end-stage renal disease (ESRD)

Introduction

Advanced renal disease (GFR < 8-10 mL/min) requiring dialysis.

Also see chronic renal failure & chronic renal failure stage 5.

* Kidney Failure Risk Equation (KFRE) estimates 2 year risk of ESRD in patients with chronic renal failure.

Etiology

• chronic glomerulonephritis (33%)
• chronic tubulointerstitial disease (21%)
• polycystic kidney disease (10%)
• diabetes mellitus (20%)
• hypertension
  • blacks (33%)
  • whites (10%)
• analgesics (5%)
• familial (5%)
• obesity is risk
• idiopathic (5%)

Epidemiology

• > 250,000 patients in USA 1995; > 726,000 in 2019
• ~ 100,000 are on a transplant waiting list
• 20% of traditional Medicare dollars are spent on kidney disease
• black patients, Mexican & Native Americans with 3 to 4-fold increase relative to whites

Clinical manifestations

• symptoms of uremia
  • fatigue, nausea, loss of appetite
  • isomnia, irritability, difficulty concentrating, confusion
  • pruritus
• signs of uremia
  • pleuritis, pericarditis

Laboratory

• hemoglobin A1c values may not be reliable
  • uremia may increase hemoglobin A1c in some assays
  • diminished half-life of erythrocytes & increased erythropoiesis due to erythropoiesis-stimulating agents may diminish hemoglobin A1c
• measure post-prandial serum glucose to resolve discrepancy between hemoglobin A1c & preprandial or fasting serum glucose

Radiology

• abdominal CT
  • kidney size is often preserved in:
    • diabetes mellitus
    • amyloidosis
    • myeloma
    • polycystic kidney disease

Complications

• major causes of morbidity & mortality
  • sepsis
  • pneumonia
  • access infection (intravascular catheter-related infection)
• complications of common associated disorders
  • ischemic heart disease
    • 70% rate of restenosis within 6 months of angioplasty in patients on dialysis
  • cardiomyopathy
  • left ventricular hypertrophy due to hypertension
  • anemia
• acquired cystic kidney disease
  • increased risk for renal cell carcinoma
• calciphylaxis
• depression
• comorbidities that impair quality of life
  • pruritus
  • sleep disorders
    • restless legs syndrome
    • obstructive sleep apnea

* 7 item, 19-point risk score for 6-month mortality

• age 80 years or older (2 points)
• glomerular filtration rate of 10-14.9 mL/min/1.73m2 when dialysis initiated (3 points)
• atrial fibrillation (2 points)
• congestive heart failure (2 points)
• metastatic cancer (3 points)
• lymphoma (5 points)
• hospitalization within the past 6 months (2 points)

• disease interaction(s) of heart failure with ESRD

Management

• hemodialysis
  • early initiation of hemodialysis is associated with increased mortality
  • elderly with multiple comorbidities are best managed medically
    • elderly patients with comorbidities may live as long or longer without attempting hemodialysis
    • nephrologists often reluctant to offer conservative therapy to elderly
  • refusal of dialysis
    • associated with 60-80% 1 year mortality
    • functional status tends to be stable until the final month of life, when a steep decline in function occurs
    • offer hospice services
  • the start of hemodialysis is associated with a substantial & sustained decline in functional status
  • daily nocturnal hemodialysis seemed to work well in 1 elderly patient
  • maintain central venous patency in patients who may need hemodialysis
    • avoid central venous catheters including PICC lines if possible
      • central venous stenosis most commonly occurs from endothelial damage from central venous catheters
    • use peripheral venous access if possible
    • use hands for venipuncture & peripheral venous access if possible
    • use internal jugular vein for antibiotic therapy of weeks duration
• peritoneal dialysis, outcomes equivalent to hemodialysis
• management of electrolyte disturbances
  • hyperkalemia
  • hyperphosphatemia
  • do not use magnesium-containing antacids
• management of pain
  • hydromorphone is a good choice of opiate
  • see pain management in palliative care
• dietary protein 1.2-1.3 g/kg/day if on dialysis
• treat anemia of chronic renal failure
• anticoagulation for venous thromboembolism with apixaban is associated with less major bleeding & similar recurrence as warfarin
• renal transplantation
  • referral for renal transplantation without delay
    • risk of renal graft loss & overall mortality increase with length of dialysis prior to transplant
    • superior quality of life for renal transplantation
    • lower health care costs for renal transplantation
  • survival advantage of cadaveric renal transplantation over dialysis, most significant for diabetic patients
  • preemptive renal transplantation before dialysis & transplantation shortly after initiation of dialysis associated with patient & allograft survival advantage
• prophylaxis
  • control of risk factors, diabetes mellitus & hypertension
  • ACE inhibitors & ARBs may offer some advantage
• palliative care is a reasonable option for older patients with multiple comorbidities

More general terms

• chronic renal failure (CRF)

Additional terms

• hemodialysis
• peritoneal dialysis; continuous abdominal/ambulatory (cycling) peritoneal dialysis (CAPD, CCPD)
• renal transplantation

Patient information

end stage renal disease patient information