What is kidney dialysis (Renal Replacement Therapy)?

From the Guidelines

Kidney dialysis should be initiated when the benefits of solute clearance and extracellular fluid volume control outweigh the physical risks and psychosocial toll of therapy, considering the patient's overall quality of life and clinical condition. When considering kidney dialysis, it is crucial to weigh the risks and benefits, especially in older and more fragile patients, as all forms of kidney replacement therapy entail important trade-offs 1. The decision to start dialysis is complex and involves clinical judgment, taking into account the patient's physiological benefits, physical risks, and psychosocial factors. Some key points to consider in the management of patients with kidney failure include:

• The use of dietary and pharmacological therapy to minimize uremic symptoms and maintain volume homeostasis, such as low-protein diets, keto-analogs of essential amino acids, loop diuretics, and sodium polystyrene sulfonate 1.
• The importance of maximizing quality of life and length of life for patients who choose conservative therapy without dialysis or transplantation.
• Familiarity with the principles of palliative care and consideration of hospice referral for patients with advanced kidney failure 1. In terms of the types of dialysis, there are two main options: hemodialysis and peritoneal dialysis, each with its own schedule and requirements. For patients undergoing dialysis, medications such as erythropoietin stimulating agents, phosphate binders, and vitamin D supplements may be prescribed to manage related conditions. Additionally, patients must adhere to a strict renal diet and fluid restriction to manage their condition effectively. Ultimately, the goal of kidney dialysis is to prevent the accumulation of waste products in the blood, which can lead to severe complications if left untreated.

From the Research

Kidney Dialysis Overview

• Kidney dialysis is a treatment for individuals with end-stage renal disease (ESRD) or chronic kidney failure, where the kidneys are no longer able to filter waste and excess fluids from the blood 2.
• There are two main types of dialysis: hemodialysis and peritoneal dialysis, both of which remove metabolic waste and excess body water and rebalance electrolytes to sustain life 2.

Initiating Dialysis

• The decision to initiate dialysis is complex and influenced by many factors, including ESKD-related symptoms and signs, patient preferences, and therapy cost and availability 3.
• Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study 3.
• The latest guidelines place greater emphasis on the assessment of patients' symptoms and signs rather than eGFR, suggesting that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2 if there is careful clinical follow-up and adequate patient education 3.

Comparison of Dialysis Modalities

• Urgent-start peritoneal dialysis (PD) may reduce the incidence of catheter-related bacteraemia compared with hemodialysis (HD) initiated with a central venous catheter (CVC) 4.
• However, the effects of urgent-start PD on other complications of dialysis, such as peritonitis, exit-site/tunnel infection, and patient survival, are uncertain due to the low certainty of evidence 4.
• A retrospective cohort study found that patients initiating dialysis therapy due to volume overload may have increased risk for mortality compared with patients initiating dialysis due to laboratory evidence of kidney function decline 5.

Mortality and Survival

• The 5-year survival rate after initiation of maintenance dialysis is approximately 40%, with similar mortality rates for hemodialysis and peritoneal dialysis 2.
• A study found that the adjusted difference in estimated survival time after 3 years on dialysis treatment was 2.5 months in favor of timely starters, although the average delay in dialysis initiation for late starters was at least 4.1 months 6.
• Another study reported that initiation of dialysis therapy for uremic symptoms, volume overload or hypertension, or other/unknown reasons was associated with a higher risk for subsequent mortality compared to initiation for laboratory evidence of kidney function decline 5.