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{{CMG}}
{{CMG}}{{AE}}{{SMP}}
{{Dialysis}}
==Overview==
 
 
[[Chronic renal failure|Chronic kidney disease]] (CKD) prevalence has an increased rate worldwide due to increased prevalence of [[diabetes mellitus]] and [[hypertension]] as the leading causes of [[Chronic renal failure|CKD]], increasing [[life expectancy]], and [[Ageing|aging]] of the populations. On the other hand, [[acute kidney injury]] requires renal replacement therapy in certain circumstances. Dialysis is an intervention aiming to substitutes for solutes and removing extra fluids to help or substitute the failing [[Kidney|kidneys]]. It is considered as a renal replacement therapy method which is indicated in certain condition depending on severity and chronicity of the underlying condition. In acute setting, refractory increased electrolytes and fluid overload are the most common indications for dialysis. [[eGFR]] is the determining factor to initiate dialysis in [[Chronic renal failure|chronic kidney disease]] however, [[Uremia|uremic]] symptoms, presence of comorbidities, and nutritional status are important factors influencing nephrologist's judgement to consider early versus late dialysis. In 2010, it is estimated that 2.3-7.1 million patients died of [[Chronic renal failure|end stage renal disease]] (ESRD) without having access to dialysis. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030.<ref name="pmid25777665">{{cite journal |vauthors=Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, Zhao MH, Lv J, Garg AX, Knight J, Rodgers A, Gallagher M, Kotwal S, Cass A, Perkovic V |title=Worldwide access to treatment for end-stage kidney disease: a systematic review |journal=Lancet |volume=385 |issue=9981 |pages=1975–82 |date=May 2015 |pmid=25777665 |doi=10.1016/S0140-6736(14)61601-9 |url=}}</ref> Timely initiating dialysis could save lives, prevent complications, and decrease comorbidities. Patients should be educated about the process and goals of this method of treatment.
 
==Classification==
There are two main types of dialysis, [[hemodialysis]] and [[peritoneal dialysis]]. The mode of dialysis should be selected based on patients preference, chronicity of disease, underlying disease, comorbidities, and availability of the modality.


==Overview==
[[Image:Hemodialysismachine.jpg|thumb|A hemodialysis machine]]
In [[medicine]], '''dialysis''' is primarily used to provide an artificial replacement for lost [[kidney]] function ([[renal replacement therapy]]) due to [[renal failure]]. Dialysis may be used for very sick patients who have suddenly but temporarily, lost their kidney function ([[acute renal failure]]) or for quite stable patients who have permanently lost their kidney function ([[end stage renal failure]]). When healthy, the kidneys maintain the body's internal equilibrium  of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate) and the kidneys remove from the blood the daily metabolic load of fixed hydrogen ions. The kidneys also function as a part of the endocrine system producing [[erythropoietin]] and 1,25-dihydroxycholecalciferol ([[calcitriol]]). Dialysis treatments imperfectly replace some of these functions through the [[diffusion]] (waste removal) and [[convection]] (fluid removal). Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney.<ref>http://www.kidneyatlas.org/book5/adk5-01.ccc.QXD.pdf Atlas of Diseases of the Kidney, Volume 5, Principles of Dialysis: Diffusion, Convection, and Dialysis Machines</ref>


