Failure
End Stage Renal Disease
search
End Stage Renal Disease
, ESRD
See Also
Chronic Kidney Disease
Chronic Kidney Disease related Bone Disease
(
Renal Osteodystrophy
)
Proteinuria
Drug Dosing in Chronic Kidney Disease
Nephrotoxic Drug
s
Prevention of Kidney Disease Progression
Intravenous Contrast Related Acute Renal Failure
Gadolinium-Associated Nephrogenic Systemic Fibrosis
(
Nephrogenic Fibrosing Dermopathy
)
Hypotension in the Dialysis Patient
Calciphylaxis
Definitions
Chronic Kidney Disease
Abnormal
Kidney
structure or function lasting more than 3 months, with associated health implications
Estimated
Glomerular Filtration Rate
(eGFR) <60 ml/min OR
Positive
Kidney
damage markers (e.g. albuminuria) OR
Polycystic or dysplastic
Kidney
s
End Stage Renal Disease
Kidney Function
not adequate for longterm survival without
Dialysis
or
Renal Transplant
Stage 5
Chronic Kidney Disease
(GFR <15 ml/min/1.73m2)
Causes
See
Chronic Kidney Disease
Findings
See
Chronic Kidney Disease
Labs
See
Chronic Kidney Disease
Management
Renal Replacement
See
Chronic Kidney Disease
for secondary prevention
Hemodialysis
or
Peritoneal Dialysis
See
Hemodialysis
See
Peritoneal Dialysis
Absolute
Dialysis
Indications
Uremic Symptoms
Uremic Pericarditis
Relative
Dialysis
Indications
Hypervolemia
Hyperkalemia
or other
Electrolyte
abnormalities
Severe
Metabolic Acidosis
Creatinine Clearance
<10 ml/min (<15 ml/min in
Diabetes Mellitus
)
Renal Transplantation
Improves overall survival and quality of life in comparison to
Dialysis
and conservative management
Refer to
Renal Transplant
when GFR <30 ml/min/1.73m2 to allow for adequate planning, preparation, wait list time
As of 2020, the median time of
Renal Transplant
wait list is 4 years
Less rejection if transplant before
Dialysis
started
Mange (2001) N Engl J Med 344:726-31 [PubMed]
Conservative management options (palliative approach)
Optimizes quality of life over prolongation of life
Survival benefit of
Hemodialysis
is reduced in elderly and comorbidity
Uremia
symptoms may not significantly improve with
Hemodialysis
Hemodialysis
is associated with increased medical interventions
More than half of chronic
Hemodialysis
patients regret their decision to undergo
Hemodialysis
Davison (2010) Clin J Am Soc Nephrol 5(2): 195-204 [PubMed]
Non-
Dialysis
with
Hospice
care
Delayed
Dialysis
until
Creatinine Clearance
<5 ml/min (similar morbidity and mortality)
Cooper (2010) N Engl J Med 363(7):609-19 [PubMed]
Management
Anemia
in ESRD
Erythropoietin
(EPO)
Efficacy
Initial studies showed benefit for
Erythropoietin
Renicki (1995) Am J Kidney Dis 25:548-54 [PubMed]
Recent studies show no benefit and higher risk of
Cerebrovascular Accident
Outcomes are the same with and without normalized
Hemoglobin
via erythropoetin
Morbidity and patient sense of well-being is not improved on erythropoetin
Pfeffer (2009) N Engl J Med 361 [PubMed]
Indications for Erythropoeitin
Hemoglobin
<9 to 10 mg/dl
Do not target a
Hemoglobin
>11 mg/dl
Adverse effects
Increased risk of
Cerebrovascular Accident
Iron Supplementation
Often indicated in
Hemodialysis
patients
Parenteral
replacement is often needed (decreased oral absorption)
Non-
Dextran
IV
Iron
Indicated in significant
Iron Deficiency
refractory to oral replacement
Options:
Ferumoxytol
(Feraheme), iron sucrose (venafer) or
Sodium Ferric Gluconate
(
Ferrlecit
)
Ferric pyrophosphate (Triferic)
Available in 2015 (U.S.)
