ESRD: Dialysis

CKD complications

dialysis indications

early v late initiation of dialysis

ESRD prevalence

-prevalence of ESRD increased over 30 years (all modalities)

-since 2019 prevalence and incidence counts decreased slightly (COVID-related)

-815,896 patients with ESRD in 2022

ESRD incidence

goals of dialysis

-eliminate nitrogenous waste products

-maintain euvolemia

-control acid base and electrolyte balance

-maintain large proteins and blood in circulation

-additional ESRD treatments: stimulation of erythropoiesis, vitamin D metabolism

hemodialysis membrane

hemodialysis process

hemodialysis principles

creating dialysate

treatment complications

-allergy to membrane or circuit

-infection from “sterile water”

-hemolysis from contaminants, trauma, temp, osmolarity

-decreased bp from removing blood and plasma

-electrolyte shifts

vascular access for hemodialysis- type, description, benefit, drawback

vascular access epidemiology

in-center hemodialysis (iHD)

-sessions generally 3x/week at center

-done by dialysis nurse or tech

-high dialysate flows (500-800ml/min) → fast solute removal

-limited weekly dialysis time (average 10.5hrs) → more sx during and after iHD

-travel and wait-times can be burdensome

home hemodialysis (HHD)

-same principles as iHD including access, however a smaller HD machine is brought into the home

-patients trained to do their own dialysis (usually lasts 4-6 weeks)

-to minimize dialysate use, dialysate flows are slower, and blood and dialysate almost completely equilibrate

-slower dialysate flows necessitate more frequent dialysis to get adequate clearance (4-5x/week)

-more frequency HD → decreased symptoms

peritoneal dialysis

PD membrane

PD diffusion and convection

comparing dialysis modalities- type, benefit, drawback (iHD, HHD, PD)

measuring adequacy

conservative kidney management

good candidates for CKM

->/= 1 life-shortening comorbidity

-frailty with significant preexisting functional or cognitive impairment

-reside in long-term care facility

-severe pain or suffering

-cognitive impairment that impairs safe dialysis delivery

-in patients >/= 80, dialysis may not confer a survival advantage

other advantages of CKM

approaching ESRD preparation

-multidisciplinary team- patient navigator, clinical nurse specialist or a NP with expertise in modality education, nutritionist, social worker, nephrologist, palliative care

-discuss pros and cons of each modality- very few absolute contraindications to home dialysis

-education through multimodal means (written, audio, video)

-use decision guides and electronic tools for prognostication

-facility tours and simulation (digital or high fidelity)

dialysis complications

ESRD complications- mortality

causes of death and hospitalization

elevated CV risk

independent CV risk factor

mortality and CV risk- inflammation

morbidity- infection

factors affecting morbidity and mortality

long interdialytic interval and mortality

volume overload and mortality

intervention- more frequent dialysis

intervention- dietary modification

dialysis complications- poor QOL

-HrQOL for patients on dialysis is significantly worse than the general population and among the worst of any chronic illness

-PCS/MCS are on average 33/46 in US patients on dialysis- both are significantly lower than norms for the general population (~50)

-scores are worse for patients with limited use of arm(s) and/or leg(s), depression, chronic lung disease, CHF, arthritis, cancer, diabetes, angina, hypertension

what leads to poor QOL on dialysis?

-depression

-burdens of self-care: dietary restrictions, medications, comorbid conditions, HD treatment

-symptoms: itching, cramping, fatigue, sexual dysfunction, sleep disorders

depression in ESRD

symptoms in hemodialysis

improving QOL- depression

exercise and QOL

benefits of transplant