== History ==
Many have played a role in developing dialysis as a practical treatment for renal failure, starting with [[Thomas Graham (chemist)|Thomas Graham]] of Glasgow, who first presented the principles of solute transport across a semipermeable membrane in 1854.<ref>http://links.jstor.org/sici?sici=0261-0523(1854)144%3C177%3ATBLOOF%3E2.0.CO%3B2-E Graham T. The Bakerian lecture: on osmotic force. Philosophical Transactions of the Royal Society in London. 1854;144:177–228.</Ref> The  artificial kidney was first developed by [[John Jacob Abel|Abel]], Rountree and Turner in 1913,<ref>http://books.google.com/books?id=KMcCAAAAYAAJ&dq=&pg=PA51&ots=UM7CVprPEW&sig=Xpnf-kEJTYO7iFSxhdSoC2Ujh3Y&prev Abel, J. J., Rountree, L. G., and Turner, B. B. The removal of diffusible substances from the circulating blood by means of dialysis. Tn. Assoc. Am. Phys., 28:51, 1913.</ref> the first Peritoneal Dialysis was by Georg Ganter (1923),<ref>http://www.ispd.org/history/genesis.php3 Ganter, G. About the elimination of poisonous substances from the blood by dialysis. Munch Med Wchnschr v 70:1478-1480, 1923</ref>the first hemodialysis in a human being was by [[Georg Haas|Hass]] (February 28, 1924)<ref>http://www.uniklinikum-giessen.de/med3/history/haas/2001-Dial-Transpl.pdf Georg Haas (1886–1971): The Forgotten
Hemodialysis Pioneer</ref> and the artificial kidney was develop a into clinically useful apparatus by [[Willem Johan Kolff|Kolff]] in 1943 - 1945.<ref>http://jasn.asnjournals.org/cgi/reprint/8/12/1959 Kolff, W. J., and Berk, H. T. J. Artificial kidney, dialyzer with great area. Geneesk. gids., 21:1944.</ref> This research showed that life could be prolonged in patients dying of [[renal failure]]. Yet, the technical problems associated with blood access or access to the peritoneum made dialysis limited to patients with acute renal failure until 1960 (though a chronic renal failure patient was treated in 1956 with peritoneal dialysis<ref>http://www.multi-med.com/pdigifs/Volume5/vol5-1/27pioneer05no1.pdf Pioneers in peritoneal dialysis McBride, Patrich</ref>). In 1960 work on subcutaneous arteriovenous shunt (a plastic tube connected to an artery and a vein) by [[Belding H. Scribner|Scribner]] and Quinton made hemodialysis available as a treatment for people with chronic renal failure.<ref>http://kidney.niddk.nih.gov/about/Research_Updates/win00-01/contrib.htm NIDDK Contributions to Dialysis</ref>.


==Principle==
{{Family tree/start}}
Dialysis works on the principles of the [[diffusion]] and osmosis of solutes and fluid across a [[semipermeable membrane]]. Blood flows by one side of a semipermeable membrane, and a dialysate or fluid flows by the opposite side. Smaller solutes and fluid pass through the membrane. The blood flows in one direction and the dialysate flows in the opposite.  The concentrations of undesired solutes (for example [[potassium]], [[calcium]], and urea) are high in the blood, but low or absent in the dialysis solution and constant replacement of the dialysate ensures that the concentration of undesired solutes is kept low on this side of the membrane.  The dialysis solution has levels of minerals like potassium and calcium that are similar to their natural concentration in healthy blood. For another solute, [[bicarbonate]], dialysis solution level is set at a slightly higher level than in normal blood, to encourage diffusion of [[bicarbonate]] into the blood, to neutralise the [[metabolic acidosis]] that is often present in these patients.
{{Family tree | | | | | | | | | | | | | | | | A01| | | |A01= Dialysis}}
{{Family tree | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|.| | }}
{{Family tree | | | | | | | | | C01 | | | | | | | | | | | | | | | C02 |C01= Peritoneal dialysis| C02= Hemodialysis}}
{{Family tree | | | |,|-|-|-|-|-|+|-|-|-|-|-|.|}}
{{Family tree | | | D01 | | | | D02 | | | | D03 |D01=Continuous ambulatory <br>peritoneal dialysis (CAPD) | D02=Continuous cyclic <br>peritoneal dialysis (CCPD)| D03=Intermittent<br> peritoneal dialysis (IPD)|}}
{{Family tree/end}}


==Types==
==Indications==
There are two main types of dialysis, [[hemodialysis]] and [[peritoneal dialysis]].
The decision to initiate dialysis or hemofiltration in patients with [[renal failure]] can depend on several factors. The following factors are the most important aspects that nephrologists consider in every patient individually to initiate dialysis.
===Hemodialysis===
[[Image:Hemodialysis schematic.gif|thumb|Hemodialysis schematic]]
{{main|hemodialysis}} <!-- these should not be erased -->
In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer, exposing it to a semipermeable membrane. The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane.  This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer.  This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows removal of several litres of excess salt and water during a typical 3 to 4 hour treatment. 
Hemodialysis treatments are typically given three times per week, but more frequent sessions, which are usually 2 to 3 hours in duration given 5 or 6 times per week can be sometimes prescribed.  Hemodialysis treatments can be given either as an [[outpatient]] or as [[home hemodialysis]].
<!-- If you want to add more info about hemodialysis please do this in the hemodialysis article. The above is meant to be just a short summary. -->


