End Stage Renal Disease

Aka: End Stage Renal Disease, ESRD

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II. Definitions

  1. Chronic Kidney Disease
    1. Abnormal Kidney structure or function lasting more than 3 months, with associated health implications
    2. Estimated Glomerular Filtration Rate (eGFR) <60 ml/min OR
    3. Positive Kidney damage markers (e.g. albuminuria) OR
    4. Polycystic or dysplastic Kidneys
  2. End Stage Renal Disease
    1. Kidney Function not adequate for longterm survival without Dialysis or Renal Transplant
    2. Stage 5 Chronic Kidney Disease (GFR <15 ml/min/1.73m2)

III. Causes

  1. See Chronic Kidney Disease

IV. Findings

  1. See Chronic Kidney Disease

V. Labs

  1. See Chronic Kidney Disease

VI. Management: Renal Replacement

  1. See Chronic Kidney Disease for secondary prevention
  2. Hemodialysis or Peritoneal Dialysis
    1. See Hemodialysis
    2. See Peritoneal Dialysis
    3. Absolute Dialysis Indications
      1. Uremic Symptoms
      2. Uremic Pericarditis
    4. Relative Dialysis Indications
      1. Hypervolemia
      2. Hyperkalemia or other Electrolyte abnormalities
      3. Severe Metabolic Acidosis
      4. Creatinine Clearance <10 ml/min (<15 ml/min in Diabetes Mellitus)
  3. Renal Transplantation
    1. Improves overall survival and quality of life in comparison to Dialysis and conservative management
    2. Refer to Renal Transplant when GFR <30 ml/min/1.73m2 to allow for adequate planning, preparation, wait list time
    3. As of 2020, the median time of Renal Transplant wait list is 4 years
    4. Less rejection if transplant before Dialysis started
      1. Mange (2001) N Engl J Med 344:726-31 [PubMed]
  4. Conservative management options (palliative approach)
    1. Optimizes quality of life over prolongation of life
      1. Survival benefit of Hemodialysis is reduced in elderly and comorbidity
      2. Uremia symptoms may not significantly improve with Hemodialysis
      3. Hemodialysis is associated with increased medical interventions
    2. More than half of chronic Hemodialysis patients regret their decision to undergo Hemodialysis
      1. Davison (2010) Clin J Am Soc Nephrol 5(2): 195-204 [PubMed]
    3. Non-Dialysis with Hospice care
    4. Delayed Dialysis until Creatinine Clearance <5 ml/min (similar morbidity and mortality)
      1. Cooper (2010) N Engl J Med 363(7):609-19 [PubMed]

VII. Management: Anemia in ESRD

  1. Erythropoietin (EPO)
    1. Efficacy
      1. Initial studies showed benefit for Erythropoietin
        1. Renicki (1995) Am J Kidney Dis 25:548-54 [PubMed]
      2. Recent studies show no benefit and higher risk of Cerebrovascular Accident
        1. Outcomes are the same with and without normalized Hemoglobin via erythropoetin
        2. Morbidity and patient sense of well-being is not improved on erythropoetin
        3. Pfeffer (2009) N Engl J Med 361 [PubMed]
    2. Indications for Erythropoeitin
      1. Hemoglobin <9 to 10 mg/dl
      2. Do not target a Hemoglobin >11 mg/dl
    3. Adverse effects
      1. Increased risk of Cerebrovascular Accident
  2. Iron Supplementation
    1. Often indicated in Hemodialysis patients
    2. Parenteral replacement is often needed (decreased oral absorption)
      1. Non-Dextran IV Iron
        1. Indicated in significant Iron Deficiency refractory to oral replacement
        2. Options: Ferumoxytol (Feraheme), iron sucrose (venafer) or Sodium Ferric Gluconate (Ferrlecit)
      2. Ferric pyrophosphate (Triferic)
        1. Available in 2015 (U.S.)
        2. Indicated for maintenance iron infusion
        3. May be delivered inline with Hemodialysis
    3. References
      1. (2015) Presc Lett 22(4)

