From the Guidelines
Indications for Hemodialysis in Chronic Kidney Disease
Hemodialysis (HD) is indicated in patients with End-Stage Renal Disease (ESRD), which is the final stage of Chronic Kidney Disease (CKD), where the kidneys have lost nearly all their ability to do their job effectively, and as a result, the body accumulates wastes, excess water, and other toxins [ 1 ].
Common Complications of Dialysis
Common complications of dialysis include thrombosis, infection, and vascular access dysfunction, which can lead to access failure and increased healthcare expenditure [ 1 ]. The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for ESRD patients.
Vascular Access Types and Recommendations
The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend Arteriovenous Fistulas (AVF) as the preferred vascular access for hemodialysis due to increased patency rates and decreased risk of infection and thrombosis when compared to Arteriovenous Grafts (AVG) and Central Venous Catheters (CVC) [ 1 ].
Monitoring and Surveillance
To preempt adverse outcomes and identify lesions with the vascular access before they provoke complications, the KDOQI guidelines suggest monitoring and surveillance of the vascular access, including physical examination, noninvasive device-based methods, and diagnostic imaging [ 1 ].
Importance of Quality of Dialysis
The quality of dialysis is directly dependent on the integrity and reliability of the access to the patient's vascular system, and optimal hemodialysis vascular access is one that provides reliable, complication-free access [ 1 ].
Initiating Dialysis
The decision to initiate dialysis should be based on the individual patient's needs and clinical presentation, and starting dialysis earlier does not necessarily improve patient outcomes [ 1 ]. The KDOQI clinical practice guideline for hemodialysis adequacy provides guidance on the initiation of dialysis and the management of patients with ESRD [ 1 ].
From the Research
Indications for Hemodialysis in Chronic Kidney Disease
- The decision to initiate hemodialysis is based on patient-clinician shared decision-making, taking into account signs and symptoms of uremia, volume overload, worsening estimated glomerular filtration rate (eGFR), metabolic acidosis, and hyperkalemia 2
- There is no recommended eGFR threshold for initiating dialysis, and the timing of therapy initiation should be individualized 2
- Persistent signs and symptoms of uremia and volume overload, such as nausea, fatigue, dyspnea, and peripheral edema, inform the timing of therapy initiation 2
Common Complications of Dialysis
- Cardiovascular complications, such as arrhythmias and cardiac arrest, are common in patients undergoing maintenance dialysis 2
- Infection-related complications, including hemodialysis catheter-related bloodstream infections and peritonitis, are also common 2
- Other complications of dialysis include hypotension, refractory symptoms, and malfunction of dialysis access 2
- Intradialytic hypotension (IDH) and long recovery time after a dialysis session are common complications of hemodialysis, and can be reduced with intensive hemodialysis 3
Hemodialysis Frequency and Duration
- More frequent and longer hemodialysis sessions, also known as extended hemodialysis, may improve blood pressure management and quality of life in end-stage renal disease patients 4
- Intensive hemodialysis, including short daily and nocturnal schedules, can reduce the likelihood of IDH and decrease recovery time after dialysis 3
- However, the evidence for the benefits of more frequent and longer hemodialysis sessions is limited, and further studies are needed to fully understand the effects of different dialysis regimens on patient outcomes 5, 3, 4