===Peritoneal dialysis===
=== Uremic Symptoms ===
{{main|peritoneal dialysis}}
The following table describe the uremic symptoms and signs according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines.<ref name="pmid26498415">{{cite journal |vauthors=Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ |title=Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline |journal=Am. J. Kidney Dis. |volume=66 |issue=5 |pages=823–36 |date=November 2015 |pmid=26498415 |doi=10.1053/j.ajkd.2014.11.031 |url=}}</ref><ref name="pmid26498416">{{cite journal |vauthors= |title=KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update |journal=Am. J. Kidney Dis. |volume=66 |issue=5 |pages=884–930 |date=November 2015 |pmid=26498416 |doi=10.1053/j.ajkd.2015.07.015 |url=}}</ref>
In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube into the [[peritoneum|peritoneal cavity]], the [[abdomen|abdominal]] body cavity around the [[intestine]], where the peritoneal membrane acts as a semipermeable membrane. The dialysate is left there for a period of time to absorb waste products, and then it is drained out through the tube and discarded. This cycle or "exchange" is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system). Ultrafiltration occurs via [[osmosis]]; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate.  As a result, more fluid is drained than was instilled. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis.  Peritoneal dialysis is carried out at home by the patient and it requires motivation.  Although support is helpful, it is not essential.  It does free patients from the routine of having to go to a dialysis clinic on a fixed schedule multiple times per week, and it can be done while travelling with a minimum of specialized equipment.
<br>
<!-- If you want to add more info about peritoneal dialysis please do this in the peritoneal dialysis article. The above is meant to be just a short summary. -->
{| align="center"
|-
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Uremia manifestations
|-
! align="center" style="background:#4479BA; color: #FFFFFF;" |Symptoms
! align="center" style="background:#4479BA; color: #FFFFFF;" |Signs
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Fatigue]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Seizure]]/change in seizure threshold
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Lethargy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Amenorrhea]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Confusion]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Reduced core body temperature
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Anorexia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Protein-energy wasting
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Alteration in smelling and tasting senses
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Insulin resistance]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Cramp|Cramps]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Heightened [[catabolism]]
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Restless legs syndrome|Restless legs]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Serositis ([[Pleurisy|pleuritis]], [[pericarditis]])
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Sleep disorder|Sleep disturbances]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hiccup|Hiccups]]
|-
| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[Itch|Pruritus]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Platelet]] dysfunction
|-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Somnolence]]
|}
|}


===Hemofiltration===
=== Nutritional Status ===
{{main|hemofiltration}}
[[Nutrition|Nutritional]] status of CKD patients should be assessed frequently. Many factors could be considered as indicator, such as normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), assessment of body composition by bioelectrical impedance analysis (BIA), lean body mass, and serum [[albumin]] level. Deterioration of nutritional status which is considered as [[protein energy malnutrition]], resistant to dietary supplementation is an indication for dialysis.<ref name="pmid16208532">{{cite journal |vauthors=Cano F, Azocar M, Cavada G, Delucchi A, Marin V, Rodriguez E |title=Kt/V and nPNA in pediatric peritoneal dialysis: a clinical or a mathematical association? |journal=Pediatr. Nephrol. |volume=21 |issue=1 |pages=114–8 |date=January 2006 |pmid=16208532 |doi=10.1007/s00467-005-2048-9 |url=}}</ref><ref name="pmid25194620">{{cite journal |vauthors=Moreau-Gaudry X, Jean G, Genet L, Lataillade D, Legrand E, Kuentz F, Fouque D |title=A simple protein-energy wasting score predicts survival in maintenance hemodialysis patients |journal=J Ren Nutr |volume=24 |issue=6 |pages=395–400 |date=November 2014 |pmid=25194620 |doi=10.1053/j.jrn.2014.06.008 |url=}}</ref><ref name="pmid24474221">{{cite journal |vauthors=Segall L, Moscalu M, Hogaş S, Mititiuc I, Nistor I, Veisa G, Covic A |title=Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients |journal=Int Urol Nephrol |volume=46 |issue=3 |pages=615–21 |date=March 2014 |pmid=24474221 |doi=10.1007/s11255-014-0650-0 |url=}}</ref><ref name="pmid23411424">{{cite journal |vauthors=Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, Averbukh Z, Weissgarten J |title=Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients |journal=Clin J Am Soc Nephrol |volume=8 |issue=3 |pages=443–51 |date=March 2013 |pmid=23411424 |pmc=3586967 |doi=10.2215/CJN.04980512 |url=}}</ref><ref name="pmid22526487">{{cite journal |vauthors=Zhang R, Ren YP |title=Protein-energy wasting and peritoneal function in elderly peritoneal dialysis patients |journal=Clin. Exp. Nephrol. |volume=16 |issue=5 |pages=792–8 |date=October 2012 |pmid=22526487 |doi=10.1007/s10157-012-0631-5 |url=}}</ref>
Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used.  A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, facilitating the transport of dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis.  Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the [[extracorporeal]] circuit during the treatment. [[Hemodiafiltration]] is a term used to describe several methods of combining hemodialysis and hemofiltration in one process.


