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INTRODUCTION

Key Clinical Questions

  • image How are the stages of chronic kidney disease defined?

  • image What are the different dialysis modalities, and how do patients choose one over another?

  • image What is the difference between an arteriovenous fistula and an arteriovenous graft? What are their associated complications?

  • image When is it appropriate to initiate dialysis?

  • image How are hemodialysis and peritoneal dialysis performed? What are their common complications?

  • image What complications are common in hospitalized patients with chronic kidney disease?

Over 26 million Americans, or approximately one in nine adults, have chronic kidney disease (CKD). These patients require special attention from hospitalists because of the high incidence of acute kidney injury (AKI) and other complications during hospitalization. These patients are at risk of AKI not only from known nephrotoxins, such as contrast agents and nonsteroidal anti-inflammatory drugs (NSAIDs), but also from other commonly prescribed agents. Other major issues in the hospital care of these patients include preservation of venous access, electrolyte and acid-base correction, and anemia management. As many of these patients advance to end-stage renal disease (ESRD) requiring dialysis, hospitalists should have a basic understanding of the principles of renal replacement therapy (RRT).

CHRONIC KIDNEY DISEASE

The National Kidney Foundation has defined a staging system for CKD (Table 245-1) based on glomerular filtration rate (GFR) as the best marker of kidney function. CKD is defined as an absolute GFR less than 60 cc/min, or structural or functional kidney abnormalities such as hematuria, proteinuria, or abnormal renal imaging in association with a preserved GFR (> 90cc/min). Serum creatinine concentration (sCr) is a poor marker of kidney function, as normal values vary significantly with age, gender, and muscle mass. It is especially inadequate in the setting of AKI. In the early phases of acute kidney injury, the sCr may be falsely reassuring, as it may begin to rise well after the initial insult.

TABLE 245-1Chronic Kidney Disease Staging System

As GFR is not readily measured, mathematical formulae are used to estimate it. The Cockcroft-Gault and the Modification of Diet in Renal Disease (MDRD) formulas are most commonly used. The newer Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is also being used in some clinical laboratories (Table 245-2). The Cockcroft-Gault formula is simple, but often overestimates kidney function. The MDRD is a more arduous calculation, but is more accurate in patients with advanced CKD. The CKD-EPI equation is superior to the others in that it allows for accurate GFR estimations in patients ...

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