VIII. Management: Metabolic Bone Disease (Secondary Hyperparathyroidism)

  1. See Chronic Kidney Disease related Bone Disease (Renal Osteodystrophy)

IX. Management: Anorexia and Protein Energy Wasting in ESRD

  1. Minimize Uremia with adequate Dialysis frequency
  2. Consider Major Depression, Gastroparesis, and Xerostomia
  3. Protein Energy Wasting Findings
    1. BMI < 23 kg/m2
    2. Unintentional Weight Loss (>5% over 3 months or >10% over 6 months)
    3. Serum Albumin <3.8 g/dl
  4. General Measures
    1. Dietician Consultation
    2. High Protein diet 1.0 to 1.2 g Protein/kg/day in ESRD
      1. Contrast with the limited Protein diet in Chronic Kidney Disease to prevent progression
      2. Consider dietary Protein Supplementation
  5. Medications
    1. Dronabinol 2.5 mg orally before meals
    2. Megestro 400 mg orally daily
    3. Prednisone 10 mg orally daily

X. Management: Symptomatic Management in ESRD

  1. Agitation
    1. Haloperidol 1 mg PO, IV or IM every 12 hours
  2. Dyspnea
    1. Regular Physical Activity to prevent deconditioning
    2. Fentanyl (Duragesic) 12.5 mg IV or SQ every two hours as needed for end-of-life
  3. Fatigue
    1. Treat Anemia if present
    2. Consider Depression Management with Fluoxetine 20 mg daily or Sertraline 50 mg daily
  4. Nausea and Vomiting
    1. Minimize Uremia with adequate Dialysis frequency
    2. Ondansetron 4 mg orally every 8 hours
    3. Metoclopramide (Reglan) 5 mg twice daily
    4. Haloperidol (Haloperidol) 0.5 mg orally every 8 hours
  5. Pruritus
    1. Minimize Uremia with adequate Dialysis frequency
    2. Phosphate Binders
    3. Standar Dry Skin therapy (e.g. barrier creams)
    4. Ondansetron 4 mg orally every 8 hours
    5. Hydroxyzine (Atarax or Vistaril), 25 mg orally every 6 hours
    6. Naltrexone (Revia) 50 mg orally daily
    7. Phototherapy (UV-B Light)
  6. Insomnia
    1. See Sleep Hygiene
    2. Treat Restless Leg Syndrome
    3. Treat Obstructive Sleep Apnea
    4. Zolpidem 5 mg orally at bedtime
    5. Temazepam (Restoril) 15 mg orally at bedtime

XI. Management: Advanced Directives in ESRD

  1. Cardiopulmonary Resuscitation (CPR)
    1. Survival in ESRD is only 8% at hospital discharge and 3% at six months
    2. Contrast with CPR in non-ESRD with survival of 12% at discharge and 9% at six months
    3. Discuss Do-Not-Reuscitate status at routine visits
  2. Hospice
    1. Criteria to qualify for Hospice services paid by Medicare in End Stage Renal Disease
      1. ESRD on no-Dialysis management or
      2. ESRD on Dialysis and other Hospice qualifying condition (e.g. cancer)

XII. Complications

  1. See Chronic Kidney Disease

XIII. Prognosis

  1. See Chronic Kidney Disease for course
  2. Annual mortality of ESRD: 24%
  3. Five Year survival of ESRD
    1. All ages: 38%
    2. Age over 65 years: 18%

XIV. References

  1. (2018) Presc Lett 25(8)
  2. Golder (2003) AAFP Board Review, Seattle
  3. (2002) Am J Kidney Dis 39:s1-266 [PubMed]
  4. Baumgarten (2011) Am Fam Physician 84(10): 1138-48 [PubMed]
  5. Gaitonde (2017) Am Fam Physician 96(12): 776-83 [PubMed]
  6. Goodbred (2023) Am Fam Physician 108(6): 554-61 [PubMed]
  7. Hood (1996) Postgrad Med 100(5):163-75 [PubMed]
  8. Snyder (2005) Am Fam Physician 72(9):1723-32 [PubMed]
  9. (2007) Am J Kidney Dis 49(2 suppl 2):S12-S154 [PubMed]
  10. O'Connor (2012) Am Fam Physician 85(7):705-10 [PubMed]
  11. Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
  12. Wouk (2021) Am Fam Physician 104(5): 493-99 [PubMed]

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