Indicated for maintenance iron infusion
May be delivered inline with
Hemodialysis
References
(2015) Presc Lett 22(4)
Management
Metabolic Bone Disease (Secondary
Hyperparathyroidism
)
See
Chronic Kidney Disease related Bone Disease
(
Renal Osteodystrophy
)
Management
Anorexia
and
Protein
Energy Wasting in ESRD
Minimize
Uremia
with adequate
Dialysis
frequency
Consider
Major Depression
,
Gastroparesis
, and
Xerostomia
Protein
Energy Wasting Findings
BMI < 23 kg/m2
Unintentional Weight Loss
(>5% over 3 months or >10% over 6 months)
Serum Albumin
<3.8 g/dl
Gene
ral Measures
Dietician
Consultation
High
Protein
diet 1.0 to 1.2 g
Protein
/kg/day in ESRD
Contrast with the limited
Protein
diet in
Chronic Kidney Disease
to prevent progression
Consider dietary
Protein Supplementation
Medications
Dronabinol
2.5 mg orally before meals
Megestro 400 mg orally daily
Prednisone
10 mg orally daily
Management
Symptomatic Management in ESRD
Agitation
Haloperidol
1 mg PO, IV or IM every 12 hours
Dyspnea
Regular
Physical Activity
to prevent deconditioning
Fentanyl
(
Duragesic
) 12.5 mg IV or SQ every two hours as needed for end-of-life
Fatigue
Treat
Anemia
if present
Consider
Depression Management
with
Fluoxetine
20 mg daily or
Sertraline
50 mg daily
Nausea
and
Vomiting
Minimize
Uremia
with adequate
Dialysis
frequency
Ondansetron
4 mg orally every 8 hours
Metoclopramide
(
Reglan
) 5 mg twice daily
Haloperidol
(
Haloperidol
) 0.5 mg orally every 8 hours
Pruritus
Minimize
Uremia
with adequate
Dialysis
frequency
Phosphate Binder
s
Standar
Dry Skin
therapy (e.g. barrier creams)
Ondansetron
4 mg orally every 8 hours
Hydroxyzine
(
Atarax
or
Vistaril
), 25 mg orally every 6 hours
Naltrexone
(
Revia
) 50 mg orally daily
Phototherapy
(UV-B Light)
Insomnia
See
Sleep Hygiene
Treat
Restless Leg Syndrome
Treat
Obstructive Sleep Apnea
Zolpidem
5 mg orally at bedtime
Temazepam
(
Restoril
) 15 mg orally at bedtime
Management
Advanced Directive
s in ESRD
Cardiopulmonary Resuscitation
(CPR)
Survival in ESRD is only 8% at hospital discharge and 3% at six months
Contrast with CPR in non-ESRD with survival of 12% at discharge and 9% at six months
Discuss Do-Not-Reuscitate status at routine visits
Hospice
Criteria to qualify for
Hospice
services paid by medicare in End Stage Renal Disease
ESRD on no-
Dialysis
management or
ESRD on
Dialysis
and other
Hospice
qualifying condition (e.g. cancer)
Complications
See
Chronic Kidney Disease
Prognosis
See
Chronic Kidney Disease
for course
Annual mortality of ESRD: 24%
Five Year survival of ESRD
All ages: 38%
Age over 65 years: 18%
References
(2018) Presc Lett 25(8)
Golder (2003) AAFP Board Review, Seattle
(2002) Am J Kidney Dis 39:s1-266 [PubMed]
Baumgarten (2011) Am Fam Physician 84(10): 1138-48 [PubMed]
Gaitonde (2017) Am Fam Physician 96(12): 776-83 [PubMed]
Goodbred (2023) Am Fam Physician 108(6): 554-61 [PubMed]
Hood (1996) Postgrad Med 100(5):163-75 [PubMed]
Snyder (2005) Am Fam Physician 72(9):1723-32 [PubMed]
(2007) Am J Kidney Dis 49(2 suppl 2):S12-S154 [PubMed]
O'Connor (2012) Am Fam Physician 85(7):705-10 [PubMed]
Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
Wouk (2021) Am Fam Physician 104(5): 493-99 [PubMed]
Type your search phrase here