==Starting indications==
=== Comorbidities ===
The decision to initiate dialysis or hemofiltration in patients with [[renal failure]] can depend on several factors, which can be divided into acute or chronic indications.
Conditions like volume overload and [[Congestive heart failure|heart failure]] may result in clinical deterioration in [[Chronic renal failure|CKD]] patients regardless of [[eGFR]] level. Accordingly, these conditions must be assessed in every patients for early diagnosis and dialysis initiation.<ref name="pmid24508475">{{cite journal |vauthors=Crews DC, Scialla JJ, Boulware LE, Navaneethan SD, Nally JV, Liu X, Arrigain S, Schold JD, Ephraim PL, Jolly SE, Sozio SM, Michels WM, Miskulin DC, Tangri N, Shafi T, Wu AW, Bandeen-Roche K |title=Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD |journal=Am. J. Kidney Dis. |volume=63 |issue=5 |pages=806–15 |date=May 2014 |pmid=24508475 |pmc=4117406 |doi=10.1053/j.ajkd.2013.12.010 |url=}}</ref><ref name="pmid24158988">{{cite journal |vauthors=Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, Jaar BG, Sozio SM, Miskulin DC, Tangri N, Shafi T, Meyer KB, Wu AW, Powe NR, Boulware LE |title=Predialysis health, dialysis timing, and outcomes among older United States adults |journal=J. Am. Soc. Nephrol. |volume=25 |issue=2 |pages=370–9 |date=February 2014 |pmid=24158988 |pmc=3904572 |doi=10.1681/ASN.2013050567 |url=}}</ref><ref name="pmid16253729">{{cite journal |vauthors=Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, Kausz AT |title=Effect of comorbidity on the increased mortality associated with early initiation of dialysis |journal=Am. J. Kidney Dis. |volume=46 |issue=5 |pages=887–96 |date=November 2005 |pmid=16253729 |doi=10.1053/j.ajkd.2005.08.005 |url=}}</ref>
* Acute Indications for Dialysis/Hemofiltration:
** 1) [[Hyperkalemia]]
** 2) [[Metabolic Acidosis]]
** 3) [[Fluid overload]] (which usually manifests as [[pulmonary oedema]])
** 4) Uremic [[pericarditis]], a potentially life threatening complication of renal failure
** 5) And in patients without renal failure, acute poisoning with a dialysable drug, such as [[lithium]], or aspirin.
* Chronic Indications for Dialysis:
** 1) Symptomatic renal failure.
** 2) Low [[glomerular filtration rate]] (GFR) ([[renal replacement therapy|RRT]] often recommended to commence at a GFR of less than 10-15 mls/min/1.73m2)
** 3) Difficulty in medically controlling serum phosphorus or anaemia when the GFR is very low


==Related Chapters==
=== Metabolic Derangements ===
* [[Apheresis]] is another [[extracorporeal]] technique that selectively removes specific constituents from blood.
Persistent metabolic and electrolyte derangements despite medical therapy are conditions that may require incident dialysis in acute settings. They include [[hyperkalemia]], [[metabolic acidosis]], and dialysable drug intoxications, such as [[lithium]] or [[aspirin]] toxicity.
*[[Acute renal failure]]
*[[Chronic renal failure]]
*[[Hepatorenal syndrome]]
*[[Nephrology]]
*[[Renal failure]]


