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End-stage renal disease (ESRD) occurs when there is progressive loss
of kidney function over a period of months to years to the point where
the kidneys can no longer remove wastes; concentrate urine; maintain
acid–base homeostasis; and regulate fluid, electrolytes, and other
Dialysis is a process that facilitates the removal of excess water and
solutes from the body, both of which accumulate as a result of
inadequate kidney function. Solutes from the blood are removed through
diffusion and convection. Accumulated water is removed by
The ability of a dialyzer to remove solutes and water is determined by its
composition, pore size, surface area, and configuration.
Dialysate is an electrolyte solution that simulates plasma. The
concentration of electrolytes in dialysate can be manipulated to control
the diffusion of electrolytes from the blood into dialysate to maintain
homeostasis. Metabolic acidosis is controlled with the addition of
Different types of vascular access are available: arteriovenous (AV)
fistula, AV graft, and double-lumen or tunneled catheters. An AV
fistula is preferred because of its longer survival rates and low rates of
Anticoagulation is necessary during hemodialysis (HD) to prevent blood
from clotting in the extracorporeal circuit. Several methods have been
used to provide adequate anticoagulation without increasing the risk of
Complications can arise during HD. The most common complications
are hypotension and muscle cramps. Graft thrombosis and graft
infection are common chronic complications.
Continuous ambulatory peritoneal dialysis is performed by instilling sterile
dialysate into the peritoneal cavity through a surgically placed resident
catheter. The solution dwells within the cavity for 4 to 8 hours, and then
it is drained and replaced with a fresh solution. This process of fill,
dwell, and drain is performed 3 to 4 times during the day, with a longer
The process of peritoneal dialysis (PD) is similar to HD; in this process,
however, the peritoneal membrane covering the abdominal contents
serves as an endogenous dialysis membrane, and the vasculature
embedded in the peritoneum serves as the blood supply. Fluid is
removed by manipulating the dextrose concentration in dialysate to
control the osmotic pressure gradient for fluid removal.
The most significant complication among patients having PD is
peritonitis. Empiric antibiotics can be administered by the intraperitoneal
(IP) route and must cover both gram-positive and gram-negative
Other medications can be administered IP. Heparin can be added to
dialysate to prevent fibrin clots from forming and obstructing outflow
from the peritoneal cavity. Regular insulin can be administered IP to
Prevention of catheter exit-site infections (and thus peritonitis) is the
primary goal of exit-site care. Routine care consists of hand cleansing
with antiseptics or antibacterialsoap before touching the exit site,
washing the exit site daily with antibacterialsoap, and use of
antimicrobial creams around the exit site.
End-stage renal disease (ESRD) occurs when there is progressive loss of kidney
function over a period of months to years to the point where the kidneys can no longer
remove wastes, concentrate urine, maintain acid–base homeostasis, and regulate fluid
and electrolytes and other important body functions. ESRD is classified under stage 5
chronic kidney disease (CKD), which refers to patients with an estimated glomerular
filtration rate (eGFR) less than 15 mL/minute/1.73 m2
, or those requiring dialysis or
1,2 Demographic characteristics of ESRD population are based
primarily on data from the Centers for Medicare and Medicaid Services, because
patients with ESRD are eligible for Medicare benefits. Coverage for ESRD began in
1972, when Congress enacted the End-Stage Renal Disease Program as an
amendment to Medicare. Data from the ESRD program are reported annually by the
United States Renal Data System. According to the 2014 Annual Report, diabetes and
hypertension continue to be leading causes of ESRD.
older account for the largest segment of the ESRD population. Racial differences in
the prevalence of ESRD persist. While prevalence of ESRD in Native Americans has
declined since 2000, prevalence rates remain much higher in Blacks/African
Americans than in other racial groups, at nearly twofold higher than Native
Americans, 2.5-fold higher than Asians, and fourfold higher than Whites.
In 2012 there were 636,905 prevalent cases of ESRD in the United States, an
increase of 3.7% from the previous year. Of these, 402,514 patients were treated by
hemodialysis (HD), 40,605 were on peritoneal dialysis (PD), and 17,305 kidney
transplantations were performed.
