Dialysis may be required for the treatment of either acute or chronic kidney disease (CKD). The use of continuous renal replacement therapies (CRRT) and prolonged intermittent renal replacement therapy (PIRRT)/slow low-efficiency dialysis (SLED) is specific to the management of acute renal failure and is discussed in Chap. 304. These modalities are performed continuously (CRRT) or over 6–12 h per session (PIRRT/SLED), in contrast to the 3–4 h of an intermittent hemodialysis session. Advantages and disadvantages of CRRT and PIRRT/SLED are discussed in Chap. 304.
Peritoneal dialysis is rarely used in developed countries for the treatment of acute renal failure because of the increased risk of infection and (as will be discussed in more detail below) less efficient clearance per unit of time. The focus of this chapter will be on the use of peritoneal and hemodialysis for end-stage renal disease (ESRD).
With the widespread availability of dialysis, the lives of hundreds of thousands of patients with ESRD have been prolonged. In the United States alone, there are now ~675,000 patients with treated ESRD (kidney failure requiring dialysis or transplantation), the vast majority of whom require dialysis. Since 2000, the prevalence of treated ESRD has increased 74%, which reflects both a small increase in the incidence rate and marginally enhanced survival of patients receiving dialysis. The incidence rate for treated ESRD in the United States is 370 cases per million population per year; ESRD is disproportionately higher in African Americans (875 per million population per year) as compared with white Americans (285 per million population per year). In the United States, the leading cause of ESRD is diabetes mellitus, currently accounting for almost 45% of newly diagnosed cases of ESRD. Approximately 30% of patients have ESRD that has been attributed to hypertension, although it is unclear whether in these cases hypertension is the cause or a consequence of vascular disease or other unknown causes of kidney failure. Other prevalent causes of ESRD include glomerulonephritis, polycystic kidney disease, and obstructive uropathy. A fraction of the excess incidence of ESRD in African Americans is likely related to transmission of high-risk alleles for the APOL1 gene.
Globally, mortality rates for patients with ESRD are lowest in Europe and Japan but very high in the developing world because of the limited availability of dialysis. In the United States, the mortality rate of patients on dialysis has decreased slightly but remains extremely high, with a 5-year survival rate of ~40% for patients receiving dialysis. Deaths are due mainly to cardiovascular diseases and infections (~40 and 10% of deaths, respectively). Older age, male sex, nonblack race, diabetes mellitus, malnutrition, and underlying heart disease are important predictors of death.
TREATMENT OPTIONS FOR PATIENTS WITH ESRD
Commonly accepted criteria for initiating patients on maintenance dialysis include the presence of uremic symptoms, the presence of hyperkalemia unresponsive to conservative measures, persistent extracellular volume expansion ...