Once a patient has reached stage 4 chronic kidney disease (CKD), with size-adjusted estimated glomerular filtration rate (eGFR/1.73 m2) of <30 mL/min, he or she should be under a nephrologist’s care. Ideally, the patient should also be a part of a multidisciplinary predialysis program that includes patient and family education, early choice of appropriate renal replacement modality, and, if dialysis is being considered, elective creation of dialysis access. The advantage of a programmatic approach to care is a planned outpatient initiation of dialysis in a patient who is both mentally and physically prepared. It is likely that this approach results in fewer hospital days in the first month after beginning dialysis and substantial cost savings.
I. CHOICE OF MODALITY
A. Patient education. Of key importance is patient education about the various treatment options available in the event that renal replacement therapy will become necessary. Would the patient best benefit from some form of dialysis, from preemptive transplantation, or from continued conservative management? In some cases, due to extreme patient debility or other reasons, dialysis may not be an appropriate option, and conservative management may be the best choice. These discussions are best initiated once a patient is still in stage 4 CKD, and well before stage 5 has been reached.
B.
Options for renal replacement therapy (
Table 2.1)
1.
Preemptive transplantation. Transplantation offers survival superior to the standard forms of dialysis being offered today. Transplantation may not be indicated, however, for a patient who has severe problems with compliance in terms of medications. Preemptive transplantation has a higher success rate in general than when transplantation is initiated after hemodialysis (
Kallab, 2010), and for this reason, discussions about the feasibility of transplantation and transplantation workup should begin well in advance of any need for dialysis, usually when eGFR/1.73 m
2 is still well above 10 mL/min (
Kupin, 2011).
2. Dialysis: Home versus in-center therapy. Among the end-stage renal disease (ESRD) therapies, the choices made will depend on what is available in the local community. One of the main decisions to be made is whether the patient will be coming in to a clinic for regular dialysis (hemodialysis in this case), or whether he or she would prefer the independence of dialyzing at home, using either a home hemodialysis system or peritoneal dialysis (PD). Obviously transportation issues are very important here, as is the status of a patient’s home, the amount of support available through interested family members who might assist as caregivers, and technical issues such as available water quality and electricity.
In observational studies, mortality rates are lower in home hemodialysis patients than in in-center hemodialysis patients, sometimes dramatically so, even after adjustments for common comorbidities and at similar total weekly dialysis times. Some of this home dialysis advantage may be due to unaccounted for patient selection bias, as patients undertaking the responsibility to dialyze at home usually have a strong positive attitude, good compliance, and strong caregiver and/or family support structure, factors which are associated in their own right with increased survival. Mortality rates for in-center hemodialysis are similar to those for home PD, so the selection of home versus in-center modality should be based primarily on patient preferences versus any anticipated survival benefit.
3.
“Short daily” hemodialysis. Normally, whether done at home or in-center, hemodialysis therapy is offered 3 times per week, usually 3-5 hours per session. When the same amount of dialysis time is broken up into five or six sessions per week, some observational studies have shown better control of blood pressure, better nutrition (weight gain, increased appetite and albumin), and better control of anemia. In the only moderate-sized randomized trial that has been
done, the FHN trial, where patients were randomized to get 6 treatments per week but in fact averaged only 5, those assigned to more frequent dialysis for 1 year were found to have reduction in left ventricular hypertrophy, improved physical functioning (those were the two primary outcomes of the FHN trial), a reduced severity of hypertension, and marginally improved control of serum phosphorus. There was no improvement in serum albumin, nutritional measurements, or control of anemia (
FHN Trial Group, 2010). The details of various “short daily” hemodialysis regimens are discussed in
Chapter 16. Usually frequent hemodialysis is done at home and is only rarely offered in-center or in self-care units. “Short daily” hemodialysis is gaining in popularity, especially with the availability of easy-to-use machines dedicated to delivering such therapy in the home setting.
