Approach to the management of end-stage renal disease

Types of transplantation

The potential for a live donor transplant should be fully explored. Ideally, those within six months of the anticipated date of ESRD should proceed to pre-emptive live donor transplantation (Fig 1). If this is not possible, they should be placed on the transplant waiting list – although the average waiting time for a deceased donor kidney is currently more than three years.⁹ If the patient also has type 1 diabetes, a combined deceased donor kidney and pancreas transplant should be considered, for which there is a waiting time of less than eight months.^9,10

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Fig 1.

Care pathway for patients approaching end-stage renal disease ESRD. (ESRF = end-stage renal failure; RRT = renal replacement therapy).

Suitability

Patients not eligible for transplantation will usually be suitable for treatment by dialysis if that is their wish.¹¹ Extensive or severe comorbidity that limits life expectancy to less than a few months is generally considered a contraindication to dialysis, but some patients with a better prognosis may elect not to be dialysed and instead to receive conservative and, later, palliative care.

The assessment of patient suitablity for dialysis is best carried out by an MDT. When there is uncertainty, either in the mind of the patient or in the decision of the MDT, a trial of dialysis is indicated.

Peritoneal dialysis

Peritoneal dialysis (PD) is less efficient than haemodialysis (HD) in removing waste products. It usually needs to be carried out daily at home, whereas conventional HD is a thrice-weekly treatment carried out either at home or in hospital. PD may not provide adequate dialysis for large patients and those who have lost all renal function, and many patients will transfer to HD within 2–3 years of starting PD unless they receive a kidney transplant.¹²

PD is relatively simple. Most patients who can self-care or have a carer and whose peritoneum is intact will be medically suitable for this type of dialysis (Fig 2). In appropriately selected and trained patients, infective peritonitis should occur less than every 18–24 patient-months. Sclerosing peritonitis leading to intractable bowel obstruction is a rare but serious complication.^13,14

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Fig 2.

Catheter for peritoneal dialysis.

Conventional haemodialysis

The range of HD treatment times is generally 3–5 hours and some patients experience symptoms of hypotension during dialysis and increased fatigue afterwards, limiting its acceptability. It is more complicated to perform than PD and, for those able and willing to self-care, the training period is longer. Most patients who receive HD attend a hospital or satellite dialysis unit. For them, the travelling and waiting times to start dialysis and for their transport to arrive to take them home are a major source of frustration.

Septicaemia is a serious complication of HD. Delay in its recognition or treatment will increase the risk of sequelae such as endocarditis and discitis.¹⁵ It is least likely to occur in patients whose vascular access is an arteriovenous fistula, while those with central lines (venous catheters) are at much greater risk.¹⁶

Daily and overnight dialysis

Daily HD with shorter treatment times is popular with some patients who dialyse at home, and may be associated with an improvement in quality of life, blood pressure, fluid balance control and laboratory parameters.¹⁷ Longer treatment times thrice weekly, often delivered overnight, may offer similar advantages and are not restricted to patients dialysing at home.¹⁸ Both these options are more expensive than standard HD treatment in terms of dialysis consumables, but may offer savings in drug costs because of better control of hyperphosphataemia and anaemia.

Haemodiafiltration

In haemodiafiltration (HDF), a variation of HD, blood in the extracorporeal circuit is delivered to a highly permeable membrane so that waste product removal occurs principally by convection but also by dialysis. HDF is also more expensive and its superiority over HD is unproven, but it may improve intradialytic symptoms in some patients.¹⁹

Self-care and home dialysis

When deciding on their most suitable dialysis modality patients need unbiased counselling from the MDT who should usually see the patient at home and not just in the hospital setting. In making their choice, patients will often initially be attracted to the idea of receiving their dialysis fully cared for by nurses because they are frightened by their illness and lack the confidence that they can treat themselves. It is important to allay these fears and to reassure the patient, their carers and family.

The appropriate level of self-care should be part of the assessment. Once this has been gauged, the patient should decide whether they would ideally prefer to receive their treatment at home or in a hospital or satellite dialysis setting with other patients.¹¹ The most cost-effective forms of dialysis are home or self-care, but patient choice is paramount. Currently, most patients elect for hospital-based haemodialysis.³

Starting dialysis: have access established

The first RRT for most patients will be some form of dialysis. With early identification, appropriate counselling and forward planning, this should be an anxiety-free experience with very little risk. A key factor is to have had successful dialysis access surgery at least 2–3 months previously to create an arteriovenous fistula ready to use for haemodialysis (Fig 3). This will avoid the need for dialysis via central lines with a much increased risk of serious infection. For those patients who present late and have an unscheduled start to dialysis there should be a pathway in place to allow more urgent patient education and access surgery.¹¹

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Fig 3.

Radial-cephalic arteriovenous fistula during haemodialysis.