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end-stage renal disease (ESRD)

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: 1) chronic glomerulonephritis (33%) 2) chronic tubulointerstitial disease (21%) 3) polycystic kidney disease (10%) 4) diabetes mellitus (20%) 5) hypertension a) blacks (33%) b) whites (10%) 6) analgesics (5%) 7) familial (5%) 8) obesity is risk [4] 9) idiopathic (5%) Epidemiology: 1) > 250,000 patients in USA 1995; > 726,000 in 2019 [17] 2) ~ 100,000 are on a transplant waiting list 3) 20% of traditional Medicare dollars are spent on kidney disease [17] 4) 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 [2] - signs of uremia - pleuritis, pericarditis [2] 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 [2] Radiology: - abdominal CT - kidney size is often preserved in: - diabetes mellitus - amyloidosis - myeloma - polycystic kidney disease Complications: 1) major causes of morbidity & mortality a) sepsis b) pneumonia c) access infection (intravascular catheter-related infection) 2) complications of common associated disorders a) ischemic heart disease - 70% rate of restenosis within 6 months of angioplasty in patients on dialysis b) cardiomyopathy c) left ventricular hypertrophy due to hypertension d) anemia 3) acquired cystic kidney disease [2] - increased risk for renal cell carcinoma [2] 4) calciphylaxis 5) depression 6) 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 [14] - 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) Management: 1) hemodialysis a) early initiation of hemodialysis is associated with increased mortality [6,9,16] b) elderly with multiple comorbidities are best managed medically [20] - elderly patients with comorbidities may live as long or longer without attempting hemodialysis [2,15] - nephrologists often reluctant to offer conservative therapy to elderly [17] c) refusal of dialysis 1] associated with 60-80% 1 year mortality [7] 2] functional status tends to be stable until the final month of life, when a steep decline in function occurs 3] offer hospice services [2] d) the start of hemodialysis is associated with a substantial & sustained decline in functional status [10] e) daily nocturnal hemodialysis seemed to work well in 1 elderly patient [11] f) maintain central venous patency in patients who may need hemodialysis [2,12] - avoid central venous catheters including PICC lines if possible [2,13] - central venous stenosis most commonly occurs from endothelial damage from central venous catheters - use peripheral venous access if possible [2,12] - use hands for venipuncture & peripheral venous access if possible [2] - use internal jugular vein for antibiotic therapy of weeks duration [2] 2) peritoneal dialysis, outcomes equivalent to hemodialysis [2] 3) management of electrolyte disturbances a) hyperkalemia b) hyperphosphatemia c) do not use magnesium-containing antacids [2] 4) management of pain - hydromorphone is a good choice of opiate - see pain management in palliative care 4) dietary protein 1.2-1.3 g/kg/day if on dialysis [2] 5) treat anemia of chronic renal failure [8] 6) anticoagulation for venous thromboembolism with apixaban is associated with less major bleeding & similar recurrence as warfarin [19] 7) renal transplantation a) referral for renal transplantation without delay [2] - risk of renal graft loss & overall mortality increase with length of dialysis prior to transplant [2] - superior quality of life for renal transplantation [2] - lower health care costs for renal transplantation [2] b) survival advantage of cadaveric renal transplantation over dialysis [2], most significant for diabetic patients c) preemptive renal transplantation before dialysis & transplantation shortly after initiation of dialysis associated with patient & allograft survival advantage 8) prophylaxis a) control of risk factors, diabetes mellitus & hypertension b) ACE inhibitors & ARBs may offer some advantage [3] 9) palliative care is a reasonable option for older patients with multiple comorbidities [2]

Interactions

disease interactions

Related

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

General

chronic renal failure (CRF)

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 616-17
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16. 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Casas JP, Chua W, Loukogeorgakis S, Vallance P, Smeeth L, Hingorani AD, MacAllister RJ. Effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis. Lancet. 2005 Dec 10;366(9502):2026-33. Review. PMID: 16338452
  4. Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Ann Intern Med. 2006 Jan 3;144(1):21-8. Summary for patients in: Ann Intern Med. 2006 Jan 3;144(1):I28. PMID: 16389251
  5. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Dialysis for Kidney Patients https://www.niddk.nih.gov/health-information/healthy-moments/episodes/dialysis-kidney-patients
  6. Clark WF et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ 2011 Jan 11; 183:47 PMID: 21135082
  7. Murtagh FE. End-stage renal disease: a new trajectory of functional decline in the last year of life. J Am Geriatr Soc 2011; 59(2):304-308. PMID: 21275929
  8. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  9. Cooper BA, Branley P, Bulfone L et al A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19 PMID: 20581422
  10. Kurella Tamura M, Covinsky KE, Chertow GM et al Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009 Oct 15;361(16):1539-47. PMID: 19828531
  11. Cornelis T, Kotanko P, Goffin E et al Can intensive hemodialysis prevent loss of functionality in the elderly ESRD patient? Semin Dial. 2011 Nov-Dec;24(6):645-52. PMID: 22122593
  12. Hoggard J, Saad T, Schon D et al Guidelines for venous access in patients with chronic kidney disease. A Position Statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008 Mar-Apr;21(2):186-91 PMID: 18364015
  13. El Ters M, Schears GJ, Taler SJ et al Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients. Am J Kidney Dis. 2012 Oct;60(4):601-8. PMID: 22704142 Free PMC Article
  14. Wick JP et al. A clinical risk prediction tool for 6-month mortality after dialysis initiation among older adults. Am J Kidney Dis 2017 May; 69:568 PMID: 27856091
  15. Grubbs V, Tuot DS, Powe NR, O'Donoghue D, Chesla CA. System-level barriers and facilitators for foregoing or withdrawing dialysis: A qualitative study of nephrologists in the United States and England. Am J Kidney Dis 2017 Nov; 70:602 PMID: 28242134 http://www.ajkd.org/article/S0272-6386(17)30116-6/fulltext
  16. Kurella Tamura M, Thomas IC, Montez-Rath ME, et al Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs. JAMA Intern Med. Published online April 9, 2018. PMID: 29630695 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2677061 - Chen Z, Hsu C. Appropriate Time for Chronic Dialysis Initiation. A Cause for Humility. JAMA Intern Med. Published online April 9, 2018 PMID: 29630690 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2677057
  17. Ladin K, Pandya R, Kannam A et al. Discussing conservative management with older patients with CKD: An interview study of nephrologists. Am J Kidney Dis 2018 May; 71:627. PMID: 29396240
  18. Verberne WR, Geers AB, Jellema WT et al Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis. Clin J Am Soc Nephrol. 2016 Apr 7;11(4):633-40. PMID: 26988748 Free PMC Article
  19. Ellenbogen MI et al. Safety and effectiveness of apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease: A national cohort study. J Hosp Med 2022 Oct; 17:809 PMID: 359295 https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12926
  20. NEJM Knowledge+ Nephrology/Urology
  21. Davison NS Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol 2019 14(6):917-931 PMID: 30833302 PMCID: PMC6556722 Free PMC article
  22. Owsiany MT, Hawley CE, Triantafylidis LK, Paik JM. Opioid Management in Older Adults with Chronic Kidney Disease: A Review. Am J Med. 2019 Dec;132(12):1386-1393. PMID: 31295441 PMCID: PMC6917891 Free PMC article. Review.