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KEY CONCEPTS
Hemodialysis (HD) involves the perfusion of blood and dialysate on opposite sides of a semipermeable membrane. Solutes are removed from the blood by diffusion and convection. Excess plasma water is removed by ultrafiltration.
Native arteriovenous (AV) fistulas are the preferred access for HD because of fewer complications and a longer survival rate. Venous catheters are plagued by complications such as infection and thrombosis and often deliver low blood flow rates.
Adequacy of HD can be assessed by the Kt/V and urea reduction ratio (URR). The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative minimum goal Kt/V is greater than 1.2 per treatment and the URR is greater than 65%.
During HD, patients commonly experience hypotension and cramps. Other more serious complications include infection and thrombosis of the vascular access.
Peritoneal dialysis (PD) involves the instillation of dialysate into the peritoneal cavity via a permanent peritoneal catheter. The peritoneal membrane lines the highly vascularized abdominal viscera and acts as the semipermeable membrane. Solutes are removed from the blood across the peritoneum via diffusion and ultrafiltration. Excess plasma water is removed via ultrafiltration created by osmotic pressure generated by various dextrose or icodextrin concentrations.
Patients on PD are required to instill and drain, manually or via automated systems, several liters of fresh dialysate each day. The more exchanges completed each day results in greater solute removal.
Peritonitis is a common complication of PD. Initial empiric therapy for peritonitis should include intraperitoneal antibiotics that are effective against both gram-positive and gram-negative organisms.
Nasal carriage of Staphylococcus aureus is associated with an increased risk of catheter-related infections and peritonitis. Prophylaxis with intranasal mupirocin (twice a day for 5 days every month) or mupirocin (daily) at the exit site can effectively reduce S. aureus infections.
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The three primary treatment options for patients with end-stage renal disease (ESRD) are hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation. The United States Renal Data System (USRDS) is the national system that “collects, analyzes, and distributes” data relating to patients with ESRD or Stage 5 chronic kidney disease (CKD) in the United States and releases these data yearly.1 According to the 2014 USRDS, at the end of 2012, there were 636,905 patients in the United States with ESRD. Of these, greater than 475,000 patients were being treated with HD or PD, and 186,303 had a functioning kidney transplant. In 2012, 114,813 new patients started therapy for ESRD (dialysis or transplantation) and more than 88,000 patients died. Greater than 90 percent of new dialysis patients are treated with HD. The number of patients treated with PD has decreased steadily since 2000.1
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Since 1972, the cost of treating ESRD (both dialysis and kidney transplantation) has been covered by Medicare. The total cost of ESRD in 2012 was $42.5 million. This includes Medicare costs ($28.6 billion) and Medicare patient obligation costs, which together make up approximately 75% of ...