What is permanent renal replacement therapy for patients with end-stage renal disease (ESRD)?

Definition of Permanent Renal Replacement Therapy

Permanent renal replacement therapy refers to long-term dialysis or kidney transplantation required when kidney function has irreversibly failed and can no longer sustain life without intervention. 1

Core Definition

Permanent renal replacement therapy (RRT) encompasses the following modalities for patients with kidney failure (GFR <15 mL/min per 1.73 m²):

• Chronic hemodialysis - typically performed three times weekly at a dialysis center through vascular access 2, 3
• Chronic peritoneal dialysis - performed at home with regular exchanges of dialysis fluid 4, 2
• Kidney transplantation - the preferred definitive treatment offering superior survival and quality of life 5, 2

The term "permanent" distinguishes this from temporary or acute kidney replacement therapy used for reversible acute kidney injury. 1

Modern Nomenclature Considerations

The KDIGO 2020 consensus strongly recommends avoiding the term "end-stage renal disease" (ESRD) in clinical practice. 1 The rationale includes:

• The term "end-stage" is poorly defined and inconsistently used outside administrative contexts 1
• It misleadingly implies imminent death despite patients surviving years with treatment 1
• It carries stigma and does not apply to patients with kidney failure who choose not to receive treatment 1

The preferred terminology is "kidney failure" with specification of treatment status (treated by dialysis, treated by transplantation, or untreated). 1

Clinical Threshold for Initiation

Permanent RRT should be initiated based on clinical symptoms of uremia rather than GFR alone, typically when one or more of the following are present: 5

• Uremic symptoms (nausea, vomiting, cognitive impairment, pruritus) 5, 4
• Fluid overload unresponsive to medical management 5
• Severe metabolic acidosis or hyperkalemia refractory to treatment 2, 3
• Protein-energy wasting despite nutritional intervention 3

While GFR typically falls between 5-10 mL/min/1.73 m² at dialysis initiation, symptoms should drive the decision, not the number alone. 5

Treatment Modality Selection

Kidney transplantation should be considered the preferred treatment option, as it offers superior outcomes in mortality and quality of life compared to dialysis. 5, 2 Living donor preemptive kidney transplantation should be considered when GFR falls below 20 mL/min/1.73 m² with evidence of progressive and irreversible chronic kidney disease. 5

For dialysis modalities, no significant differences in long-term mortality exist between hemodialysis and peritoneal dialysis. 2, 6 The choice should be based on:

• Patient preference and lifestyle considerations 7, 2
• Vascular access feasibility for hemodialysis 2, 3
• Home environment suitability for peritoneal dialysis 4, 6
• Comorbid conditions and functional status 6

Conservative Management Alternative

Conservative management without dialysis is an appropriate option for patients who choose not to pursue RRT, particularly those with: 5

• Age ≥75 years with multiple comorbidities 5
• Significant frailty or functional impairment 5
• Cognitive impairment 5
• Limited life expectancy 5, 3

This approach focuses on symptom management and palliative care rather than life-prolonging interventions. 3

Critical Pitfalls to Avoid

• Do not initiate dialysis based solely on GFR level without uremic symptoms present 5
• Do not offer only one dialysis modality without discussing all options including transplantation and conservative management 5
• Do not preserve peripheral veins inadequately in patients with stage III-V chronic kidney disease who may require future hemodialysis access 3
• Do not delay nephrology referral for patients at risk of kidney failure, as early multidisciplinary management improves outcomes 5, 3