==Resources==
=== National Kidney Foundation Recommendation ===
* [http://www.homedialysis.org  Home Dialysis Central] - Doing dialysis at home allows more personal control; fewer diet and fluid limits and medications; reduces symptoms and hospitalizations, and makes it more possible to keep a job.  Learn all about it.
Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis:
* [http://www.dialysistips.com/ Dialysis Tips] - Resource for dialysis personnel and general background with good understanding of the basic problems of dialysis therapy.
* Signs and/or symptoms associated with [[uremia]]
* [http://www.globaldialysis.com Global Dialysis] - Resource and community for dialysis patients and professionals
* Evidences of protein-energy wasting
* [http://www.homedialysis.org/learn/museum/ Virtual Dialysis Museum] - History and pictures of dialysis machines through time
* Inability to safely manage [[metabolic]] abnormalities and/or volume overload with medical therapy
* [http://www.therenalunit.com The Renal Unit] - News and resources for those undergoing dialysis
* [http://hdcn.com/inslidef.htm  HDCN Online journal] - Free medical lectures pertaining to various aspects of dialysis and nephrology; intended for physicians and nurses, not for patients.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{Nephrology}}


[[Category:Nephrology]]
[[Category:Nephrology]]
[[Category:Renal dialysis| ]]
[[Category:Uptodate]]


[[cs:Dialýza]]
[[cs:Dialýza]]

Latest revision as of 18:39, 7 June 2018

For patient information page, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Dialysis Main Page

Patient Information

Overview

Classification

Hemodialysis
Peritoneal Dialysis

Indications

Overview

Chronic kidney disease (CKD) prevalence has an increased rate worldwide due to increased prevalence of diabetes mellitus and hypertension as the leading causes of CKD, increasing life expectancy, and aging of the populations. On the other hand, acute kidney injury requires renal replacement therapy in certain circumstances. Dialysis is an intervention aiming to substitutes for solutes and removing extra fluids to help or substitute the failing kidneys. It is considered as a renal replacement therapy method which is indicated in certain condition depending on severity and chronicity of the underlying condition. In acute setting, refractory increased electrolytes and fluid overload are the most common indications for dialysis. eGFR is the determining factor to initiate dialysis in chronic kidney disease however, uremic symptoms, presence of comorbidities, and nutritional status are important factors influencing nephrologist's judgement to consider early versus late dialysis. In 2010, it is estimated that 2.3-7.1 million patients died of end stage renal disease (ESRD) without having access to dialysis. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030.[1] Timely initiating dialysis could save lives, prevent complications, and decrease comorbidities. Patients should be educated about the process and goals of this method of treatment.

Classification

There are two main types of dialysis, hemodialysis and peritoneal dialysis. The mode of dialysis should be selected based on patients preference, chronicity of disease, underlying disease, comorbidities, and availability of the modality.


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dialysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal dialysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodialysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continuous ambulatory
peritoneal dialysis (CAPD)
 
 
 
Continuous cyclic
peritoneal dialysis (CCPD)
 
 
 
Intermittent
peritoneal dialysis (IPD)

Indications

The decision to initiate dialysis or hemofiltration in patients with renal failure can depend on several factors. The following factors are the most important aspects that nephrologists consider in every patient individually to initiate dialysis.

Uremic Symptoms

The following table describe the uremic symptoms and signs according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines.[2][3]

Uremia manifestations
Symptoms Signs
Fatigue Seizure/change in seizure threshold
Lethargy Amenorrhea
Confusion Reduced core body temperature
Anorexia Protein-energy wasting
Alteration in smelling and tasting senses Insulin resistance
Cramps Heightened catabolism
Restless legs Serositis (pleuritis, pericarditis)
Sleep disturbances Hiccups
Pruritus Platelet dysfunction
Somnolence

Nutritional Status

Nutritional status of CKD patients should be assessed frequently. Many factors could be considered as indicator, such as normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), assessment of body composition by bioelectrical impedance analysis (BIA), lean body mass, and serum albumin level. Deterioration of nutritional status which is considered as protein energy malnutrition, resistant to dietary supplementation is an indication for dialysis.[4][5][6][7][8]

Comorbidities

Conditions like volume overload and heart failure may result in clinical deterioration in CKD patients regardless of eGFR level. Accordingly, these conditions must be assessed in every patients for early diagnosis and dialysis initiation.[9][10][11]

Metabolic Derangements

Persistent metabolic and electrolyte derangements despite medical therapy are conditions that may require incident dialysis in acute settings. They include hyperkalemia, metabolic acidosis, and dialysable drug intoxications, such as lithium or aspirin toxicity.

