Dialysis may be required for the treatment of either acute or chronic kidney disease. The use of continuous renal replacement therapies (CRRTs) and slow low-efficiency dialysis (SLED) is specific to the management of acute renal failure and is discussed in Chap. 334. These modalities are performed continuously (CRRT) or over 6–12 h per session (SLED), in contrast to the 3–4 h of an intermittent hemodialysis session. Advantages and disadvantages of CRRT and SLED are discussed in Chap. 334.
Peritoneal dialysis is rarely used in developed countries for the treatment of acute renal failure because of the increased risk of infection and (as will be discussed in more detail below) less efficient clearance per unit of time. The focus of this chapter will be on the use of peritoneal and hemodialysis for end-stage renal disease (ESRD).
With the widespread availability of dialysis, the lives of hundreds of thousands of patients with ESRD have been prolonged. In the United States alone, there are now approximately 615,000 patients with ESRD, the vast majority of whom require dialysis. The incidence rate for ESRD is 357 cases per million population per year. The incidence of ESRD is disproportionately higher in African Americans (940 per million population per year) as compared with white Americans (280 per million population per year). In the United States, the leading cause of ESRD is diabetes mellitus, currently accounting for nearly 45% of newly diagnosed cases of ESRD. Approximately 30% of patients have ESRD that has been attributed to hypertension, although it is unclear whether in these cases hypertension is the cause or a consequence of vascular disease or other unknown causes of kidney failure. Other prevalent causes of ESRD include glomerulonephritis, polycystic kidney disease, and obstructive uropathy.
Globally, mortality rates for patients with ESRD are lowest in Europe and Japan but very high in the developing world because of the limited availability of dialysis. In the United States, the mortality rate of patients on dialysis has decreased slightly but remains extremely high, with a 5-year survival rate of approximately 35–40%. Deaths are due mainly to cardiovascular diseases and infections (approximately 40 and 10% of deaths, respectively). Older age, male sex, nonblack race, diabetes mellitus, malnutrition, and underlying heart disease are important predictors of death.
TREATMENT OPTIONS FOR ESRD PATIENTS
Commonly accepted criteria for initiating patients on maintenance dialysis include the presence of uremic symptoms, the presence of hyperkalemia unresponsive to conservative measures, persistent extracellular volume expansion despite diuretic therapy, acidosis refractory to medical therapy, a bleeding diathesis, and a creatinine clearance or estimated glomerular filtration rate (GFR) below 10 mL/min per 1.73 m2 (see Chap. 335 for estimating equations). Timely referral to a nephrologist for advanced planning and creation of a dialysis access, education about ESRD treatment options, and management of the complications of advanced chronic kidney disease (CKD), including hypertension, ...