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Chronic kidney disease (CKD) prevalence has an incremental pattern worldwide due to increased rate 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 are important to consider early versus late dialysis not only according to eGFR. | [[Chronic renal failure|Chronic kidney disease]] (CKD) prevalence has an incremental pattern worldwide due to increased rate 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 kidney disease however, [[Uremia|uremic]] symptoms are important to consider early versus late dialysis not only according to eGFR. | ||
==Starting indications== | ==Starting indications== | ||
The decision to initiate dialysis or hemofiltration in patients with [[renal failure]] can depend on several factors. | The decision to initiate dialysis or hemofiltration in patients with [[renal failure]] can depend on several factors. | ||
| Line 19: | Line 19: | ||
!Signs | !Signs | ||
|- | |- | ||
|Fatigue | |[[Fatigue]] | ||
|Seizure/change in seizure | |[[Seizure]]/change in seizure threshold | ||
|- | |- | ||
|Lethargy | |[[Lethargy]] | ||
|Amenorrhea | |[[Amenorrhea]] | ||
|- | |- | ||
|Confusion | |[[Confusion]] | ||
|Reduced core body temperature | |Reduced core body temperature | ||
|- | |- | ||
|Anorexia | |[[Anorexia]] | ||
|Protein-energy wasting | |Protein-energy wasting | ||
|- | |- | ||
|Alteration in smelling and tasting senses | |Alteration in smelling and tasting senses | ||
|Insulin resistance | |[[Insulin resistance]] | ||
|- | |- | ||
|Cramps | |[[Cramp|Cramps]] | ||
|Heightened catabolism | |Heightened [[catabolism]] | ||
|- | |- | ||
|Restless legs | |[[Restless legs syndrome|Restless legs]] | ||
|Serositis (pleuritis, pericarditis) | |Serositis ([[Pleurisy|pleuritis]], [[pericarditis]]) | ||
|- | |- | ||
|Sleep disturbances | |[[Sleep disorder|Sleep disturbances]] | ||
|Hiccups | |[[Hiccup|Hiccups]] | ||
|- | |- | ||
| rowspan="2" |Pruritus | | rowspan="2" |[[Itch|Pruritus]] | ||
|Platelet dysfunction | |[[Platelet]] dysfunction | ||
|- | |- | ||
|Somnolence | |[[Somnolence]] | ||
|} | |} | ||
=== Nutritional Status === | === 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.<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> | [[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> | ||
=== Comorbidities === | === 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.<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> | 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> | ||
=== Metabolic Derangements === | === 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 === | === National Kidney Foundation Recommendation === | ||
Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis: | Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis: | ||
* Signs and/or symptoms associated with uremia | * Signs and/or symptoms associated with [[uremia]] | ||
* Evidences of protein-energy wasting | * Evidences of protein-energy wasting | ||
* Inability to safely manage metabolic abnormalities and/or volume overload with medical therapy | * Inability to safely manage [[metabolic]] abnormalities and/or volume overload with medical therapy | ||
==Related Chapters== | ==Related Chapters== | ||
Revision as of 17:25, 6 June 2018
For patient information page, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Dialysis Main Page |
Overview
Chronic kidney disease (CKD) prevalence has an incremental pattern worldwide due to increased rate 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 are important to consider early versus late dialysis not only according to eGFR.
Starting indications
The decision to initiate dialysis or hemofiltration in patients with renal failure can depend on several factors.
Uremic Symptoms
The following table describe the uremic symptoms and signs according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines.[1][2]
| Uremia manifestations | |
|---|---|
| Sypmtoms | 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.[3][4][5][6][7]
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.[8][9][10]
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
Related Chapters
References
- ↑ 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.
- ↑ "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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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