3 The number of kidney transplants has remained
stable since 2005. Recipients living with a functioning graft continue to grow,
reaching 186,303 in 2012 reflecting a 3.6% increase from 2011. However, the
shortage of donor kidneys and the existence of patients with ESRD, who are
unacceptable transplant recipients, sustain the demand for dialysis. Kidney
transplantation is further discussed in Chapter 34, Kidney and Liver Transplantation.
The two primary modes of dialysis therapy are HD and PD. Both HD and PD were
developed as methods for the removal of metabolic waste products across a
HD is an extracorporeal (dialysis membrane is outside of the body) process,
whereas PD uses the patient’s peritoneal membrane for the clearance of water and
solutes. Variations of PD include continuous ambulatory peritoneal dialysis (CAPD)
and automated peritoneal dialysis (APD), an increasingly common modality that
permits greater patient flexibility with dialysis at home. Among the 443,119 dialysis
patients in the United States, 91% undergo HD.
3 Most of these patients receive
dialysis 3 times a week in a center designed primarily for stable, ambulatory patients
at either a hospital-based or a free-standing dialysis facility. Home HD accounts for
less than 1% of dialysis patients. Patients having PD are also managed through
dialysis centers for routine care, although less often than patients on HD. The most
frequent form of dialysis in children is APD. Several factors are considered in the
selection of the type of dialysis for each patient. Often, the overriding consideration
is the suitability of the procedure for the patient’s lifestyle. A patient who needs
flexibility and freedom from a rigid schedule may prefer PD versus HD to avoid the
necessity of being at a dialysis center 3 times weekly for a 3- to 4-hour dialysis
treatment. Other considerations include the availability of a vascular access site for
HD, a patient’s ability to perform self-care for dialysate exchanges with PD, or the
capability of the patient, parent, or caregiver to carry out APD at home.
Without dialysis or transplantation, patients with ESRD will die from the
metabolic complications of their renal failure. Survival on dialysis has improved
over the years. Since 1993, mortality rates have fallen across all renal replacement
modalities with a 28% reduction for HD patients, 47% reduction for PD patients, and
51% reduction for transplant patients.
3 While these rates are encouraging, only 54%
of HD patients and 65% of PD patients survive beyond 3 years after ESRD onset.
All-cause mortality rates are 6.1 to 7.8 times higher for dialysis patients compared to
the general population, and highest in the second and third months of dialysis.
Dialysis patients are expected to live one-third as long as people of the same age in
the general population. Transplant patients live longer with an estimated lifetime that
is 83% to 87% of the general population.
The rapid growth of the number of patients having dialysis calls attention to the
need for practitioners who understand the processes and therapies for these patients.
This chapter addresses the fundamental clinical aspects of both HD and PD,
including principles, complications, and management. Throughout the chapter,
reference will be made, when appropriate, to the Kidney Disease Outcomes Quality
Initiative (K/DOQI) clinical practice guidelines developed by the National Kidney
Principles and Transport Processes
Dialysis is a process that facilitates the removal of excess water and toxins from the
body, both of which accumulate as a result of inadequate kidney function. During HD,
a patient’s anticoagulated blood (circulated to the dialyzer from a vein in the arm)
and an electrolyte solution that simulates plasma (dialysate) are simultaneously
perfused through a dialyzer (artificial kidney) on opposite sides of a semipermeable
membrane. Solutes (e.g., metabolic waste products, toxins, potassium, and other
electrolytes) are removed from the patient’s blood by diffusing across concentration
gradients into the dialysate. The rate of removal of various solutes from the blood is
a function of blood and dialysate flow rates through the dialyzer, relative
concentration of each solute in the blood and dialysis solution (thus determining their
concentration gradients across the membrane), physical characteristics of the dialysis
membrane (e.g., total available surface area, thickness, and pore size), and properties
of the solute being removed (e.g., molecular size in daltons, molecular weight,
volume of distribution, and protein binding). Because blood and dialysate flow in
opposite directions through the dialyzer, the concentration gradient for each solute
across the membrane is amplified (Fig. 30-1). This principle is defined in greater
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