End Stage Renal Disease

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Contents 1 Introduction 2 Etiology 3 Epidemiology 4 Radiology 5 Complications 6 Management 7 More General Terms 8 Additional Terms 9 References

Introduction

• Advanced renal disease ( GFR < 8-10 mL/min) requiring dialysis. (see 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 [4]
• idiopathic (5%)

Epidemiology

• > 250,000 patients in USA 1995
• black patients, Mexican & Native Americans with 3 to 4-fold increase relative to whites

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

• 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

Management

• hemodialysis

• early initiation of hemodialysis is associated with increased mortality [6]
• refusal of dialysis

• asscociated with 60-80% 1 year mortality [7]
• functional status tends to be stable until the final month of life, when a steep decline in function occurs

• peritoneal dialysis
• management of electrolyte disturbances

• hyperkalemia
• hyperphosphatemia

• renal transplantation

• survival advantage of cadaveric renal transplantation over dialysis [2], most significant for diabetic patients
• superior quality of life for renal transplantation

• prophylaxis

• control of risk factors, diabetes mellitus & hypertension
• ACE inhibitors & ARBs may offer some advantage [3]

• dietary protein 1.2-1.3 g/kg/day if on dialysis [2]
• treat anemia of chronic renal failure [8]

More General Terms

• chronic renal failure (CRF)

Additional Terms

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

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, American College of Physicians, Philadelphia 1998, 2009
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: [1]
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: [2]
5. Kidney Failure and Dialysis: NIH Institute and Center Resources [3]
6. Clark WF et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ 2011 Jan 11; 183:47 PMID: [4]
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: [5]
8. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
9. National Guideline Clearinghouse Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. ngc-guideline: [6]
   - Guideline recommendations and their rationales for the treatment of neonates, infants, children, and adolescents. In: Shared decision-making in the appropriate initiation of and withdrawal from dialysis, 2nd edition. ngc-guideline: [7]

end-stage renal disease (ESRD)