caregivers should receive concurrent education about treatment choices 1
• Early education improves outcomes and reduces costs by allowing appropriate timing of dialysis initiation with permanent access already in place 1

Timing of Kidney Replacement Therapy Initiation

Nephrologists should evaluate benefits, risks, and disadvantages of beginning KRT when patients reach stage 5 CKD (eGFR < 15 mL/min/1.73 m²) 1

Specific indications for earlier initiation include:

• Uremic symptoms (malnutrition, fluid overload, bleeding, serositis, depression, cognitive impairment, peripheral neuropathy, infertility, increased infection susceptibility) 1
• BUN > 100 mg/dL with altered mental status requires urgent hemodialysis 2
• Rapidly deteriorating neurological status with elevated ammonia levels 2
• Inability to maintain acid-base, electrolyte, and fluid balance 3

GFR estimation for decision-making:

• Use validated estimating equations or measurement of creatinine and urea clearances—not simply serum creatinine and urea nitrogen alone 1
• Approximately 98% of patients with kidney failure in the United States begin dialysis when GFR is < 15 mL/min/1.73 m² 1

Treatment Modalities

Kidney Transplantation

• Typically yields the best patient outcomes and should be prioritized when feasible 4
• Evaluation for transplantation should occur early in the disease course 2

Hemodialysis

• Most patients with end-stage renal disease elect hemodialysis 4
• Preserve peripheral veins in patients with stage III-V CKD to maintain future vascular access options 4
• Urgent hemodialysis is first-line for severe uremic symptoms with BUN of 100 and altered mental status 2
• For severe hyperammonemia, consider high-dose continuous kidney replacement therapy (CKRT) with blood flow rate 30-50 mL/min 2

Peritoneal Dialysis

• Home-based option that provides continuous therapy 1
• Requires patient education and ability to perform exchanges 1

Conservative Management

• A reasonable alternative to dialysis, particularly for patients with limited life expectancy, severe comorbid conditions, or who wish to avoid medical interventions 1, 4
• Palliative approach focuses on maximizing quality of life and length of life 1
• Includes low-protein diets, keto-analogs of essential amino acids, loop diuretics, and sodium polystyrene sulfonate 1
• Nephrologists should be familiar with palliative care principles and hospice referral 1

Monitoring During Acute Treatment

When initiating dialysis for acute uremic complications:

• Serial BUN and ammonia measurements every 2-4 hours during initial treatment 2
• Monitor electrolytes, particularly potassium, calcium, and phosphorus 2
• Assess for uremic encephalopathy and neurological status 2

Multidisciplinary Long-Term Management

Essential components:

• Referral to nephrology for ongoing CKD stage 4 management 2
• Evaluation for permanent dialysis access 2
• Patient education about different dialysis modalities and transplantation options 2
• Dietary counseling and management of CKD complications 2

Blood pressure control:

• Controlling blood pressure in patients receiving dialysis improves mortality 4
• Volume control through adequate dialysis and sodium restriction optimizes hypertension treatment 4

Diabetes management:

• Insulin is the preferred treatment for patients with kidney failure and diabetes mellitus requiring medication 4

Nutritional monitoring:

• Monitor for signs of protein-energy wasting and malnutrition 4

Vaccinations:

• Seasonal influenza, tetanus, hepatitis B, human papillomavirus (through age 26), and Streptococcus pneumoniae 4

Special Considerations in Advanced Heart Failure

For patients with concomitant advanced heart failure and kidney dysfunction:

• Early identification of kidney dysfunction is crucial for timely interventions 1
• Optimization of congestion and guideline-directed medical therapy may stabilize kidney function 1
• Quantify extent of irreversible intrinsic kidney disease to predict recovery potential 1

Common Pitfall

The decision to initiate dialysis remains informed by clinical judgment, not solely by GFR thresholds—social and psychological factors, symptom burden, and patient preferences must be weighed against physiological benefits of solute clearance and volume control 1