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End-stage renal disease (ESRD) is the irreversible loss of renal function, resulting in the accumulation of toxins and the loss of internal homeostasis. Uremia, the clinical syndrome resulting from ESRD, is universally fatal without some form of renal replacement therapy. At present, renal replacement therapy consists of two basic modalities: renal transplant and dialysis.

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This chapter discusses the pathophysiology and clinical features of uremia and the specific techniques and complications related to hemodialysis and peritoneal dialysis (PD).

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According to the 2005 annual report of the United States Renal Data System, >350,000 patients with ESRD are being treated by dialysis, with approximately 92% receiving hemodialysis and about 8% on continuous ambulatory PD (CAPD).1 ESRD is a disease of the elderly, with patients >65 years of age comprising 47.9% of new cases of ESRD and accounting for 37.2% of all living patients with ESRD. Diabetes mellitus is the most common disease responsible for ESRD (42.8%), followed by hypertension (25.9%), glomerulonephritis (9.0%), cystic kidney disease (2.3%), and other causes (20.0%). The United States Renal Data System projects a 6% to 7% growth per year in the incidence of ESRD. An increasing incidence and life span will result in an expected rising prevalence of ESRD of 8% to 9% per year.

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Of those receiving renal replacement therapy for ESRD, 70% are undergoing dialysis therapy and 30% have received renal transplants. Children (aged 0 to 19 years) have higher rates of renal transplantation (77.7%) and PD (12.1%) than do other age groups. The 1-, 2-, and 5-year survival rates (adjusted for age, race, sex, and primary disease) for individuals with ESRD are 79.6%, 64.9%, and 34.4%, respectively. Cardiac causes account for approximately 50% of all deaths in patients with ESRD. Infectious causes of death are seen in 10% to 25% of patients. Cerebrovascular events make up 6% of deaths in ESRD, with malignancy accounting for another 1% to 4%. Approximately 20% of dialysis patients withdraw from therapy before death. Patients >65 years of age have the highest withdrawal rate (25%), which is linked to an increasing severity of comorbid conditions affecting patients’ quality of life on renal replacement therapy.

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Uremia, contamination of the blood with urine, is the term used to describe the clinical syndrome resulting from ESRD. Azotemia is the buildup of nitrogen in the blood.

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Excretory Failure

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Excretory failure leads to elevated levels of >70 chemicals in uremic plasma, which gives rise to the hypothesis that these toxins, individually or in combination, cause uremic organ dysfunction and produce the symptoms of uremia. Limiting protein intake markedly improves the symptoms of uremia. Urea, the major breakdown product of proteins, reproduces a few of the neurobehavioral uremic symptoms, but only at very high concentrations. Other potential uremic toxins include cyanate, guanidine, polyamines, and β2-microglobulin. The toxins accumulating in ESRD excretory failure do not explain all its clinical features. In addition, ...

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