National Kidney Foundation Recommendation

Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis:

  • Signs and/or symptoms associated with uremia
  • Evidences of protein-energy wasting
  • Inability to safely manage metabolic abnormalities and/or volume overload with medical therapy

References

  1. ↑ Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, Zhao MH, Lv J, Garg AX, Knight J, Rodgers A, Gallagher M, Kotwal S, Cass A, Perkovic V (May 2015). "Worldwide access to treatment for end-stage kidney disease: a systematic review". Lancet. 385 (9981): 1975–82. doi:10.1016/S0140-6736(14)61601-9. PMID 25777665.
  2. ↑ Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ (November 2015). "Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline". Am. J. Kidney Dis. 66 (5): 823–36. doi:10.1053/j.ajkd.2014.11.031. PMID 26498415.
  3. ↑ "KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update". Am. J. Kidney Dis. 66 (5): 884–930. November 2015. doi:10.1053/j.ajkd.2015.07.015. PMID 26498416.
  4. ↑ Cano F, Azocar M, Cavada G, Delucchi A, Marin V, Rodriguez E (January 2006). "Kt/V and nPNA in pediatric peritoneal dialysis: a clinical or a mathematical association?". Pediatr. Nephrol. 21 (1): 114–8. doi:10.1007/s00467-005-2048-9. PMID 16208532.
  5. ↑ Moreau-Gaudry X, Jean G, Genet L, Lataillade D, Legrand E, Kuentz F, Fouque D (November 2014). "A simple protein-energy wasting score predicts survival in maintenance hemodialysis patients". J Ren Nutr. 24 (6): 395–400. doi:10.1053/j.jrn.2014.06.008. PMID 25194620.
  6. ↑ Segall L, Moscalu M, Hogaş S, Mititiuc I, Nistor I, Veisa G, Covic A (March 2014). "Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients". Int Urol Nephrol. 46 (3): 615–21. doi:10.1007/s11255-014-0650-0. PMID 24474221.
  7. ↑ Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, Averbukh Z, Weissgarten J (March 2013). "Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients". Clin J Am Soc Nephrol. 8 (3): 443–51. doi:10.2215/CJN.04980512. PMC 3586967. PMID 23411424.
  8. ↑ Zhang R, Ren YP (October 2012). "Protein-energy wasting and peritoneal function in elderly peritoneal dialysis patients". Clin. Exp. Nephrol. 16 (5): 792–8. doi:10.1007/s10157-012-0631-5. PMID 22526487.
  9. ↑ Crews DC, Scialla JJ, Boulware LE, Navaneethan SD, Nally JV, Liu X, Arrigain S, Schold JD, Ephraim PL, Jolly SE, Sozio SM, Michels WM, Miskulin DC, Tangri N, Shafi T, Wu AW, Bandeen-Roche K (May 2014). "Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD". Am. J. Kidney Dis. 63 (5): 806–15. doi:10.1053/j.ajkd.2013.12.010. PMC 4117406. PMID 24508475.
  10. ↑ Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, Jaar BG, Sozio SM, Miskulin DC, Tangri N, Shafi T, Meyer KB, Wu AW, Powe NR, Boulware LE (February 2014). "Predialysis health, dialysis timing, and outcomes among older United States adults". J. Am. Soc. Nephrol. 25 (2): 370–9. doi:10.1681/ASN.2013050567. PMC 3904572. PMID 24158988.
  11. ↑ Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, Kausz AT (November 2005). "Effect of comorbidity on the increased mortality associated with early initiation of dialysis". Am. J. Kidney Dis. 46 (5): 887–96. doi:10.1053/j.ajkd.2005.08.005. PMID 16253729.

cs:Dialýza de:Dialyse fa:دیالیز it:Dialisi he:דיאליזה mn:Диализ эмчилгээ nl:Dialyse no:Dialyse sq:Dializa sk:Dialýza (lekárstvo) fi:Dialyysi sv:Dialys


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